Imre Rurik

The research agenda for general practice/family medicine and primary health care in Europe. Part 3. Results: Person centred care, comprehensive and holistic approach

Abstract The recently published ‘Research Agenda for General Practice/Family Medicine and Primary Health Care in Europe’ summarizes the evidence relating to the core competencies and characteristics of the Wonca Europe definition of GP/FM, and its implications for general practitioners/family doctors, researchers and policy makers. The European Journal of General Practice publishes a series of articles based on this document. In a first article, background, objectives, and methodology were discussed. In a second article, the results for the two core competencies ‘primary care management’ and ‘community orientation’ were presented. This article reflects on the three core competencies, which deal with person related aspects of GP/FM, i.e. ‘person centred care’, ‘comprehensive approach’ and ‘holistic approach’. Though there is an important body of opinion papers and (non-systematic) reviews, all person related aspects remain poorly defined and researched. Validated instruments to measure these competencies are lacking. Concerning patient-centredness, most research examined patient and doctor preferences and experiences. Studies on comprehensiveness mostly focus on prevention/care of specific diseases. For all domains, there has been limited research conducted on its implications or outcomes.

The Research Agenda for General Practice/Family Medicine and Primary Health Care in Europe. Part 1. Background and methodology 1

Abstract At the WONCA Europe conference 2009 the recently published ‘Research Agenda for General Practice/Family Medicine and Primary Health Care in Europe’ was presented. The Research Agenda is a background paper and reference manual for GPs/ family doctors, researchers and policy makers, providing advocacy of general practice/family medicine GP/FM in Europe. The Research Agenda summarizes the evidence relating to the core competencies and characteristics of the WONCA Europe definition of GP/FM, and its meaning for researchers and policy makers. Evidence gaps and research needs are pointed out to provide a basis for planning research for which there is a need and for action that may influence health and research policy, i.e. applying/lobbying for research funds. WONCA Europe and its associated networks and special interest groups could consider the agendas research priorities when planning future conferences, courses, or projects, and for funding purposes. The European Journal of General Practice will publish a series of articles based on this document. In this first article, background, objectives, methodology and relevant literature are discussed. In subsequent articles, the results will be presented.

Criteria for Centers of Reference for pediatric diabetes – a European perspective

‘SWEET’ is an acronym standing for ‘Better control in pediatric and adolescent diabeteS: Working to crEate CEnTers of Reference (CORs)’ and is based on a partnership of established national and European diabetes organizations such as International Diabetes Federation, Federation of European Nurses in Diabetes, and Primary Care Diabetes Europe (PCDE, www.sweet-project.eu). A three‐level classification of centers has been put forward. In addition to centers for local care, SWEET collaborating centers on their way to being a COR have been defined. Peer‐audited CORs with a continuous electronic documentation of at least 150 pediatric patients with diabetes treated by a multidisciplinary team based on the International Society for Pediatric and Adolescent Diabetes (ISPAD) Clinical Practice recommendations have been created in 12 European countries. In 2011, they cared for between 150 to more than 700 youth with diabetes with an average hemoglobin A1c between 7.6 and 9.2%. Although these clinics should not be regarded as representative for the whole country, the acknowledgment as COR includes a common objective of targets and guidelines as well as recognition of expertise in treatment and education at the center. In a first step, the SWEET Online platform allows 12 countries using 11 languages to connect to one unified diabetes database. Aggregate data are de‐identified and exported for longitudinal health and economic data analysis. Through their network, the CORs wish to obtain political influence on a national and international level and to facilitate dissemination of new approaches and techniques. The SWEET project hopes to extend from the initial group of centers within countries, throughout Europe, and beyond with the help of the ISPAD network.

Nutritional Differences between Elderly Men and Women

Background: Many differences exist between the two genders, i.e., biological, sociological, and also behavioral, which often depend on age. Objectives: The aim of this study was to find characteristic differences between nutritional habits of elderly men and women. Methods: 266 elderly people (109 men >65 years, and 157 women >60 years) were consecutively selected from primary care patients, in Budapest, Hungary. A self-managed questionnaire was filled in on lifestyle and eating habits, including a food frequency questionnaire. Medical check-up, registration of anthropometrical parameters, and laboratory tests were also performed. 53 subjects were also involved in a 3-day dietary recall. Results: The meal frequency was increased during aging in both genders, especially in men. Lunch was preferred by most of the women as a principal meal, but one quarter of the men had a filling dinner instead of lunch. Alcoholic beverages were consumed more and frequently by men. The fluid intake was low, especially in women. Milk and diary products, fresh fruit, bread, biscuits, chocolate, coffee and vitamin supplements were consumed more frequently by women. Almost all types of meat, eggs, and vegetables were more preferred by men and their energy intake was also higher (9.75 vs. 8.78 MJ). In both genders, fat represented a higher ratio (39%) of energy intake than recommended. The increase of body weight from youth to elderly was greater in women (14.04 vs. 10.65 kg). Prices had a higher impact on food purchases by women. Conclusion: High energy intake over decades led to overweight in both genders (BMI >27 kg/m2). It seemed that the eating habits and food choices of women were closer to healthy ones and recent recommendations, although due to metabolic reasons and to the lower energy expenditure, they gained more weight. The elderly are the target population on every level of medical care. Further evaluations are needed to determine the differences in nutrition and to promote better administration of drugs and to establish public health suggestions.

Series: The research agenda for general practice/family medicine and primary health care in Europe. Part 4. Results: Specific problem solving skills

Abstract The ‘Research Agenda for General Practice/Family Medicine and Primary Health Care in Europe’ summarizes the evidence relating to the core competencies and characteristics of the Wonca Europe definition of GP/FM, and its implications for general practitioners/family doctors, researchers and policy makers. The European Journal of General Practice publishes a series of articles based on this document. The previous articles presented background, objectives, and methodology, as well results on ‘primary care management’ and ‘community orientation’ and the person-related core competencies of GP/FM. This article reflects on the general practitioners ‘specific problem solving skills’. These include decision making on diagnosis and therapy of specific diseases, accounting for the properties of primary care, but also research questions related to quality management and resource use, shared decision making, or professional education and development. Clinical research covers most specific diseases, but often lacks pragmatism and primary care relevance. Quality management is a stronghold of GP/FM research. Educational interventions can be effective when well designed for a specific setting and situation. However, their message that ‘usual care’ by general practitioners is insufficient may be problematic. GP and their patients need more research into diagnostic reasoning with a step-wise approach to increase predictive values in a setting characterized by uncertainty and low prevalence of specific diseases. Pragmatic comparative effectiveness studies of new and established drugs or non-pharmaceutical therapy are needed. Multi-morbidity and complexity should be addressed. Studies on therapy, communication strategies and educational interventions should consider impact on health and sustainability of effects.

Primary care obesity management in Hungary: evaluation of the knowledge, practice and attitudes of family physicians

BackgroundObesity, a threatening pandemic, has an important public health implication. Before proper medication is available, primary care providers will have a distinguished role in prevention and management. Their performance may be influenced by many factors but their personal motivation is still an under-researched area.MethodsThe knowledge, attitudes and practice were reviewed in this questionnaire study involving a representative sample of 10% of all Hungarian family physicians. In different settings, 521 practitioners (448 GPs and 73 residents/vocational trainees) were questioned using a validated questionnaire.ResultsThe knowledge about multimorbidity, a main consequence of obesity was balanced.Only 51% of the GPs were aware of the diagnostic threshold for obesity; awareness being higher in cities (60%) and the highest among residents (90%). They also considered obesity an illness rather than an aesthetic issue.There were wider differences regarding attitudes and practice, influenced by the the doctors’ age, gender, known BMI, previous qualification, less by working location.GPs with qualification in family medicine alone considered obesity management as higher professional satisfaction, compared to physicians who had previously other board qualification (77% vs 68%). They measured their patients’ waist circumference and waist/hip ratio (72% vs 62%) more frequently, provided the obese with dietary advice more often, while this service was less frequent among capital-based doctors who accepted the self-reported body weight dates by patients more commonly. Similar reduced activity and weight-measurement in outdoor clothing were more typical among older doctors.Diagnosis based on BMI alone was the highest in cities (85%). Consultations were significantly shorter in practices with a higher number of enrolled patients and were longer by female providers who consulted longer with patients about the suspected causes of developing obesity (65% vs 44%) and offered dietary records for patients significantly more frequently (65% vs 52%). Most of the younger doctors agreed that obesity management was a primary care issue.Doctors in the normal BMI range were unanimous that they should be a model for their patients (94% vs 81%).ConclusionMore education of primary care physicians, available practical guidelines and higher community involvement are needed to improve the obesity management in Hungary.

Heterogeneity in the systems of pediatric diabetes care across the European Union

It is known that the systems of pediatric diabetes care differ across the member states of the European Union (EU). The aim of this project was to characterize some of the main differences among the national systems.

Series: The research agenda for general practice/family medicine and primary health care in Europe. Part 5: Needs and implications for future research and policy

The European General Practice Research Network (EGPRN) has provided the discussions on priorities in research in general practice/family medicine (GP/ FM) and primary health care (PHC) with an important background document. In this issue the conclusions are presented, framing a broad perspective for setting the future research agenda (1). It will be strategically important to defi ne some spearheads that may guide priority setting for the next decade. The following principles could be used to underpin the debate: relevance, equity, quality, cost effectiveness, sustainability, person-centeredness, and innovation.AbstractThe recently published ‘Research Agenda for General Practice/Family Medicine and Primary Health Care in Europe’ summarizes the evidence relating to the core competencies and characteristics of the Wonca Europe definition of GP/FM, and highlights related needs and implications for future research and policy. The European Journal of General Practice publishes a series of articles based on this document. In a first article, background, objectives, and methodology were discussed. In three subsequent, articles the results for the six core competencies of the European Definition of GP/FM were presented. This article formulates the common aims for further research and appropriate research methodologies, based on the missing evidence and research gaps identified form the comprehensive literature review. In addition, implications of this research agenda for general practitioners/family doctors, researchers, research organizations, patients and policy makers are presented. The concept of six core competenci...

The European EUCCLID pilot study on care and complications in an unselected sample of people with type 2 diabetes in primary care.

BACKGROUND European studies on quality of diabetes care in an unselected primary care diabetes population are scarce. RESEARCH QUESTION To test the feasibility of the set-up and logistics of a cross-sectional EUropean study on Care and Complications in patients with type 2 diabetes (T2DM) in Primary Care (EUCCLID) in 12 European countries. METHOD One rural and one urban practice from each country participated. The central coordinating centre randomly selected five patients from each practice. Patient characteristics were assessed including medical history, anthropometric measures, quality indicators, UKPDS-risk engine, psychological and general well-being. RESULTS We included 103 participants from 22 GPs in 11 countries. Central data and laboratory samples were successfully collected. Of the participants 54% were female, mean age was 66 years and mean duration of diabetes was 9.6 years. Besides, 18% were using insulin, 31% had a history of cardiovascular disease, mean HbA1c was 7.1% (range 6.6-8.0), mean systolic blood pressure was 133.7 mmHg (range 126.1-144.4) and mean total cholesterol was 4.9 mmol/l (range 4.0-6.2). CONCLUSION A European study on care and complications in a random selection of people with T2DM is feasible. There are large differences in indicators of metabolic control and wellbeing between countries.

Evaluation on lifestyle and nutrition among Hungarian elderly

Summary.A cross-sectional study on nutritional habits and lifestyle on 250 elderly Hungarian people was performed. The education level, marital status, housing situation, the time for social and outdoor activities, smoking and drinking habits and the general health condition were evaluated.Some anthropometric parameters, the nutritional habits, daily meal patterns and food preference were also briefly analyzed.The overweight, lack of physical activity and unfavourable nutritional habits were the main observations on this population.These trends should be turned by stronger medical intervention based on primary care.Zusammenfassung.Es wurde eine Querschnittsuntersuchung von Ernährung und Lebensweise von 250 ungarischen älteren Personen durchgeführt. Untersucht wurden, Schulbildung, Familienstand, Wohnverhältnisse, soziale Aktivität, Freiluftaktivität, allgemeiner Gesundheitszustand, Rauchen und Trinkgewohnheit.Anthropometrische Angaben und Kost wurden auch analysiert.Übergewicht, wenig physische Aktivität und gesundheitsschädliche Ernährung waren die wichtigsten Beobachtungen.Diese Tendenz sollte durch stärkeres medizinisches Eingreifen mit Hilfe von Hausärzten umgedreht werden.