J De Maeseneer

Is GP-patient communication related to their perceptions of illness severity, coping and social support?

The aim of the study was to explore the relationship between the communicative behaviour of general practitioner and patient on the one hand and the perception of the coping behaviour of the patient, the severity of the complaint and the presence of social support on the other hand. From 20 general practitioners (GP), 15 consultations per GP were videotaped and analysed using the Roter Interaction Analysis System. Doctors and patients rated their perceptions on questionnaires. The finding was that doctors and patients used predominantly task-oriented (instrumental) behaviour, with some exceptions. With older patients and patients with low social support the GPs used more affective communication, mainly consisting of social talk and mutual agreement. In the case of complex problems, the GP paid special attention to the relationship with the patient. Within the domain of instrumental communication, some differences between doctor and patient were observed. Although doctors and patients exchanged a lot of information about medical issues, patients gave information about their lifestyle and emotions, which the doctors did not verbally explore. In consultations where the patient perceived the complaint as severe, he or she was more focussed on the medical content. When the GP considered psychosocial issues important, doctor and patient communicated about lifestyle, emotions and social relations. This doctor-patient correlation was not found when patients perceived their problem as psychosocial.

Exploring the Key Principles of Family Medicine in Sub-Saharan Africa: International Delphi Consensus Process

Abstract Background: The purpose of this study was to establish consensus on the key principles of Family Medicine for Sub-Saharan Africa. Methods: A three-stage Delphi technique process involving nine countries in sub-Saharan Africa and individuals from two stakeholder groups (teachers or students/graduates of family medicine programmes). Consensus in rounds one and two was defined as at least 70% agreement. Ranking in round three depended on individuals selecting and ranking the top 20 principles; following this, aggregate scores were calculated. Results: Of the participants, 40 gave consent and 28 participated in the first round (23 teachers and 17 students/graduates); 27/40 (67.5%) participated in the second round; 22/40 (60%) in the third round. The 50 principles seen as relevant were ranked in order of importance. Core values and characteristics such as holistic, longitudinal, comprehensive and family-orientated care and community orientation were recognised as relevant, with differences from more developed settings in terms of emphasis. Several key organisational principles, such as home visiting and definition of the practice population, were seen differently. Principles relating to the scope of practice showed the greatest difference, with the need for family physicians to perform major surgery in the district hospital, to act as consultant and teacher to the first-contact primary care team and to include clinical nurse practitioners in the definition of family medicine being raised. Conclusion: The study contributes towards a clearer definition of Family Medicine in the region, which would enable comparison between regions, influence local curriculum content and outcomes, as well as inform the policy makers and managers of the health system.

What is the role of quality circles in strategies to optimise antibiotic prescribing? A pragmatic cluster-randomised controlled trial in primary care

Objective: To evaluate the effect on antibiotic prescribing of an intervention in existing local quality circles promoting an evidence-based guideline for acute rhinosinusitis. Design: A pragmatic cluster-randomised controlled trial comparing standard dissemination of the guideline by mail with an additional strategy using quality circles. Setting: General practice in Flanders, Belgium. Participants: General practitioners (GPs) in 18 local quality circles were randomly allocated to two study arms. All GPs received the guideline by mail. GPs in the nine quality circles allocated to the intervention arm received an additional group intervention, which consisted of one self-led meeting using material introduced to the group moderator by a member of the research team. Main outcome measures: Adherence to the guideline was measured as differences in the proportion of antibiotic prescriptions, including the choice of antibiotic, between the two study arms after the intervention period. GPs registered their encounters with patients presenting with signs and symptoms of acute rhinosinusitis in a booklet designed for the study. Results: A total of 75 doctors (29% of GPs in the participating quality circles) registered 408 consultations. In the intervention group, 56.9% of patients received an antibiotic compared with 58.3% in the control group. First-choice antibiotics were issued in 34.5% of antibiotic prescriptions in the intervention group compared with 29.4% in the control group. After adjusting for patient and GP characteristics, the ORadj for antibiotics prescribed in the intervention arm compared with the control arm was 0.63 (95% CI 0.29 to 1.37). There was no effect on the choice of antibiotic (ORadj 1.07, 95% CI 0.34 to 3.37). Conclusion: A single intervention in quality circles of GPs integrated in the group’s normal working procedure did not have a significant effect on the quality of antibiotic prescribing. More attention to the context and structure of primary care practice, and insight into the process of self-reflective learning may provide clues to optimise the effectiveness of quality circles.

Health-related quality of life and cost of ambulatory care in osteoporosis: how may such outcome measures be valuable information to health decision makers and payers?

The objective was to quantify the outcome of osteoporosis (OP) in terms of health-related quality of life (HR-QOL) and cost of ambulatory care and to look at the association between these two outcomes variables. A cross-sectional health survey of 4800 Belgian individuals over the age of 45 years was used. Individuals having reported OP were retrieved and for each of them, at least two matched individuals for age, sex, residency location, and health insurance status were identified. All individuals were assessed with the SF-36. The two major health insurance providers furnished cost value for ambulatory care. HR-QOL and cost data were compared between the OP group and control group. Beta-coefficients from linear regression were calculated to give information on the relative importance of the association between each SF-36 dimensions and cost of ambulatory care. Of 4796 individuals appropriately surveyed, 221 (4.8%) reported OP. The control group included 651 individuals. The OP group experienced impaired HR-QOL compared to their matched counterparts, all the difference in mean or median SF-36 scores being significant at the level of P < 0.001. Osteoporotic respondents averaged 816 in cost of ambulatory care whereas controls averaged 579 (P < 0.001). When looking at detailed comparisons between categories of cost, costs in the OP group far exceeded those in the control group, all the differences being significant at the level of P < 0.001 except for home health nurse (P = 0.012). In the OP group, vitality dimensions played the most important role in the determination of cost (beta = -0.28, P < 0.001), followed by physical functioning (beta = -0.26, P < 0.01), general health, and social functioning (beta = -0.23, P < 0.01). This study evidences the burden of OP in terms of HR-QOL and cost of ambulatory care. Exploring the association between HR-QOL and cost show that mental dimension such as vitality can play an important role in the determination of cost. Conclusively, they should not be neglected in future management of OP.

Impact of the transition from a conventional to an integrated contextual medical curriculum on students' learning patterns: A longitudinal study

Background: Until now, most research studying the impact of curriculum innovations on student learning patterns was restricted to short term or cross-sectional research. Aim: Studying longitudinal changes in student learning patterns parallel to the implementation of a curriculum innovation from a discipline based to an integrated contextual medical curriculum (ICMC). Methods: A post hoc study applying General Linear Model ANOVA one-way repeated-measures. The inventory of learning styles (126-item version) is used to determine changes in student learning patterns. Results: Though not all hypotheses could be accepted, the results suggest a significant impact of the ICMC on learning processing strategies; regulation strategies; and on learning orientations. The clear build-up of the curriculum and vertical and horizontal integration of subject knowledge seem to have significantly reduced lack of regulation and promoted at an earlier stage structuring, relating, critical processing and vocational-orientation. The effect on use of sources of knowledge, self-regulation of learning content and certificate-orientation was less important than expected. It was yet not possible to confirm the hypothesis that ICMC students become better in translating study topics into their own phrasing or expressions; and neither the expected impact on vocation-orientation could be confirmed. Conclusions: There is little doubt that the present results are important to curriculum (re)designers and those interested in the evaluation of curriculum reforms.

Intensive and prolonged health promotion strategy may increase awareness of osteoporosis among postmenopausal women.

Abstract: The aim of the study was to measure the results of a 15-year health promotion strategy towards osteoporosis, in an urban community of subjects over 45 years old, in terms of osteoporosis awareness and handling. To this end an ancillary study to a large survey of the Belgian population’s self-perceived health status was carried out. A rectangular sample of 4800 individuals over 45 years old was randomly selected in two Belgian cities, among the affiliates of the two main health insurance providers. One of the cities (Lie`ge) had been, since the early 1980s, the target of a constant health promotion strategy, directed to both the medical community and the general population, aimed at increasing osteoporosis awareness in women after the menopause. During the same period, no particular steps were taken in the other city (Aalst) to increase osteoporosis awareness in the community. In our study, the participants were asked to spontaneously report any chronic, serious and/or severe disorders that they had been suffering from, for at least 6 months, during the previous 12 months. They also provided a list of drugs they were taking at the time of the survey. Osteoporosis was reported to be a disease affecting 1.5% of men in Aalst and 1.3% of men in Lie`ge (p= 0.61). For women, osteoporosis was reported to be present in 4.8% in Aalst and 10.8% in Lie`ge (p<0.001). Self-reporting of osteoporosis prevalence in Lie`ge was statistically significantly higher in women aged 45–64 years, 65–74 years or over 75 years (p<0.001). Obesity, alcohol consumption or physical activity were equally distributed between women from Lie`ge and Aalst. Prescription drugs used for osteoporosis had been delivered to a similar proportion of men in Aalst and Lie`ge. In women, a statistically significant difference in these prescription drugs was observed between Lie`ge and Aalst, both for the overall population (p<0.001) and in each of the age classes (p<0.001 for 45–64 years and 65–74 years; p<0.009 for over 75 years). A continuous long-term health promotion strategy, directed toward both physicians and the general population, thus appears to increase awareness about osteoporosis in women over 45 years and/or in the medical community. This is reflected by an increase in self-reported prevalence of osteoporosis and in the prescription of drugs aimed at prevention and treatment of this disorder. Whether these observations reflect an appropriate diagnosis and a proper handling of the disease remains to be evaluated by objective diagnostic tools such as bone densitometry and by an evaluation of the effectiveness of prescription practices in postmenopausal women.

The potential of the inventory of learning styles to study students' learning patterns in three types of medical curricula

Background: Introducing innovative curricular designs can be evaluating by scrutinizing the learning patterns students use. Aim: Studying the potential of Vermunts Inventory of Learning Styles (ILS) in detecting differences in student learning patterns in different medical curricula. Methods: Cross-sectional between-subjects comparison of ILS-scores in third-year medical students in a conventional, an integrated contextual and a PBL-curriculum using one-way post hoc ANOVA. Results: Response rate was 85%: 197 conventional, 130 integrated contextual and 301 PBL students. The results show a differential impact from the three curricula. In relation to processing strategies, the students in the problem-based curriculum showed less rote learning and rehearsing, greater variety in sources of knowledge used and less ability to express study content in a personal manner than did the students in the conventional curriculum. The students of the integrated contextual curriculum showed more structuring of subject matter by integrating different aspects into a whole. In relation to regulation strategies, the students in the problem-based curriculum showed significantly more self-regulation of learning content and the students in the integrated contextual curriculum showed lower levels of regulation. As to learning orientations, the students in the problem-based curriculum showed less ambivalence and the students of the conventional curriculum were less vocationally oriented. Conclusion: The study provides empirical support for expected effects of traditional and innovative curricula which thus far were not well supported by empirical studies.

Influence of the presence of doctors-in-training on the blood pressure of patients: a randomised controlled trial in 22 teaching practices

Until now, no information is available about the effect of the presence of a doctor-in-training on a patients blood pressure. We tested the hypothesis that the presence of a last year medical student might increase the blood pressure of the patient, in addition to the possible pressor response to the doctor-trainer. Normotensive and hypertensive patients with a minimum age of 25 years, visiting for any reason, were recruited at 22 teaching general practices. Patients were randomised into a ‘trainee’ group (n=133) and a ‘no trainee’ (n=129) group. The blood pressure was measured at two subsequent contacts. In the ‘trainee’ group, a student was present at the first visit only. In the ‘no trainee’ group, both visits were without student. Both groups had similar anthropometric characteristics at entry. At the first visit, systolic pressure was higher in the ‘trainee’ group than in the control group (139.5 vs 133.1 mmHg, P=0.004), with a similar trend for diastolic pressure (80.2 vs 77.8 mmHg, P=0.07). From the first contact to the follow-up visit, blood pressure decreased in the trainee group by 4.8 mmHg systolic (P<0.001) and 1.7 mmHg diastolic (P=0.03), whereas the corresponding changes in the control group were −0.1 mmHg (P=0.90) and +1.5 mmHg (P=0.03). Thus, the between group differences in these trends averaging 4.7 mmHg (CI 1.5–7.9, P=0.005) systolic and 3.2 mmHg (CI 1.1–5.3, P=0.003) diastolic were statistically significant. We conclude that in teaching-practices, the presence of a doctor-in-training has a significant pressor effect when an experienced general practitioner measures a patients blood pressure. If confirmed, our findings imply that doctors should be cautious to initiate or adjust antihypertensive treatment when blood pressure readings are obtained in the presence of a student.

Original Paper: Home visits in Belgium: a multivariate analysis

Background: In Belgium 46% of the GP-patient encounters are home visits. This is the highest percentage in the world.Objective: To analyse ‘system characteristics’ and ‘patient characteristics’ that may contribute to the explanation of the proportion of home visits.Methods: Historical trend analysis and multivariate analysis of healthcare utilisation data. We analysed the change over time of the proportion of home visits in relation to the increase in the number of GPs and the increase of the co-payment in the fee-for-service system. Moreover, a random sample of members of the two largest health insurance companies in two major regions (Aalst and Liege) were interviewed on morbidity, socio-economical data, attitudes and functional status. We used a multivariate linear regression analysis with the percentage of home visits (recorded during two years) as the dependent variable and data from the interview as explaining variables.Results: Historical trend analysis showed almost no change over time of the perc...

Which bacteria are found in Belgian women with uncomplicated urinary tract infections in primary health care, and what is their susceptibility pattern anno 95-96?

Dysuria is a frequent reason for encounter in general practice and also gynaecologists and urologists will be frequently confronted with it. In female patients 1/2 to 2/3 of dysuric episodes are due to urinary tract infections. In nearly all cases therapy is started before the results of a culture is available. Therefore it is very important to know which bacteria are most prevalent in the treated population, and what their susceptibility pattern is . Because most available information is based on retrospective data issued from very mixed populations, we performed a prospective study including the most frequently involved population: symptomatic adult women without any symptom of complicated UTI. Among 279 urine specimens collected in general practices, 164 were positive (59%). The most frequent micro-organism found was E. coli (78%), followed by S. saprophyticus (9%) and Proteus spp. (4%). In the 15 remaining specimens, 8 different bacterial species were found. Overall resistance to ampicillin was 30%, to cotrimoxazole 14%, to nitrofurantoin 7%, to fluoroquinolones 1%. The E.coli resistance to ampicillin was 27%, to co-trimoxazole 17%, to nitrofurantoin 1% and to fluoroquinolones 1%. In this population the same bacteria, in the same proportion, are found as in earlier studies in other countries. The susceptibility pattern confirms a substantial resistance level to ampicillin and co-trimoxazole. On the contrary, resistance to nitrofurantoin and fluoroquinolones is negligible. Resistance data from Belgian regional laboratories in their outpatient population were significantly different from ours.