Janko Kersnik

Frequent attenders in general practice: quality of life, patient satisfaction, use of medical services and GP characteristics.

OBJECTIVE To determine the predictors of frequent attendance in general practice. DESIGN A postal survey using a questionnaire including instruments for measuring patient satisfaction (EUROPEP), quality of life (EUROQOL), anxiety and depression (DUKE-AD). SETTING Primary health care in Slovenia. PATIENTS A representative sample of 2160 adult patients. MAIN OUTCOME MEASURES Number of contacts with the health care services, levels of self-care, patient satisfaction scores, quality of life scores, well-being scores, presence of chronic condition. RESULTS Frequent attenders were more likely to have lower educational status, were more satisfied with their GP, had higher scores of anxiety and depression, and lower perceived quality of life. They were more likely to have a chronic disease. Frequent attenders were less likely to try self-care and more likely to use health services. They were more likely to visit more experienced GPs, GPs working a greater distance from other GPs and GPs who did not use the appointment system. The multivariable modelling explained 19.7% of the variation; 16.9% was attributed to patient characteristics and 3.1% to GP characteristics. CONCLUSIONS The study confirmed that lower education levels, chronicity and higher use of other health services are predictors of higher attendance.Objective - To determine the predictors of frequent attendance in general practice. Design - A postal survey using a questionnaire including instruments for measuring patient satisfaction (EUROPEP), quality of life (EUROQOL), anxiety and depression (DUKE-AD). Setting - Primary health care in Slovenia. Patients - A representative sample of 2160 adult patients. Main outcome measures - Number of contacts with the health care services, levels of self-care, patient satisfaction scores, quality of life scores, well-being scores, presence of chronic condition. Results - Frequent attenders were more likely to have lower educational status, were more satisfied with their GP, had higher scores of anxiety and depression, and lower perceived quality of life. They were more likely to have a chronic disease. Frequent attenders were less likely to try self-care and more likely to use health services. They were more likely to visit more experienced GPs, GPs working a greater distance from other GPs and GPs who did not use the appointment system. The multivariable modelling explained 19.7% of the variation; 16.9% was attributed to patient characteristics and 3.1% to GP characteristics. Conclusions ? The study confirmed that lower education levels, chronicity and higher use of other health services are predictors of higher attendance.

Perspectives of family medicine in Central and Eastern Europe.

INTRODUCTION In the last decade of the 20th century, the countries of Central and Eastern Europe (CEE) have experienced rapid changes in health policies. This process was largely supported by international grants. After this support has ended, it is important to keep up with the development, developing its own strategies and priorities. Aims and methods. The aim of the paper is to make a proposal for the future development of the discipline in CEE countries. The proposal is based on reports on an invitational conference that was organized for the key representatives of family medicine from CEE countries. For the purpose of this paper, additional information about the situation was gathered from literature reviews, country visits and personal interviews. RESULTS Information shows that although family medicine has been formally recognized and introduced in university curricula, there is a very big difference in its academic position. Postgraduate training has been established in all CEE countries, according to the European Directive. Quality measures such as the development and implementation of guidelines and the re-certification procedure have also been formally introduced, but its quality varies. The key areas of concern are atomization of practices, unsatisfactory payment systems, lack of academic infrastructure and unsatisfactory continuous professional development. On the other hand, examples of good practice exist and need to be promoted. CONCLUSION There is a need for continuous exchange of expertise within the countries. The paper will serve as a discussion paper for the next meeting of experts from CEE countries.

The effect of carbon dioxide on near-death experiences in out-of-hospital cardiac arrest survivors: a prospective observational study

IntroductionNear-death experiences (NDEs) are reported by 11-23% of cardiac arrest survivors. Several theories concerning the mechanisms of NDEs exist - including physical, psychological, and transcendental reasons - but so far none of these has satisfactorily explained this phenomenon. In this study, we investigated the effect of partial pressures of O2 and CO2, and serum levels of Na and K on the occurrence of NDEs in out-of-hospital cardiac arrest survivors.MethodsA prospective observational study was conducted in the three largest hospitals in Slovenia. Fifty-two consecutive patients (median age 53.1 years, 42 males) after out-of-hospital cardiac arrest were included. The presence of NDEs was assessed with a self-administered Greysons NDE scale. The initial partial pressure of end-tidal CO2, the arterial blood partial pressures of O2 and CO2 and the levels of Na and K in venous blood were analysed and studied. Univariate analyses and multiple regression models were used.ResultsNDEs were reported by 11 (21.2%) of the patients. Patients with higher initial partial pressures of end-tidal CO2 had significantly more NDEs (P < 0.01). Patients with higher arterial blood partial pressures of CO2 had significantly more NDEs (P = 0.041). Scores on a NDE scale were positively correlated with partial pressures of CO2 (P = 0.017) and with serum levels of potassium (P = 0.026). The logistic regression model for the presence of NDEs (P = 0.002) explained 46% of the variance and revealed higher partial pressures of CO2 to be an independent predictor of NDEs. The linear regression model for a higher score on the NDE scale (P = 0.001) explained 34% of the variance and revealed higher partial pressures of CO2, higher serum levels of K, and previous NDEs as independent predictors of the NDE score.ConclusionsHigher concentrations of CO2 proved significant, and higher serum levels of K might be important in the provoking of NDEs. Since these associations have not been reported before, our study adds novel information to the field of NDEs phenomena.

Knowledge and acceptance of hypertension guidelines in clinical practice : Experience from Slovenia

SummaryBACKGROUND: Arterial hypertension, which is an important risk factor for cardiovascular disease, is mainly treated by general practitioners. The initial step in an optimal therapeutic strategy for patients with arterial hypertension is the recognition and acceptance of hypertension guidelines by the physicians themselves. AIMS: To find out how well Slovene general practitioners know the current hypertension guidelines and to what extent they accept them. PARTICIPANTS AND METHODS: Knowledge of current recommendations in hypertension diagnosis, treatment, follow-up and special indications was assessed for 813 general practitioners in Slovenia using a questionnaire. The Slovene National Guidelines were taken as the reference standard. Adequate knowledge of the guidelines’ recommendations was defined as correct answers to at least seven out of eleven items; the correct answers had to include the appropriate target blood pressure, the elements of the “minimal diagnostic program” in hypertension and the correct estimation of cardiovascular risk. Acceptance of the guidelines was estimated on a five-grade scale: 5 meaning very useful, 1 meaning useless. RESULTS: A total of 321 questionnaires were suitable for analysis from 327 that were returned (a response rate of 40.2%). The mean number of correct answers was 7.8 (SD, 1.8, range, 4–11), but only 124 (38.8%) of the participating physicians answered the three key questions correctly. The physicians who answered the key questions correctly also answered more of the other questions correctly (6.1 vs. 5.4, p < 0.001). Adequate knowledge of the guidelines was found in 116 (36.8%) of the total study population; mean score for acceptance on the five-grade scale was 4.25. Knowledge of the guidelines was influenced by the physicians’ acceptance of the guidelines’ recommendations (p = 0.024). No other characteristics of physicians or organizational factors influencing knowledge of the guidelines were identified. Most of the participating physicians (72%) were willing to attend a workshop on managing hypertension and there was no connection between knowledge of the guidelines and willingness to attend the workshop. CONCLUSION: Knowledge of the hypertension guidelines among Slovene general practitioners is limited, and is comparable to the results of similar studies. The physicians’ acceptance of the guidelines is high and correlates with their knowledge of the guidelines. A workshop is an accepted form of continuing medical education among general practitioners.ZusammenfassungHINTERGRUND: Arterielle Hypertonie, ein wichtiger Risikofaktor für kardiovaskuläre Erkrankungen, wird hauptsächlich von Allgemeinmedizinern behandelt. Der erste Schritt in einer idealen therapeutischen Strategie für Patienten mit arterieller Hypertonie ist die Anerkennung und die Akzeptanz von Hypertonie-Leitlinien durch die Ärzte selbst. FRAGESTELLUNG: Wie gut kennen slowenische Ärzte für Allgemeinmedizin die ärztlichen Leitlinien für die Behandlung der Hypertonie und wie schätzen sie diese Leitlinien ein? METHODIK: Mittels eines Fragebogens wurden 813 slowenische Ärzte für Allgemeinmedizin über ihre Kenntnis der slowenischen Leitlinien zur Behandlung der Hypertonie befragt, wobei diese Leitlinien den internationalen Vorgaben folgen. Die Kenntnis galt als ausreichend, wenn mindestens 7 von 11 Fragen richtig beantwortet wurden. Unter den richtigen Antworten mussten der Ziel-Blutdruck, das minimale diagnostische Programm zur Abklärung und die Erfassung des kardiovaskulären Risikos sein. Die Akzeptanz der Leitlinien wurde in 5 Beurteilungsgraden erfasst: von 5, „sehr nützlich“, bis 1, „ohne Nutzen“. ERGEBNISSE: Von 327 retournierten Fragebögen (40,2 %) konnten 321 ausgewertet werden. Durchschnittlich waren 7,8 (SD, 1,8; 4 bis 11) Antworten richtig. Nur 124 oder 38,8 % der Ärzte beantworteten die drei wesentlichen Fragen richtig. Diese Ärzte beantworteten auch die restlichen der insgesamt 11 Fragen überwiegend korrekt (6,1 vs. 5,4, p < 0,001). Die Leitlinien waren damit bei 116 oder 36,8 % der Ärzte gut beziehungsweise hinreichend bekannt. Die durchschnittliche Einschätzung hinsichtlich der Nützlichkeit der Leitlinien betrug 4,25 auf der 5-teiligen Bewertungsskala. Die Kenntnis der Leitlinien und ihre Einschätzung zeigten eine signifikante Korrelation (p = 0,024). Die Kenntnis der Richtlinien bedeutete also auch bessere Akzeptanz. Keine anderen Charakteristika der Praxis oder des Arztes beeinflussten die Einschätzung der Leitlinien. Während 72 % der Ärzte bereit sind, an Fortbildungsveranstaltungen zum Management des erhöhten Blutdrucks teilzunehmen, besteht kein Zusammenhang zwischen der Kenntnis der Leitlinien und dieser Fortbildungsbereitschaft. SCHLUSSFOLGERUNGEN: Die Kenntnis der ärztlichen Leitlinien zur Behandlung der Hypertonie ist unter Ärzten für Allgemeinmedizin in Slowenien mäßig, jedoch mit den Ergebnissen von Studien aus anderen Ländern vergleichbar. Die Ärzte, die die Leitlinien kennen, beurteilen diese als sehr nützlich. Die Bereitschaft zur Teilnahme an Workshops als Methode der Fortbildung ist unter den Ärzten in Slowenien groß.

Facilitating organisational development using a group-based formative assessment and benchmarking method: design and implementation of the International Family Practice Maturity Matrix

Introduction Well-organised practices deliver higher-quality care. Yet there has been very little effort so far to help primary care organisations achieve higher levels of team performance and to help them identify and prioritise areas where quality improvement efforts should be concentrated. No attempt at all has been made to achieve a method which would be capable of providing comparisons—and the stimulus for further improvement—at an international level. Methods The development of the International Family Practice Maturity Matrix took place in three phases: (1) selection and refinement of organisational dimensions; (2) development of incremental scales based on a recognised theoretical framework; and (3) testing the feasibility of the approach on an international basis, including generation of an automated web-based benchmarking system. Results This work has demonstrated the feasibility of developing an organisational assessment tool for primary care organisations that is sufficiently generic to cross international borders and is applicable across a diverse range of health settings, from state-organised systems to insurer-based health economies. It proved possible to introduce this assessment method in 11 countries in Europe and one in Africa, and to generate comparison benchmarks based on the data collected. The evaluation of the assessment process was uniformly positive with the view that the approach efficiently enables the identification of priorities for organisational development and quality improvement at the same time as motivating change by virtue of the group dynamics. Conclusions We are not aware of any other organisational assessment method for primary care which has been ‘born international,’ and that has involved attention to theory, dimension selection and item refinement. The principal aims were to achieve an organisational assessment which gains added value by using interaction, engagement comparative benchmarks: aims which have been achieved. The next step is to achieve wider implementation and to ensure that those who undertake the assessment method ensure linkages are made to planned investment in organisational development and quality improvement. Knowing the problems is only half the story.

Factors impacting on the activation and approach times of helicopter emergency medical services in four Alpine countries

BackgroundThe outcome of severely injured or ill patients can be time dependent. Short activation and approach times for emergency medical service (EMS) units are widely recognized to be important quality indicators. The use of a helicopter emergency medical service (HEMS) can significantly shorten rescue missions especially in mountainous areas. We aimed to analyze the HEMS characteristics that influence the activation and approach times.MethodsIn a multi-centre retrospective study, we analyzed 6121 rescue missions from nine HEMS bases situated in mountainous regions of four European countries.ResultsWe found large differences in mean activation and approach times among HEMS bases. The shortest mean activation time was 2.9 minutes; the longest 17.0 minutes. The shortest mean approach time was 10.4 minutes; the longest 45.0 minutes. Short times are linked (p < 0.001) to the following conditions: helicopter operator is not state owned; HEMS is integrated in EMS; all crew members are at the same location; doctors come from state or private health institutions; organization performing HEMS is privately owned; helicopters are only for HEMS; operation area is around 10.000 km2; HEMS activation is by a dispatching centre of regional government who is in charge of making decisions; there is only one intermediator in the emergency call; helicopter is equipped with hoist or fixed line; HEMS has more than one base with helicopters, and one team per base; closest neighboring base is 90 km away; HEMS is about 20 years old and has more than 650 missions per year; and modern helicopters are used.ConclusionsAn improvement in HEMS activation and approach times is possible. We found 17 factors associated with shorter times.

Seeking health advice on the Internet in patients with health problems: A cross-sectional population study in Slovenia

Aim To determine the one-month prevalence of the seeking of web-based health information in the general adult population and to identify the symptoms associated with more frequent searching for information online. Methods This was an observational cross-sectional study in a representative sample of 1,002 randomly selected Slovenian inhabitants. We used the method of computer-assisted telephone interviews. The questionnaire consisted of demographic questions, questions about the prevalence and duration of pre-selected symptoms in the past month, questions on the presence of chronic disease and a question about using the Internet for seeking health advice in the past month. Results Among 774 respondents who reported having had symptoms in the past month, 25.8% of them reported seeking health information on the Internet. The factors found to be independently associated with the seeking of health information on the Internet were a younger age, a higher education level and the presence of constipation, irritability, fatigue, memory impairment and excessive sweating in the past month. Conclusions The study showed that the Internet was a common source of health information in the general adult population, particularly used for symptoms which are common but not well defined and not associated with a particular disease.

Attitudes of Slovenian family practice patients toward changing unhealthy lifestyle and the role of family physicians: cross-sectional study.

Aim To assess patients’ attitudes toward changing unhealthy lifestyle, confidence in the success, and desired involvement of their family physicians in facilitating this change. Methods We conducted a cross-sectional study in 15 family physicians’ practices on a consecutive sample of 472 patients (44.9% men, mean age  [± standard deviation] 49.3 ± 10.9 years) from October 2007 to May 2008. Patients were given a self-administered questionnaire on attitudes toward changing unhealthy diet, increasing physical activity, and reducing body weight. It also included questions on confidence in the success, planning lifestyle changes, and advice from family physicians. Results Nearly 20% of patients planned to change their eating habits, increase physical activity, and reach normal body weight. Approximately 30% of patients (more men than women) said that they wanted to receive advice on this issue from their family physicians. Younger patients and patients with higher education were more confident that they could improve their lifestyle. Patients who planned to change their lifestyle and were more confident in the success wanted to receive advice from their family physicians. Conclusion Family physicians should regularly ask the patients about the intention of changing their lifestyle and offer them help in carrying out this intention.

Health beliefs and practices among Slovenian Roma and their response to febrile illnesses: a qualitative study

Health beliefs and practices among Slovenian Roma and their response to febrile illnesses: a qualitative study Introduction: When the Roma fell ill in the past, they used herbal home remedies to treat diseases. If the remedy failed to cure the illness, they called the local healer. Today, most Roma visit physicians. This study investigates health beliefs and practices held by the Roma people in Slovenia and their response to febrile illnesses. Methods: Field interviews using a semi-structured questionnaire were conducted in the vicinity of Kočevje. Sociodemographic data were gathered and recorded manually, and the interviews were tape recorded. Qualitative analysis was performed by three researchers. Special attention was paid to data validation. Results: The majority of Roma are not acquainted with thermometers and therefore do not use them. About one-third of the interviewees knew what the normal body temperature should be. Only 15% of the Roma population take their body temperature when they are feeling unwell. One-half visit their physicians. More than half of the population take paracetamol or aspirin when they feel feverish. More often, they resort to tea and emphasize the healing effect of sweating. Conclusion: The Roma beliefs and practices regarding health and fever are instructive and show how impoverished a narrow biomedical approach can be. Failure to use technical devices, such as thermometers, and lack of familiarity with the numerical values defining the border between normal and elevated body temperature, nonetheless do not mean that the Roma take inappropriate measures in response to illness. Illnesses (including fever) can also be recognized without these tools and can be appropriately responded to by drinking teas, using compresses, and taking fever-reducing medications. Stališča in Ravnanje Romov v Sloveniji v Zvezi z Vročinskimi Stanji: Kvalitativna Študija Uvod: V preteklosti so Romi za zdravljenje uporabljali domače zeliščne pripravke. Kadar ta zdravila niso bila učinkovita, so poklicali lokalnega zdravilca. Danes večina Romov obišče zdravnika. V prispevku ugotavljamo, kakšno je prepričanje in ravnanje slovenskih Romov v zvezi z zdravjem in kako ukrepajo pri vročinskih stanjih. Metode: V okolici Kočevja smo na terenu izvedli intervjuje na osnovi polstrukturiranih vprašalnikov. Zbrane sociodemografske podatke smo ročno zapisovali, pogovore pa smo posneli. Kvalitativno analizo podatkov so izvedli trije raziskovalci. Posebno pozornost smo namenili validaciji podatkov. Rezultati: Večina Romov ne pozna termometra in ga zato tudi ne uporablja. Približno ena tretjina vprašanih je vedela, kakšna naj bi bila normalna telesna temperatura. Ob slabem počutju si le 15 odstotkov romskega prebivalstva meri telesno temperaturo. Polovica jih obišče zdravnika. Več kot polovica romskih prebivalcev vzame paracetamol ali aspirin, kadar ima vročino. Pogosteje se zatečejo k pitju čaja in poudarjajo zdravilne učinke potenja. Zaključek: Prepričanja in ravnanje Romov v zvezi z zdravjem in povišano telesno temperaturo so poučna in nam kažejo, kako osiromašen je lahko ozko usmerjeni biomedicinski pristop. Dejstvo, da Romi ne uporabljajo tehničnih pripomočkov, npr. termometra, in ne poznajo številčne vrednosti, ki loči med normalno in povišano telesno temperaturo, še ne pomeni, da ob bolezni ravnajo neustrezno. Bolezenska stanja, tudi povišano telesno temperaturo, lahko prepoznamo tudi brez teh orodij in se jim ustrezno postavimo po robu s pitjem čaja, z uporabo obkladkov in z jemanjem zdravil proti vročini.

The vision of health centers in Slovenia

Vizija Prihodnosti Zdravstvenih Domov V Sloveniji Članek predstavlja teoretična izhodišča za posodobitev zdravstvenih domov v Sloveniji. Novi zdravstveni dom naj bi ohranil svoje poslanstvo in osnovna izhodišča, nadgradili pa bi ga z novimi vsebinami, ki jih prinaša moderna druzKba. Zdravstveni dom naj bi postal sodobni integrirani socialnomedicinski center, v skladu z novimi usmeritvami center za promocijo zdravja s poudarkom na preventivi skrbi za zdravje. The vision of health centers in Slovenia This article presents a theoretical starting point for restructuring of heath centres in Slovenia. The new health centre should maintain its mission and the basic principles, and would be upgraded with the new contents brought about by modern society. Health centres would become a modern integrated social-medical center, in accordance with the guidelines of the new center for health promotion, with emphasis on selfpreventative health concerns.