Luciana Couto

Facilitators, barriers and expectations in the self-management of type 2 diabetes—a qualitative study from Portugal

Abstract Background: Patients with type 2 diabetes mellitus (DM) have a central role in managing their disease, but the effective adoption of self-management behaviours is often challenging. Objectives: The main objective of this study was to assess the facilitators, barriers and expectations in the self-management of type 2 DM, as perceived by patients. Methods: Patients with type 2 DM were recruited at the Portuguese Diabetes Association outpatient clinic, using a convenient sampling technique. Qualitative data was obtained using video-recorded focus groups. Each session had a moderator and an observer, and followed a pre-tested questioning route. Two independent researchers transcribed and analysed the focus groups. Results: Three major themes were identified: diet, physical exercise, and glycaemic control. Difficulties in changing dietary habits were grouped in four main categories: decisional, food quality, food quantity, and dietary schedule. Barriers related to physical exercise also included decisional aspects, as well as fatigue, muscle and joint pain, and other co-morbidities. Information and knowledge translation, as well as family and social ties, were commonly explored aspects across the three themes and were regarded as facilitators in some situations and as barriers in others. Conclusion: This study provided new insight on the barriers, facilitators and expectations in type 2 DM self-management, pointing out the importance of tailored guidance. Future research should explore interventions designed to promote and facilitate behaviour change in this population.

A Population-Based Nationwide Cross-Sectional Study on Preventive Health Services Utilization in Portugal—What Services (and Frequencies) Are Deemed Necessary by Patients?

Background Most of the strategies to induce a more rational use of preventive health services are oriented to the medical side of the doctor-patient relationship. However, the consultation model has changed, and patients now have a more important role in medical consultation. The aim of this study was to assess which healthcare services are deemed necessary, and with what frequency, by adults from the general Portuguese population. Methods Design: Population-based nationwide cross-sectional study Setting: Portuguese population Participants: One thousand Portuguese adults, surveyed by computer-assisted telephone interviewing and selected by a stratified cluster sampling design. Measurements: Proportions and population prevalence estimates were determined for each healthcare service, taking into account whether respondents considered them necessary, and with what frequency. Results Respondent ages ranged between 18 and 97 years, and 520 of 1000 (52%) respondents were women. Among Portuguese adults, 99.2% (95% confidence interval (CI): 98.5 to 99.6) believe that they should undergo general routine blood and urine tests, to be repeated every 12.0 months on average (95% CI: 11.4 to 12.6); 87.4% (95% CI: 85.3 to 89.3) of the respondents reported having actually performed these tests. Of the 15 services surveyed, 14 were considered periodically necessary by more than 60% of respondents. Among the respondents, 37.7% (95% CI: 34.5 to 41.1) reported using healthcare services by their own initiative. Conclusions The majority of Portuguese adults believe that they should utilize a great number of healthcare services, on a nearly annual basis; most actually follow this schedule. Our findings indicate a tendency towards the overuse of resources. Adequate patient-oriented strategies regarding the use of medical tests and preventive interventions—with appropriate information and discussion of risks and harms—are urgently needed, and crucial for achieving a more rational use of healthcare services and for preventing the consequences of over-testing.

Portuguese Family Physicians’ Awareness of Diagnostic and Laboratory Test Costs: A Cross-Sectional Study

Background Physicians’ ability to make cost-effective decisions has been shown to be affected by their knowledge of health care costs. This study assessed whether Portuguese family physicians are aware of the costs of the most frequently prescribed diagnostic and laboratory tests. Methods A cross-sectional study was conducted in a representative sample of Portuguese family physicians, using computer-assisted telephone interviews for data collection. A Likert scale was used to assess physician’s level of agreement with four statements about health care costs. Family physicians were also asked to estimate the costs of diagnostic and laboratory tests. Each physician’s cost estimate was compared with the true cost and the absolute error was calculated. Results One-quarter (24%; 95% confidence interval: 23%–25%) of all cost estimates were accurate to within 25% of the true cost, with 55% (95% IC: 53–56) overestimating and 21% (95% IC: 20–22) underestimating the true actual cost. The majority (76%) of family physicians thought they did not have or were uncertain as to whether they had adequate knowledge of diagnostic and laboratory test costs, and only 7% reported receiving adequate education. The majority of the family physicians (82%) said that they had adequate access to information about the diagnostic and laboratory test costs. Thirty-three percent thought that costs did not influence their decision to order tests, while 27% were uncertain. Conclusions Portuguese family physicians have limited awareness of diagnostic and laboratory test costs, and our results demonstrate a need for improved education in this area. Further research should focus on identifying whether interventions in cost knowledge actually change ordering behavior, in identifying optimal methods to disseminate cost information, and on improving the cost-effectiveness of care.

Patients' estimations of the importance of preventive health services: a nationwide, population-based cross-sectional study in Portugal

Objectives To determine, in the context of primary care preventive health services, the level of importance that Portuguese patients attribute to different preventive activities. Design Cross-sectional study. Setting Primary Healthcare, Portugal. Participants 1000 Portuguese adults selected by a stratified cluster sampling design were invited to participate in a computer-assisted telephone survey. Persons with a cognitive or physical disability that hampered the ability to complete a telephone interview and being a nursing home resident or resident in any other type of collective dwelling were excluded. Outcomes Mean level of importance assigned to 20 different medical preventive activities, using a scale of 1–10, with 1 corresponding to ‘no importance for you and your health’ and 10 indicating ‘very important’. Results The mean level of importance assigned to medical preventive activity was 7.70 (95% CI 7.60 to 7.80). Routine blood and urine tests were considered the most important, with an estimated mean of 9.15 (95% CI 9.07 to 9.24), followed by female-specific interventions (Pap smear, mammography and gynaecological and breast ultrasounds), with mean importance ranging from 8.45 (95% CI 8.23 to 8.63) for mammography to 8.56 (95% CI 8.36 to 8.76) for Pap smear. Advice regarding alcohol consumption (6.18; 95% CI 5.96 to 6.39) and tobacco consumption (5.99; 95% CI 5.75 to 6.23) were considered much less important. Conclusions Our results reveal that Portuguese patients overestimate the importance of preventive medical activities, tend to give more importance to diagnostic and laboratory tests than to lifestyle measures, do not discriminate tests that are important and evidence-based, and seem not be aware of the individualisation of risk. Family physicians should be aware of these optimistic expectations, because these can influence the doctor–patient relationship when discussing these interventions and incorporating personalised risk.

Cardiovascular risk in overweight/obese and lean hypertensive patients

INTRODUCTION Obesity and hypertension have been identified as independent risk factors for cardiovascular disease. Nevertheless, the role of obesity in the development and progression of target-organ disease in hypertensive patients is controversial. The objective of this study was to assess the impact of body weight on cardiovascular risk factors, target-organ disease and global cardiovascular risk in hypertensive patients in a primary care setting. METHODS A cross-sectional observational study was carried in Vila Nova de Gaia, Portugal (n=150). A detailed medical and personal history was obtained and a physical examination was performed. Venous blood and 24-hour urine samples were collected, and an electrocardiogram was performed. Cardiovascular risk was assessed using the Framingham score. The statistical analysis was performed using SPSS(®). A p-value <0.05 was considered statistically significant. RESULTS The sample was 71.8% female, with a mean age of 74.3 ± 10.8 years. The prevalence of obesity was 29.5%. Overweight/obese subjects presented lower mean HDL cholesterol (51.2 ± 13.9 mg/dl vs. 65.4 ± 35.2, p<0.005), higher triglycerides (137.8 ± 70.4 mg/dl vs. 111.5 ± 68.8 mg/dl, p<0.001), higher fasting glucose (111.9 ± 32.8 mg/dl vs. 98.4 ± 13.1 mg/dl, p<0.011) and more frequent mild valve disease (57.9% vs. 29.6%, p=0.021). Global cardiovascular risk was also significantly higher (10.9 ± 7.7 vs. 6.5 ± 5.7, p<0.001). CONCLUSION Overweight and obesity appear to be related to a less favorable lipid and blood glucose profile and higher cardiovascular risk in hypertensive patients. On the basis of our findings we suggest strict metabolic monitoring and improved education on weight reduction and control at primary health care clinics.

Accuracy of general practitioners’ readings of ECG in primary care

BackgroundThe electrocardiogram (ECG) is a diagnostic test commonly used in daily Primary Care practice. General Practitioners (GP) often feel unsure about their interpretation of ECGs, so they engage external services to provide it.AimTo evaluate accuracy of ECG readings done by GPs by comparison with those done by a cardiologist as the gold standard.MethodsWe studied 195 ECGs collected consecutively during first semester of 2010 in an urban Health Centre of Portugal. Each ECG was read by each physician and inter-observer agreement was evaluated. After coding by Novacode, sensitivity and specificity of GP’s readings were calculated.ResultsInter-observer agreement between GP readings was “good” with an intraclass correlation coefficient of 0.727 (CI 95%: 0.670–0.779). When compared with gold standard, GP achieved a “good” agreement with an intraclass correlation coefficient of 0.712 (CI 95%: 0.659–0.762). The overall accuracy of GP for detecting abnormalities was 81.0% (95%CI: 75.7–85.6%), with a sensitivity of 84.8% (95%CI: 77.3–90.6%) and a specificity of 77.5% (95%CI: 69.7–84.2%). For normal tests, accuracy was 79.9% (95%CI: 74.7–84.3). In the most prevalent classes of abnormalities, accuracy was higher than 90%.ConclusionGP showed good skills in reading ECGs in their practice of Primary Care. Better attention should be given to ischemic abnormalities present on ECGs. Key message: General Practitioners demonstrate good skills for reading the ECGs of patients on a primary care centre when compared to the gold standard defined by a cardiologist reading.

Health literacy as a key for effective preventive medicine

Abstract Background: A preventive approach in health care aims to anticipate the natural history of the diseases and to define break points where the procedures may act to change future events, on the limit of the patient’s free will. Patient is an active agent and the main responsible for his/her own health status. The way to achieve the best integration of the providers’ prescriptions and the patients’ decisions is through education, aiming to increase the literacy status. Body of abstract: Higher levels of literacy for health allow better health decisions, stronger commitment with them and superior levels of efficiency. Patients have to possess enough information enabling its incorporation in free and clear decision-making. In preventive approach, literacy contributes to maximize the profit of health investment and to rationalize the available resources by ceasing some old-fashioned and inadequate technologies, thus contributing to sustainability of health systems. Conclusion: The improvement of patients’ health literacy is crucial. Higher literacy means better health outcomes, both in an individual point of view as for general population, in every levels of preventive approach. Thus, literacy is a relevant determinant of individual health and a public health priority.

Diagnostic and laboratory test ordering in Northern Portuguese Primary Health Care: a cross-sectional study

Objectives To characterise the test ordering pattern in Northern Portugal and to investigate the influence of context-related factors, analysing the test ordered at the level of geographical groups of family physicians and at the level of different healthcare organisations. Design Cross-sectional study. Setting Northern Primary Health Care, Portugal. Participants Records about diagnostic and laboratory tests ordered from 2035 family physicians working at the Northern Regional Health Administration, who served approximately 3.5 million Portuguese patients, in 2014. Outcomes To determine the 20 most ordered diagnostic and laboratory tests in the Northern Regional Health Administration; to identify the presence and extent of variations in the 20 most ordered diagnostic and laboratory tests between the Groups of Primary Care Centres and between health units; and to study factors that may explain these variations. Results The 20 most ordered diagnostic and laboratory tests almost entirely comprise laboratory tests and account for 70.9% of the total tests requested. We can trace a major pattern of test ordering for haemogram, glucose, lipid profile, creatinine and urinalysis. There was a significant difference (P<0.001) in test orders for all tests between Groups of Primary Care Centres and for all tests, except glycated haemoglobin (P=0.06), between health units. Generally, the Personalised Healthcare Units ordered more than Family Health Units. Conclusions The results from this study show that the most commonly ordered tests in Portugal are laboratory tests, that there is a tendency for overtesting and that there is a large variability in diagnostic and laboratory test ordering in different geographical and organisational Portuguese primary care practices, suggesting that there may be considerable potential for the rationalisation of test ordering. The existence of Family Health Units seems to be a strong determinant in decreasing test ordering by Portuguese family physicians. Approaches to ensuring more rational testing are needed.

Motives for requesting an electrocardiogram in primary health care

The management of requests for diagnostic exams presents its own inherent characteristics in primary health care and reflects the specific nature of the physician-patient relationship. The scope of the study was to identify the reasons for requesting an electrocardiogram (ECG) in primary health care. A cross-sectional study was conducted in an urban region in Portugal, establishing the motives to ask for an ECG consecutively over two years, starting on 01/03/2007 using data retrieved from structured forms filled out by the physician at the moment of requesting the exam. A total of 870 ECGs of 817 patients were included. Symptoms manifested during the patient visit justified 48.5% of the ECGs, and follow-up of cardiovascular risk factors motivated 25.2%. A global health examination accounted for 22.8% of the requests. Multivariate analysis showed that the presence of symptoms (p < 0.001), presence of any cardiovascular risk factor (p = 0.002), hypertension (p < 0.001), diabetes (p = 0.002), and urgency (p < 0.001) were the main factors associated with the requests. The requests for electrocardiograms are predominantly for clinical reasons as a result of patients symptoms. The integration of expectations and beliefs of the patients is present in the decision-making process.

Original ArticleCardiovascular risk in overweight/obese and lean hypertensive patientsRisco cardiovascular em hipertensos com excesso de peso ‐ Obesos versus normoponderais

Introduction Obesity and hypertension have been identified as independent risk factors for cardiovascular disease. Nevertheless, the role of obesity in the development and progression of target-organ disease in hypertensive patients is controversial. The objective of this study was to assess the impact of body weight on cardiovascular risk factors, target-organ disease and global cardiovascular risk in hypertensive patients in a primary care setting.