Marco Zoller

Barriers to apply cardiovascular prediction rules in primary care: a postal survey

BackgroundAlthough cardiovascular prediction rules are recommended by guidelines to evaluate global cardiovascular risk for primary prevention, they are rarely used in primary care. Little is known about barriers for application. The objective of this study was to evaluate barriers impeding the application of cardiovascular prediction rules in primary prevention.MethodsWe performed a postal survey among general physicians in two Swiss Cantons by a purpose designed questionnaire.Results356 of 772 dispatched questionnaires were returned (response rate 49.3%). About three quarters (74%) of general physicians rarely or never use cardiovascular prediction rules. Most often stated barriers to apply prediction rules among rarely- or never-users are doubts concerning over-simplification of risk assessment using these instruments (58%) and potential risk of (medical) over-treatment (54%). 57% report that the numerical information resulting from prediction rules is often not helpful for decision-making in practice.ConclusionIf regular application of cardiovascular prediction rules in primary care is in demand additional interventions are needed to increase acceptance of these tools for patient management among general physicians.

Simple functional performance tests and mortality in COPD

Exercise tests are important to characterise chronic obstructive pulmonary disease patients and predict their prognosis, but are often not available outside of rehabilitation or research settings. Our aim was to assess the predictive performance of the sit-to-stand and handgrip strength tests. The prospective cohort study in Dutch and Swiss primary care settings included a broad spectrum of patients (n=409) with Global Initiative for Chronic Obstructive Lung Disease stages II to IV. To assess the association of the tests with outcomes, we used Cox proportional hazards (mortality), negative binomial (centrally adjudicated exacerbations) and mixed linear regression models (longitudinal health-related quality of life) while adjusting for age, sex and severity of disease. The sit-to-stand test was strongly (adjusted hazard ratio per five more repetitions of 0.58, 95% CI 0.40–0.85; p=0.004) and the handgrip strength test moderately strongly (0.84, 95% CI 0.72–1.00; p=0.04) associated with mortality. Both tests were also significantly associated with health-related quality of life but not with exacerbations. The sit-to-stand test alone was a stronger predictor of 2-year mortality (area under curve 0.78) than body mass index (0.52), forced expiratory volume in 1 s (0.61), dyspnoea (0.63) and handgrip strength (0.62). The sit-to-stand test may close an important gap in the evaluation of exercise capacity and prognosis of chronic obstructive pulmonary disease patients across practice settings. The 1-min sit-to-stand test predicts mortality in COPD patients and can easily be implemented across practice settings http://ow.ly/mxrPx

No Association of 25-Hydroxyvitamin D With Exacerbations in Primary Care Patients With COPD

BACKGROUND Cross-sectional studies suggest an association of 25-hydroxyvitamin D with exacerbations in patients with COPD, but longitudinal evidence from cohort studies is scarce. The aim of this study was to assess the association of serum 25-hydroxyvitamin D with exacerbations and mortality in primary care patients with COPD. METHODS In the main analysis, we included 356 patients with COPD (GOLD [Global Initiative for Chronic Obstructive Lung Disease] stages II-IV, free from exacerbations for ≥ 4 weeks) from a prospective cohort study in Dutch and Swiss primary care settings. We used negative binomial and Cox regression to assess the association of 25-hydroxyvitamin D with (centrally adjudicated) exacerbations and mortality, respectively. RESULTS Baseline mean ± SD serum 25-hydroxyvitamin D concentration was 15.5 ± 8.9 ng/dL, and 274 patients (77.0%) had 25-hydroxyvitamin D deficiency (< 20 ng/dL). Compared with patients with severe 25-hydroxyvitamin D deficiency (< 10 ng/dL, n = 106 [29.8%]), patients with moderately deficient (10-19.99 ng/dL, n = 168 [47.2%]) and insufficient (20-29.99 ng/dL, n = 58 [16.3%]) concentrations had the same risk for exacerbations (incidence rate ratio, 1.01 [95% CI, 0.77-1.57] vs 1.00 [95% CI, 0.62-1.61], respectively). In patients with desirable concentrations (> 30 ng/dL, n = 24 [6.7%]), the risk was lower, although not significantly (incidence rate ratio, 0.72 [95% CI, 0.37-1.42]). In patients taking vitamin D supplements, using different cutoffs for 25-hydroxyvitamin D or competing risk models did not materially change the results. We did not find a statistically significant association of 25-hydroxyvitamin D concentration with mortality. CONCLUSIONS This longitudinal study in a real-world COPD population that carefully minimized misclassification of exacerbations and the influence of confounding did not show an association of 25-hydroxyvitamin D with exacerbations and mortality.

Characteristics of Dutch and Swiss primary care COPD patients – baseline data of the ICE COLD ERIC study

Introduction International Collaborative Effort on Chronic Obstructive Lung Disease: Exacerbation Risk Index Cohorts (ICE COLD ERIC) is a prospective cohort study with chronic obstructive pulmonary disease (COPD) patients from Switzerland and The Netherlands designed to develop and validate practical COPD risk indices that predict the clinical course of COPD patients in primary care. This paper describes the characteristics of the cohorts at baseline. Material and methods Standardized assessments included lung function, patient history, self-administered questionnaires, exercise capacity, and a venous blood sample for analysis of biomarkers and genetics. Results A total of 260 Dutch and 151 Swiss patients were included. Median age was 66 years, 57% were male, 38% were current smokers, 55% were former smokers, and 76% had at least one and 40% had two or more comorbidities with cardiovascular disease being the most prevalent one. The use of any pulmonary and cardiovascular drugs was 84% and 66%, respectively. Although lung function results (median forced expiratory volume in 1 second [FEV1] was 59% of predicted) were similar across the two cohorts, Swiss patients reported better COPD-specific health-related quality of life (Chronic Respiratory Questionnaire) and had higher exercise capacity. Discussion COPD patients in the ICE COLD ERIC study represent a wide range of disease severities and the prevalence of multimorbidity is high. The rich variation in these primary care cohorts offers good opportunities to learn more about the clinical course of COPD.

The FIRE project: a milestone for research in primary care in Switzerland.

QUESTIONS UNDER STUDY/PRINCIPLES Research is scarce where most patients are found. One of the main reasons is the difficulty in extracting data from traditionally conducted paper-based medical records. Thus, until now most existing patient records have originated from invoicing-tools. Endeavours to truly reflect a doctors consultation have been rare. FIRE (Family Medicine ICPC-Research using Electronic Medical Records) is an ambitious project to establish a proper knowledge base in primary care by using the ongoing implementation of EPR (electronic patient records). FIRE will enable many questions on epidemiology and performance within the PC (primary care) setting to be answered. METHODS GPs (general practitioners) throughout Switzerland working with EPR were eligible for participation. Workshops were held to train and standardise ICPC-coding (International Classification of Primary Care), a classification system especially designed for the PC-setting. The recorded data included administrative information on the GP and patient, vital signs, ICPC codes, laboratory analysis and medication. Data exporter software was developed for extracting anonymised data automatically from the EPR onto a database for further statistical analysis. RESULTS From 1.1.2009 until the beginning of April 2010 24 GPs were successfully recruited providing standardised information on 127,922 consultations in 29,398 patients and 159,956 medical problems according to the ICPC-2 classification. CONCLUSION The project proves the feasibility of standardised ongoing collection of research data embedded in routine clinical practice. FIRE provides a unique database for research in PC and highlights the potential of broad implementation of EPR in a PC-setting. Studies resulting from the ongoing project have the potential to assess the quality of care provided by GPs.

A decision aid to rule out pneumonia and reduce unnecessary prescriptions of antibiotics in primary care patients with cough and fever

BackgroundPhysicians fear missing cases of pneumonia and treat many patients with signs of respiratory infection unnecessarily with antibiotics. This is an avoidable cause for the increasing worldwide problem of antibiotic resistance. We developed a user-friendly decision aid to rule out pneumonia and thus reduce the rate of needless prescriptions of antibiotics.MethodsThis was a prospective cohort study in which we enrolled patients older than 18 years with a new or worsened cough and fever without serious co-morbidities. Physicians recorded results of a standardized medical history and physical examination. C-reactive protein was measured and chest radiographs were obtained. We used Classification and Regression Trees to derive the decision tool.ResultsA total of 621 consenting eligible patients were studied, 598 were attending a primary care facility, were 48 years on average and 50% were male. Radiographic signs for pneumonia were present in 127 (20.5%) of patients. Antibiotics were prescribed to 234 (48.3%) of patients without pneumonia. In patients with C-reactive protein values below 10 μg/ml or patients presenting with C-reactive protein between 11 and 50 μg/ml, but without dyspnoea and daily fever, pneumonia can be ruled out. By applying this rule in clinical practice antibiotic prescription could be reduced by 9.1% (95% confidence interval (CI): 6.4 to 11.8).ConclusionsFollowing validation and confirmation in new patient samples, this tool could help rule out pneumonia and be used to reduce unnecessary antibiotic prescriptions in patients presenting with cough and fever in primary care. The algorithm might be especially useful in those instances where taking a medical history and physical examination alone are inconclusive for ruling out pneumonia

The German version of the Assessment of Chronic Illness Care: instrument translation and cultural adaptation.

BACKGROUND In Switzerland, there is a dearth of information on the extent to which patients with chronic illnesses receive care congruent with the Chronic Care Model (CCM). To drive quality improvement programmes, it is necessary to have practical assessment tools in the countrys own language to evaluate the delivery of CCM activities. METHODS German translation and adaptation of the original Assessment of Chronic Illness Care (ACIC). We followed a sequential forward and backward translation approach. In a multidisciplinary committee review the original English version and the translations were compared, instructions and formats modified and cross-cultural equivalences verified. The second version was pre-tested and multidisciplinary group discussion led to the final version which aimed to create a comprehensive culturally adapted translation capturing the original idea of the items rather than a direct one to one translation. RESULTS Difficulties encountered during the translation process consisted in the difference of health care settings and health care organization in Switzerland and USA.The adapted German version was delivered to a managed care organization in the city of Zurich to test the initial use for diabetes care. The average ACIC subscale scores were: organization of the health care delivery system: mean (m) = 7.31 (SD = 0.79), community linkages: m = 3.78 (SD = 1.09), self-management support: m = 4.88 (SD = 1.21), decision support: m = 4.79 (SD = 1.16), delivery system design: m = 5.56 (SD = 1.28) and clinical information systems: m = 4.50 (SD = 2.69). Overall, the ACIC subscale scores were comparable with the scores of the original testing. CONCLUSION After cultural adaptations the German version of the ACIC is applicable as a tool to guide quality improvement in chronic illness care in German speaking countries in Europe.

Attitudes, barriers and facilitators for health promotion in the elderly in primary care A qualitative focus group study

QUESTIONS UNDER STUDY Effective health promotion is of great importance from clinical as well as from public health perspectives and therefore should be encouraged. Especially regarding health promotion in the elderly, general practitioners (GPs) have a key role. Nevertheless, evidence suggests a lack of health promotion by GPs, especially in this age group. The aim of our study was to assess self-perceived attitudes, barriers and facilitators of GPs to provide health promotion in the elderly. METHODS We performed a qualitative focus group study with 37 general practitioners. The focus group interviews were recorded digitally, transcribed literally and analysed with ATLAS.ti, a software program for qualitative text analysis. RESULTS Among the participating GPs, definitions of health promotion varied widely and the opinions regarding its effectiveness were very heterogeneous. The two most important self-perceived barriers for GPs to provide health promotion in the elderly were lack of time and insufficient reimbursement for preventive and health promotion advice. As intervention to increase health promotion in the elderly, GPs suggested, for example, integration of health promotion into under and postgraduate training. Changes at the practice level such as involving the practice nurse in health promotion and counselling were discussed very controversially. CONCLUSION Health promotion, especially in the elderly, is crucial but in the opinion of the GPs we involved in our study, there is a gap between public health requirements and the reimbursement system. Integration of health promotion in medical education may be needed to increase knowledge as well as attitudes of GPs regarding this issue.

COPD: more than respiratory

1 Patel A; ADVANCE Collaborative Group. Eff ect of a fi xed combination of perindopril and indapamide on macrovascular and microvascular outcomes in patients with type 2 diabetes mellitus (the ADVANCE trial): a randomised controlled trial. Lancet 2007; 370: 829–40. 2 PROGRESS Collaborative Group. Randomised trial of a perindopril-based blood-pressure lowering regimen among 6105 individuals with previous stroke or transient ischaemic attack. Lancet 2001; 358: 1033–41.

Utilisation of information technologies in ambulatory care in Switzerland

BACKGROUND The importance of electronic medical records for the healthcare system is well documented. IT enables easy storage, communication and decision support and can provide important tools in the care of chronically ill patients in the form of a reminder system. METHODS A questionnaire was developed and send out to 1200 physicians extracted from the official data base. After four weeks the non-responders received a written reminder. Data collection started in December 2007 and was completed in February 2008. RESULTS 719 questionnaires were received back, representing a response rate of 59.9%. The data revealed a significant underuse of electronic medical records (EMRs) and IT compared to other European countries. Smaller practices, older physicians and especially primary care physicians tended to use less EMR. Only 10.2% of all physicians declared an interest in considering investment in IT in the next three years, 66.9% expressly denied wishing to do so. The most important barriers were the costs, the unclear benefit and a feared worsening of the doctor-patient-communication during consultation. CONCLUSION IT and especially EMRs are underused in daily ambulatory care in Switzerland. To increase the use of EMRs, several approaches could be helpful. First of all, the benefit of EMRs in daily routine care have to be increased as, for example, by decision support systems, tools to avoid pharmaceutical interactions and reminder systems to enable a proactive treatment of chronically ill patients. Furthermore, adequate approaches to offer appropriate reimbursement for the financial investments have to considered such as an additional payment for electronically generated, evidence based quality indicators.