Peter Frey

Physical Activity and Risk of Bleeding in Elderly Patients Taking Anticoagulants

Although the possibility of bleeding during anticoagulant treatment may limit patients from taking part in physical activity, the association between physical activity and anticoagulation‐related bleeding is uncertain.

From chronic conditions to relevance in multimorbidity: a four-step study in family medicine

BACKGROUNDnChronic conditions and multimorbidity (MM) are major concerns in family medicine (FM).nnnOBJECTIVESnBased on the International Classification of Primary Care, Second Edition (ICPC-2), this study aimed to list (i)the chronic conditions and (ii)those most relevant to MM in FM.nnnMETHODSnA panel of FM experts used a four-step process to identify chronic conditions among ICPC-2 items and list chronic conditions most relevant in MM. They also evaluated the importance of eight criteria, previously identified in the literature, for characterizing chronic conditions. Step one involved a focus group of five experts. Steps two, three and four involved 10, 25 and 25 experts, respectively. They rated ICPC-2 items via an online questionnaire using a Likert scale from 1 (never chronic/irrelevant in MM) to 9 (always chronic/always relevant in MM). A median value cut-off was used to evaluate appropriateness of each item and the inter-percentile range adjusted for symmetry to determine the agreement/disagreement between experts. In parallel, in steps two and three, experts rated the importance of eight criteria to characterize chronic conditions, using a Likert scale from 1 (strongly disagree) to 9 (strongly agree).nnnRESULTSnOf the ICPC-2s 686 items, experts identified 139 chronic conditions, of which 75 were deemed most relevant in the context of MM. Four of the eight criteria were retained as important to define chronic conditions: duration, sequelae, recurrence/pattern and the diagnosis itself.nnnCONCLUSIONnUsing this list of 75 chronic conditions most relevant in the context of MM should enhance the validity of studies of MM in FM.

Multimorbidity in primary care: protocol of a national cross-sectional study in Switzerland

Introduction With the ageing of the population and the general improvement of care, an increasing number of people are living with multiple chronic health conditions or ‘multimorbidity’. Multimorbidity often implies multiple medical treatments. As a consequence, the risk of adverse events and the time spent by patients for their treatments increase exponentially. In many cases, treatment guidelines traditionally defined for single conditions are not easily applicable. Primary care for individuals with multimorbidity requires complex patient-centred care and good communication between the patient and the general practitioner (GP). This often includes prioritising among the different chronic conditions. Methods and analysis The main objectives of this study are to describe the burden related to multimorbidity (disease-related burden and burden of treatment) in primary care and to identify the factors influencing it. Other objectives include evaluating patients’ perception of treatment burden and quality of life, assessing factors influencing that perception, and investigating prioritisation in the management of multimorbidity from the perspectives of GPs and patients. For this cross-sectional study, patient enrolment will take place in GPs private practices across Switzerland. A convenient sample of 100 GPs will participate; overall, 1000 patients with at least three chronic health conditions will be enrolled. Data will be collected as paper-based questionnaires for GPs and delayed telephone interview questionnaires for patients. GPs will provide demographic and practice-related data. In addition, each GP will complete a paper-based questionnaire for each patient that they enrol. Each patient will complete a telephone interview questionnaire. Ethics and dissemination This study has been approved by the research ethics committee of Canton Vaud, Switzerland (Protocol 315/14). The results of the study will be reported in international peer-reviewed journals.

Multimorbidity and patterns of chronic conditions in a primary care population in Switzerland: a cross-sectional study.

Objective To characterise in details a random sample of multimorbid patients in Switzerland and to evaluate the clustering of chronic conditions in that sample. Methods 100 general practitioners (GPs) each enrolled 10 randomly selected multimorbid patients aged ≥18 years old and suffering from at least three chronic conditions. The prevalence of 75 separate chronic conditions from the International Classification of Primary Care-2 (ICPC-2) was evaluated in these patients. Clusters of chronic conditions were studied in parallel. Results The final database included 888 patients. Mean (SD) patient age was 73.0 (12.0) years old. They suffered from 5.5 (2.2) chronic conditions and were prescribed 7.7 (3.5) drugs; 25.7% suffered from depression. Psychological conditions were more prevalent among younger individuals (≤66 years old). Cluster analysis of chronic conditions with a prevalence ≥5% in the sample revealed four main groups of conditions: (1) cardiovascular risk factors and conditions, (2) general age-related and metabolic conditions, (3) tobacco and alcohol dependencies, and (4) pain, musculoskeletal and psychological conditions. Conclusion Given the emerging epidemic of multimorbidity in industrialised countries, accurately depicting the multiple expressions of multimorbidity in family practices’ patients is a high priority. Indeed, even in a setting where patients have direct access to medical specialists, GPs nevertheless retain a key role as coordinators and often as the sole medical reference for multimorbid patients.

Symptomatic treatment of uncomplicated lower urinary tract infections in the ambulatory setting: randomised, double blind trial.

Objective To investigate whether symptomatic treatment with non-steroidal anti-inflammatory drugs (NSAIDs) is non-inferior to antibiotics in the treatment of uncomplicated lower urinary tract infection (UTI) in women, thus offering an opportunity to reduce antibiotic use in ambulatory care. Design Randomised, double blind, non-inferiority trial. Setting 17 general practices in Switzerland. Participants 253 women with uncomplicated lower UTI were randomly assigned 1:1 to symptomatic treatment with the NSAID diclofenac (n=133) or antibiotic treatment with norfloxacin (n=120). The randomisation sequence was computer generated, stratified by practice, blocked, and concealed using sealed, sequentially numbered drug containers. Main outcome measures The primary outcome was resolution of symptoms at day 3 (72 hours after randomisation and 12 hours after intake of the last study drug). The prespecified principal secondary outcome was the use of any antibiotic (including norfloxacin and fosfomycin as trial drugs) up to day 30. Analysis was by intention to treat. Results 72/133 (54%) women assigned to diclofenac and 96/120 (80%) assigned to norfloxacin experienced symptom resolution at day 3 (risk difference 27%, 95% confidence interval 15% to 38%, P=0.98 for non-inferiority, P<0.001 for superiority). The median time until resolution of symptoms was four days in the diclofenac group and two days in the norfloxacin group. A total of 82 (62%) women in the diclofenac group and 118 (98%) in the norfloxacin group used antibiotics up to day 30 (risk difference 37%, 28% to 46%, P<0.001 for superiority). Six women in the diclofenac group (5%) but none in the norfloxacin group received a clinical diagnosis of pyelonephritis (P=0.03). Conclusion Diclofenac is inferior to norfloxacin for symptom relief of UTI and is likely to be associated with an increased risk of pyelonephritis, even though it reduces antibiotic use in women with uncomplicated lower UTI. Trial registration ClinicalTrials.gov NCT01039545.

Multimorbidity and quality of preventive care in swiss university primary care cohorts

Background Caring for patients with multimorbidity is common for generalists, although such patients are often excluded from clinical trials, and thus such trials lack of generalizability. Data on the association between multimorbidity and preventive care are limited. We aimed to assess whether comorbidity number, severity and type were associated with preventive care among patients receiving care in Swiss University primary care settings. Methods We examined a retrospective cohort composed of a random sample of 1,002 patients aged 50–80 years attending four Swiss university primary care settings. Multimorbidity was defined according to the literature and the Charlson index. We assessed the quality of preventive care and cardiovascular preventive care with RAND’s Quality Assessment Tool indicators. Aggregate scores of quality of provided care were calculated by taking into account the number of eligible patients for each indicator. Results Participants (mean age 63.5 years, 44% women) had a mean of 2.6 (SD 1.9) comorbidities and 67.5% had 2 or more comorbidities. The mean Charlson index was 1.8 (SD 1.9). Overall, participants received 69% of recommended preventive care and 84% of cardiovascular preventive care. Quality of care was not associated with higher numbers of comorbidities, both for preventive care and for cardiovascular preventive care. Results were similar in analyses using the Charlson index and after adjusting for age, gender, occupation, center and number of visits. Some patients may receive less preventive care including those with dementia (47%) and those with schizophrenia (35%). Conclusions In Swiss university primary care settings, two thirds of patients had 2 or more comorbidities. The receipt of preventive and cardiovascular preventive care was not affected by comorbidity count or severity, although patients with certain comorbidities may receive lower levels of preventive care.

Prodromal schizophrenia in primary care: a randomised sensitisation study

BACKGROUNDnGPs are often the first point of contact for patients with prodromal schizophrenia. Early intervention, and therefore early detection, of schizophrenia is pivotal for the further disease course. However, recent studies have revealed that, due to its low prevalence in general practice and its insidious features, prodromal schizophrenia often remains unnoticed.nnnAIMnTo test whether a repeated sensitisation method using clinical vignettes can improve diagnostic knowledge of GPs.nnnDESIGN OF STUDYnPostal survey using anonymous questionnaires. Repeated sensitisation model using clinical vignettes.nnnSETTINGnGPs in three distinct regions in Switzerland covering a general population of 1.43 million.nnnMETHODnThe study was conducted between September 2008 and October 2009. Questionnaires were sent to 1138 GPs at baseline, and at 6 and 12 months. After randomisation, 591 GPs were sensitised at 1, 3, and 5 months, while no sensitisation was carried out in the remaining 547 GPs.nnnRESULTSnThe overall response rate was 66% (750 GPs). Sensitised GPs demonstrated a highly significant increase in diagnostic knowledge at 6 and at 12 months when compared to their own baseline knowledge scores and also to non-sensitised GPs (P<0.001). In particular, awareness of insidious features, such as functional decline and social withdrawal as signs of prodromal schizophrenia, accounted for this effect.nnnCONCLUSIONnTheoretical knowledge of prodromal schizophrenia among GPs can successfully be increased by repeated sensitisation models using clinical vignettes.

General practitioner teachers' job satisfaction and their medical students' wish to join the field - a correlational study.

BackgroundThere will be increasing competition for young physicians worldwide as more and more physicians retire. While enthusiasm towards GP work is important for GP teachers as role models, satisfaction within the profession has declined. This study aims to determine if medical students’ desire to become GPs is related to the job satisfaction of their teaching GPs and explore the factors tied to this job satisfaction.MethodsIn this cross-sectional, correlational study, teaching GPs of the University of Bern and the fourth year medical students completing internships with them filled in separate questionnaires.ResultsWhether or not the GP teacher is perceived by a student to be satisfied with her/his job is correlated to that student’s satisfaction with the internship, which in turn, is correlated with student’s wish to be a GP after the internship. Results show which factors are most related to GP job satisfaction and the effect of working hours and their composition.ConclusionsMedical students’ perception of their GP teachers’ job satisfaction positively affect their wish to become GPs, and their satisfaction with their internships adds to this. Enhancing the positive aspects of GP work, such as recognition, and improving negative ones, such as administrative duties, are necessary to attract medical students into the GP field.

International variation in GP treatment strategies for subclinical hypothyroidism in older adults: a case-based survey

BACKGROUNDnThere is limited evidence about the impact of treatment for subclinical hypothyroidism, especially among older people.nnnAIMnTo investigate the variation in GP treatment strategies for older patients with subclinical hypothyroidism depending on country and patient characteristics.nnnDESIGN AND SETTINGnCase-based survey of GPs in the Netherlands, Germany, England, Ireland, Switzerland, and New Zealand.nnnMETHODnThe treatment strategy of GPs (treatment yes/no, starting-dose thyroxine) was assessed for eight cases presenting a woman with subclinical hypothyroidism. The cases differed in the patient characteristics of age (70 versus 85 years), vitality status (vital versus vulnerable), and thyroid-stimulating hormone (TSH) concentration (6 versus 15 mU/L).nnnRESULTSnA total of 526 GPs participated (the Netherlands n = 129, Germany n = 61, England n = 22, Ireland n = 21, Switzerland n = 262, New Zealand n = 31; overall response 19%). Across countries, differences in treatment strategy were observed. GPs from the Netherlands (mean treatment percentage 34%), England (40%), and New Zealand (39%) were less inclined to start treatment than GPs in Germany (73%), Ireland (62%), and Switzerland (52%) (P = 0.05). Overall, GPs were less inclined to start treatment in 85-year-old than in 70-year-old females (pooled odds ratio [OR] 0.74 [95% confidence interval [CI] = 0.63 to 0.87]). Females with a TSH of 15 mU/L were more likely to get treated than those with a TSH of 6 mU/L (pooled OR 9.49 [95% CI = 5.81 to 15.5]).nnnCONCLUSIONnGP treatment strategies of older people with subclinical hypothyroidism vary largely by country and patient characteristics. This variation underlines the need for a new generation of international guidelines based on the outcomes of randomised clinical trials set within primary care.

Emergency telephone consultations: a new course for medical students

Background:u2002 Using the telephone for consultations is now common practice. Although there is a clear need for specific training for telephone consultations, it is uncommon for it to be taught in medical school.