Peter Tschudi

Physicians' Ability to Predict Patients' Adherence to Antihypertensive Medication in Primary Care

Addressing adherence to medication is essential and notoriously difficult. The purpose of this study was to determine physicians ability to predict patients adherence to antihypertensive therapy. Primary care physicians were asked to predict the adherence to medication of their hypertensive patients (n=42) by using a visual analogue scale (VAS) at the beginning of the study period. The patients were asked to report their adherence to medication using a VAS. The adherence was then monitored by using a Medical Event Monitoring System (MEMS) for 42±14 d. The means±SD (range) of MEMS measures for timing adherence, correct dosing, and adherence to medication were 82±27% (0 to 100%), 87±24percnt; (4 to 100%), and 94± 18% (4 to 108%), respectively. The physicians prediction of their patients adherence was 92± 15% The Spearman rank correlations between the physicians prediction and the MEMS measures of timing adherence, correct dosing, and adherence to medication was 0.42 (p=0.006), 0.47 (p=0.002), and –0.02 (p=0.888), respectively. The patients reported their own adherence to medication at 98±2% (range 83 to 100%). The Spearman correlations between the reported and actual behaviours were 0.27 (p=0.08) for timing adherence, 0.25 (p=0.12) for correct dosing, and 0.11 (p=0.51) for adherence to medication. The physicians ability to predict patients adherence to antihypertensive medication is limited and not accurate for identifying non-adherent patients in clinical practice. Even patients themselves are unable to give accurate reports of their own adherence to medication.

Management and outcome of severely elevated blood pressure in primary care A prospective observational study

OBJECTIVEnIn primary care the management of patients with acute severely elevated blood pressure (BP) is challenging. The aim of the study was to evaluate the initial management and outcome of patients presenting to their general practitioner (GP) with severe high blood pressure.nnnMETHODSnTwenty five general practitioners prospectively identified 164 patients presenting with severely elevated blood pressure (systolic BP >180 mm Hg and/or diastolic BP >110 mm Hg). At baseline, patients were categorised as having a hypertensive emergency, urgency or asymptomatic BP elevation. The therapeutic approach of the GPs was assessed and patient outcome at 12 month follow-up was analysed.nnnRESULTSnMedian age of 164 patents was 71 (range 22 to 97) years, 60 (37%) were male and 107 (65%) had pre-existing hypertension. Mean baseline systolic BP was 198 ± 16 (range 145 to 255) mm Hg, mean baseline diastolic BP was 101 ± 15 (range 60 to 130). In total, 99 (60%) of patients had asymptomatic BP elevation, 50 (31%) had hypertensive urgency, and 15 (9%) had a hypertensive emergency. Only around two thirds (61%) of patients were given immediate blood pressure lowering medication (most frequently calcium antagonists). Ten patients (6%) were immediately admitted to hospital. Systolic and diastolic BP declined significantly (p <0.01) between one and six hours after study inclusion (drop of systolic and diastolic BP, 24 ± 9 and 10 ± 1, respectively) and were significantly lower (p <0.01) at three month follow-up compared to the initial measurement (drop of systolic and diastolic BP, 37 ± 6 and 14 ± 4, respectively). On average systolic BP was still above target values after three months (148 ± 21). During 12 months of follow-up patients with hypertensive emergency, hypertensive urgency, and asymptomatic BP elevation experienced a cardiovascular event in 27% vs. 6% vs. 16%, of cases respectively (p = 0.17).nnnCONCLUSIONnThe majority of 164 patients who presented with acutely and severely elevated blood pressure (BP >180 +/or >110 mm Hg) to their GPs was asymptomatic, had pre-existing hypertension and was managed in GPs office unless a hypertensive emergency was present. At three month follow-up mean systolic BP was still above target values.

Discontinuation of secondary prevention medication after myocardial infarction - the role of general practitioners and patients.

BACKGROUNDnDespite the significant benefits of secondary prevention (SP) medication after acute myocardial infarction (MI), evidence suggests that these medications are neither consistently prescribed nor appropriately adhered to by patients. The aim of this study was to investigate the role of general practitioners (GPs) and patients regarding discontinuation of SP medication after MI and reasons for discontinuation.nnnMETHODSnIn this observational study, GPs of patients who had suffered acute MI provided information on discontinuation of SP medication 6 and 12 months after hospital discharge. A questionnaire-based approach was used (a) to assess the consistent use of SP medication after MI, (b) to determine reasons for stopping SP medication, (c) to quantify the involvement of GPs and patients regarding discontinuation, and (d) to analyse potential factors that are associated with discontinuation of medication.nnnRESULTSnOf 204 subjects 6 and 12 months after hospital discharge 83% and 75% patients, respectively, were still on recommended SP medication. Overall, one or more SP medications were stopped (53 medications) or modified (15 medications) in 52 (25%) patients. Adverse side effects were the main reason for stopping medication (63%). GPs reported being responsible for initiating discontinuation or modification more frequently than patients (62% vs 38%, p = 0.065).nnnCONCLUSIONnThe consistent use of evidence-based pharmacotherapy 6 and 12 months after myocardial infarction was adequate. Three out of four patients were still on recommended SP medication after 1 year of follow-up. Two-thirds of medication discontinuations were initiated by GPs, predominantly because of side effects.

Acute Cough Illness in General Practice - Predictive Value of Clinical Judgement and Accuracy of Requesting Chest X-Rays

The aim of the study was to evaluate the accuracy of GPs initial clinical judgement regarding presence or absence of pneumonia and to assess GPs strategy for requesting chest X-rays in patients presenting with acute cough. GPs were asked to rate their suspicion of pneumonia based on clinical assessment alone and to protocol their decision to perform chest X-rays in 212 consecutive patients. These judgements were compared to the final diagnosis as determined by chest X-ray or uneventful recovery (four weeks). After history taking and physical examination, GPs are highly accurate in judging which patients presenting with acute cough may have pneumonia (PPV 80% [95% CI 0,66-0,89]) or not (NPV 100% [95% CI 0,97-1,0]), and in which patients chest X-rays are required or not (spearmans rho 0,54, p<0,0001).

Primary care at Swiss universities - current state and perspective

BackgroundThere is increasing evidence that a strong primary care is a cornerstone of an efficient health care system. But Switzerland is facing a shortage of primary care physicians (PCPs). This pushed the Federal Council of Switzerland to introduce a multifaceted political programme to strengthen the position of primary care, including its academic role. The aim of this paper is to provide a comprehensive overview of the situation of academic primary care at the five Swiss universities by the end of year 2012.ResultsAlthough primary care teaching activities have a long tradition at the five Swiss universities with activities starting in the beginning of the 1980ies; the academic institutes of primary care were only established in recent years (2005 – 2009). Only one of them has an established chair. Human and financial resources vary substantially. At all universities a broad variety of courses and lectures are offered, including teaching in private primary care practices with 1331 PCPs involved. Regarding research, differences among the institutes are tremendous, mainly caused by entirely different human resources and skills.ConclusionSo far, the activities of the existing institutes at the Swiss Universities are mainly focused on teaching. However, for a complete academic institutionalization as well as an increased acceptance and attractiveness, more research activities are needed. In addition to an adequate basic funding of research positions, competitive research grants have to be created to establish a specialty-specific research culture.

When general practitioners don’t feel appreciated by their patients: prospective effects on well-being and work–family conflict in a Swiss Longitudinal Study

BACKGROUNDnImpaired well-being and high work-family conflict are critical issues among GPs. This research examined an understudied psychosocial risk factor for these outcomes, namely GPs perception that they invest more in the relationship with their patients than what they receive in return (i.e. lack of reward in their relationship with patients).nnnOBJECTIVEnTo test the effect of lack of reward as a risk factor for poor well-being and work-family conflict among GPs.nnnMETHODSnLongitudinal study (12 months time lag). 272 GPs in Switzerland [mean age 54.5 (SD = 8.3), 73% male] volunteered to participate in the study. 270 participants completed the baseline survey and 252 completed the follow-up survey. Of these, six retired between the baseline and the follow-up survey, resulting in a sample size of 246 participants at t2. Outcome measures were burnout, sleep problems, self-perceived health and work-family conflict.nnnRESULTSnStrength and direction of prospective effects were tested using cross-lagged models. Lack of reward was related to an increase in emotional exhaustion (β = 0.15), sleep problems (β = 0.16) and work-family conflict (β = 0.19) and a decrease in self-perceived health (β = -0.17). Effects on depersonalization and personal accomplishment were not significant. Regarding reversed effects of impaired well-being on lack of reward, emotional exhaustion (β = 0.14) and self-perceived health (β = -0.13) predicted future level of lack of reward.nnnCONCLUSIONnLack of reward by patients is a risk factor in GPs mental health.

[Teaching practice recommendations: prevention and screening].

The aim of this article is to provide guidance to family doctors on how to tutor students about effective screening and primary prevention. Family doctors know their patients and adapt national and international guidelines to their specific context, risk profile, sex and age as well as to the prevalence of the disorders under consideration. Three cases are presented to illustrate guideline use according to the level of evidence (for a 19-year-old man, a 60-year-old woman, and an 80-year-old man). A particular strength of family medicine is that doctors see their patients over the years. Thus they can progressively go through the various prevention strategies, screening, counselling and immunisation, accompanying their patients with precious advice for their health throughout their lifetime.