Wayne Putnam

Asthma in primary care: making guidelines work.

OBJECTIVE To determine the views of family physicians regarding selected asthma recommendations from a Canadian practice guideline and the supporting evidence, and to identify issues needing further development if family physicians are to find guideline recommendations to be truly useful clinical tools. SETTING Four urban communities in Nova Scotia, Prince Edward Island and New Brunswick. PARTICIPANTS Twenty community family physicians representing different practice settings, and varying according to age and sex, were recruited to participate. DATA COLLECTION Four focus groups were held, each lasting 2 h, at which recommendations from a published asthma guideline were presented for discussion on the applicability to their practices. The data were analyzed using a grounded theory method. RESULTS Physicians rely on clinical judgment in lieu of objective measures in diagnosing asthma and resist treating every exacerbation with steroids. They thought that the recommendations on smoking and patient education should have been stronger or more prominent. Patient noncompliance limits the usefulness of home peak flow measures. Topics such as allergy assessment and most pharmacological therapies triggered little discussion. DISCUSSION Asthma guideline developers and those interested in enhancing compliance with recommendations will need to attend to factors such as physician attitudes and beliefs on a variety of issues, including the use of objective measures and the availability of adequate resources to conduct the tests. Similarly, negative patient attitudes toward an increased use of corticosteroids suggest that a public education program would be most helpful regarding that group of recommendations.

Hypertension and type 2 diabetes: What family physicians can do to improve control of blood pressure - an observational study

BackgroundThe prevalence of type 2 diabetes is rising, and most of these patients also have hypertension, substantially increasing the risk of cardiovascular morbidity and mortality. The majority of these patients do not reach target blood pressure levels for a wide variety of reasons. When a literature review provided no clear focus for action when patients are not at target, we initiated a study to identify characteristics of patients and providers associated with achieving target BP levels in community-based practice.MethodsWe conducted a practice- based, cross-sectional observational and mailed survey study. The setting was the practices of 27 family physicians and nurse practitioners in 3 eastern provinces in Canada. The participants were all patients with type 2 diabetes who could understand English, were able to give consent, and would be available for follow-up for more than one year. Data were collected from each patients medical record and from each patient and physician/nurse practitioner by mailed survey. Our main outcome measures were overall blood pressure at target (< 130/80), systolic blood pressure at target, and diastolic blood pressure at target. Analysis included initial descriptive statistics, logistic regression models, and multivariate regression using hierarchical nonlinear modeling (HNLM).ResultsFifty-four percent were at target for both systolic and diastolic pressures. Sixty-two percent were at systolic target, and 79% were at diastolic target. Patients who reported eating food low in salt had higher odds of reaching target blood pressure. Similarly, patients reporting low adherence to their medication regimen had lower odds of reaching target blood pressure.ConclusionsWhen primary care health professionals are dealing with blood pressures above target in a patient with type 2 diabetes, they should pay particular attention to two factors. They should inquire about dietary salt intake, strongly emphasize the importance of reduction, and refer for detailed counseling if necessary. Similarly, they should inquire about adherence to the medication regimen, and employ a variety of patient-oriented strategies to improve adherence.

Factors Influencing the Management of Hypertension in Type 2 Diabetes

ABSTRACT OBJECTIVE To investigate the factors that influence the management of hypertension in patients with type 2 diabetes in a family practice setting. METHODS This was a qualitative study with a descriptive quantitative phase. In the quantitative phase, data were abstracted from the medical records of 50 randomly selected patients in 2 family medicine clinics. In the qualitative phase, individual interviews were conducted with 5 physicians and 7 patients. RESULTS Seventy percent of patients with type 2 diabetes were diagnosed with hypertension. Of those, the most recent blood pressure (BP) measurement was elevated for 57%. Qualitative analysis described discrepancies between patient and physician opinions regarding the inconvenience of frequent visits, objections to polypharmacy and preference for lifestyle modifications in initial management. CONCLUSION More effort is needed to lower BP in patients with type 2 diabetes. Physicians could improve the care of these patients by soliciting their views on common areas of misunderstanding related to the management of hypertension in type 2 diabetes.

Evidence-based cardiovascular care in the community: A population-based cross-sectional study

BackgroundIschaemic heart disease and congestive heart failure are common and important conditions in family practice. Effective treatments may be underutilized, particularly in women and the elderly. The objective of the study was to determine the rate of prescribing of evidence-based cardiovascular medications and determine if these differed by patient age or sex.MethodsWe conducted a two-year cross-sectional study involving all hospitals in the province of Nova Scotia, Canada. Subjects were all patients admitted with ischaemic heart disease with or without congestive heart failure between 15 October 1997 and 14 October 1999. The main measure was the previous outpatient use of recommended medications. Chi-square analyses followed by multivariate logistic regression analyses were used to examine age-sex differences.ResultsUsage of recommended medications varied from approximately 60% for beta-blockers and angiotensin converting enzyme (ACE) inhibitors to 90% for antihypertensive agents. Patients aged 75 and over were significantly less likely than younger patients to be taking any of the medication classes. Following adjustment for age, there were no significant differences in medication use by sex except among women aged 75 and older who were more likely to be taking beta-blockers than men in the same age group.ConclusionsThe use of evidence-based cardiovascular medications is rising and perhaps approaching reasonable levels for some drug classes. Family physicians should ensure that all eligible patients (prior myocardial infarction, congestive failure) are offered beta-blockers or ACE inhibitors.

Self-Reported Health Beliefs, Lifestyle and Health Behaviours in Community-Based Patients with Diabetes and Hypertension

OBJECTIVE This study describes self-reported health and lifestyle behaviours and health risk beliefs among community patients diagnosed with type 2 diabetes and hypertension. METHODS Patients with both type 2 diabetes and hypertension were recruited from community family practices across 3 Canadian Maritime provinces. Patients completed a survey targeting health risk beliefs, and health and lifestyle behaviours. Analyses examined differences in patient beliefs by age and sex, as well by health and lifestyle behaviour. RESULTS Overall, 90.8% of patients believed that controlling both blood pressure and blood glucose were important, particularly women (p<0.01), and 92.8% felt that having both conditions put them at high risk for cardiovascular problems. Older patients reported higher antihypertensive medication adherence (p<0.0001). Most (90.8%) believed that prescription drug use was most helpful for controlling blood pressure, and this belief was associated with medication adherence (p<0.0001). Overall, patients who believed in the benefits of a given lifestyle behaviour were more likely to demonstrate the behaviour. CONCLUSION The majority of patients surveyed were knowledgeable about their increased risk for cardiovascular problems. Patient lifestyle behaviours tended to mirror their health beliefs. These results provide important insight into the health beliefs and lifestyle behaviours of patients who receive the majority of their care in the community.

Qualitative Perspectives on a Facilitated Change in Provincial Pharmacare Coverage

Background: During 2000, Nova Scotias Department of Health implemented policy changes and educational interventions to encourage a switch from wet nebulization therapy to dry-dose delivery systems. The policy changes applied to beneficiaries of the Nova Scotia Pharmacare Programs, while the educational interventions had a broader provincial perspective. Methods: Researchers from Dalhousie Universitys Department of Family Medicine subsequently interviewed family physicians, pharmacists, and other health professionals to gather their views on the initiative. A single researcher (PLT) conducted interviews in the summer of 2001 in two settings. Interviews were audiotaped and transcribed. Analysis was guided by a grounded theory approach and facilitated by the use of QSR N5, a software program designed for computer-assisted qualitative data analysis. Results: The results are discussed in several categories, including the role of evidence, change strategies, user devotion to older delivery systems, and health care provider perspectives on policy change. Conclusion: Health care professionals interviewed agreed that this was a well-designed initiative in many respects. Participants identified several key elements that offer insights for future policy-implementation design, execution, and evaluation.