PALLIATIVE CARE OF PATIENT WITH GASTROINTESTINAL CANCER IN FAMILY MEDICINE

Palijativna skrb je potpuna skrb za bolesnika čiju bolest više nije moguće aktivno liječiti. Svrha palijativne skrbi je kontrola simptoma, produženje života uz postizanje najveće moguće kvalitete života za bolesnike i članove njihovih obitelji. U završnom razdoblju bolesti bolesnici 90 % vremena zadnje godine života provode u svom domu u skrbi obiteljskog liječnika i njegovih suradnika te obitelji bolesnika. Bolesnici koji boluju od raka u posljednja tri mjeseca života imaju prosječno 11,9 simptoma. Najčešće su prisutni simptomi probavnog trakta te bol. Rast i širenje raka kao i poduzeti terapijski postupci su najvažniji uzroci simptoma. Najčešći simptomi u bolesnika s rakom probavnog sustava su mučnina, povraćanje, konstipacija, bol, kaheksija i anoreksija te psihološki problemi. Ovi najčešći, ali i drugi simptomi bit će različitog intenziteta i pojavnosti ovisno o sijelu i agresivnosti raka probavnog sustava, oblika liječenja te kondicije bolesnika. Bolesnici s uznapredovalim rakom preživljavaju sve dulje i svi zdravstveni profesionalci uključeni u skrb bolesnika trebaju imati sve više znanja i vještina nužnih za učinkovito suzbijanje raznolikih simptoma. Koordinacija, organizacija i provođenje palijativne skrbi u obiteljskoj medicini kada se veliki dio skrbi pruža u domu bolesnika je jedan od najkompleksnijih zadataka liječnika obiteljske medicine Taj zadatak zahtijeva od liječnika obiteljske medicine specifi čna znanja i vještine kako bi znao i mogao učinkovito pomoći u kontroli brojnih simptoma te pružiti primjerenu potporu bolesniku i njegovoj obitelji. Komunikacija između liječnika i bolesnika koji boluje od uznapredovalog raka probavnog sustava je temeljni aspekt skrbi. Kvaliteta komunikacije značajno utječe na tok liječenja, dobrobit bolesnika i njegove obitelji, odluke o izboru liječenja i suradljivost u liječenju te na planiranje skrbi u budućnosti. U zbrinjavanju bolesnika s uznapredovalim rakom probavnog sustava liječnik obiteljske medicine treba osigurati holistički pristup te uvažavati bolesnika kao osobu i poštivati njegove odluke.Palliative care is defi ned as the care for patients whose disease is not responsive to curative treatment. The goals of palliative care are symptom control, life prolongation and enabling the best possible quality of life for patients and their families. For most patients with an advanced progressive incurable disease, 90% of care in their last year of life is provided at home by family physician and his team and patient family. Patients suffering from cancer have a mean of of 11.9 symptoms in the last three months of life. The most common symptoms are digestive tract symptoms and pain. The growth and spread of cancer, as well as the therapeutic procedures applied are the most important causes of symptoms. The most common symptoms in patients with cancer of digestive system are nausea, vomiting, constipation, pain, cachexia, anorexia, and psychological problems. These most common symptoms and many others will be of varying intensity and appearance depending on localization and aggressiveness of digestive system cancer, modality of treatment and patient condition. Patients with advanced cancer have longer survival and all health care professionals involved in the care of patients should have more knowledge and skills necessary to effectively treat various symptoms. Coordination, organization and implementation of palliative care in family medicine, when large part of care is provided at patient home, are one of the most complex tasks of family physician. This task requires a family practitioner with specifi c knowledge and skills to know how effectively control a number of symptoms and to provide adequate support to the patient and his family. Communication between doctor and patient suffering from advanced cancer of digestive system is a fundamental aspect of care. The quality of communication signifi cantly affects the course of treatment, the benefi t to patients and their families, the choice of treatment and adherence to treatment, as well as care planning. In the management of patients with advanced cancer of the digestive system, family physician should use holistic approach and respect the patient as a person and his decision

CARE QUALITY FOR PATIENTS WITH CORONARY ARTERY DISEASE IN FAMILY MEDICINE - GUIDELINE IMPLEMENTATION BY TAKING A GLANCE AT THE RISK FACTORS

Uvod: Bolesnici s koronarnom bolešću su velik izazov u skrbi liječnika obiteljske medicine (LOM) zbog brojnih komorbiditeta te primjene mjera sekundarne prevencije kojima se prate i istovremeno korigiraju rizični čimbenici koji se odnose na bolesnika, njegovu okolinu i stil života. Cilj: Istražiti uspješnost LOM-a u primjeni mjera sekundarne prevencije kardiovaskularnih bolesti i pronaći moguće rješenje za poboljšanje kvalitete skrbi. Ispitanici i metode: Opservacijsko istraživanje provedeno je 2017. godine u devet specijalističkih ordinacija obiteljske medicine diljem Hrvatske, a uključivalo je 169 bolesnika koji su ili preboljeli infarkt miokarda i/ili su bili podvrgnuti perkutanoj koronarnoj intervenciji i/ili operaciji aortokoronarnog premoštenja. Praćene su vrijednosti krvnog tlaka, LDL kolesterola i indeksa tjelesne mase, a ispitivano je pridržavanje poželjnih oblika ponašanja (nepušenje, tjelesna aktivnost, pravilna prehrana, redovno uzimanje dokazano djelotvornih lijekova) te prilagodba novom stilu života koja je mjerena Likertovom ljestvicom (1-5) kao i zadovoljstvo liječnika preglednošću elektroničkog zdravstvenog zapisa. Rezultati: Zadovoljavajuće vrijednosti arterijskog tlaka postignute su u 63,2 % ispitanika, razinu LDL kolesterola prema smjernicama imalo je 19,4 %, dok je 25,3 % ispitanika imalo uredan indeks tjelesne mase; 25,1 % ispitanika je i dalje pušilo, dok je 43,2 % ispitanika konzumiralo alkohol. Prehrambene navike promijenilo je 63,7 % ispitanika, a 63,4 % je povećalo svoju tjelesnu aktivnost. LOM je u većini slučajeva proveo savjetovanje oko promjene životnog stila nakon koronarnog incidenta. Liječnici su većinom bili zadovoljni sadržajem i količinom podataka u elektroničkom zdravstvenom zapisu, ali ne i njihove upotrebljivosti u svakodnevnoj, vremenski ograničenoj konzultaciji s bolesnikom. Osmišljeno rješenje u programu Adobe Illustrator® omogućilo bi i olakšalo bolju preglednost rizičnih čimbenika i time bi moglo imati utjecaja na učinkovitiju kontrolu provođenja mjera sekundarne prevencije. Zaključak: Skrb za bolesnike s koronarnom bolešću u obiteljskoj medicini je vrlo kompleksna, a dio kompleksnosti se odnosi na primjenu mjera sekundarne prevencije koje su od vitalne važnosti. Zbog toga je potrebno planirati i osigurati dovoljno vremena za konzultaciju s takvim bolesnicima kako bi se dobio uvid u kontrolu rizičnih čimbenika i pravovremeno učinile promjene sukladno važećim smjernicama. Rezultati istraživanja pokazali su da se u bolesnika svi rizični čimbenici ne nalaze unutar preporučenih vrijednosti te da je jedan od mogućih razloga tome što ne postoji njihov pregledan prikaz u elektroničkom zdravstvenom zapisu. Kvalitetnija skrb mogla bi se postići kada bi postojalo jasno vizualno rješenje stanja rizičnih čimbenika koje je u ovom radu osmišljeno i predloženo u obliku slika koje bi LOM-u dale brzi uvid u “profi l” bolesnika te poboljšale učinkovitost svake konzultacije s obzirom na njeno kratko vremensko ograničenje u svakodnevnim uvjetima rada u ordinacijama obiteljske medicine.Introduction: Patients with coronary artery disease represent a challenge in each family medicine practice because of many comorbidities and the application of secondary prevention measures which represent a tool for tracking and simultaneously correcting risk factors related to the patient, his surroundings and lifestyle. Objective: Explore the effectiveness of family medicine specialists in applying secondary prevention measures in cardiovascular diseases and to find a solution for improving quality of care. Participants and Methods: This observational study, was conducted in 2017. under nine specialised family medicine practices throughout Croatia and included 169 patients who suffered from myocardial infarction and/or underwent percutaneous coronary intervention and/or bypass surgery. Blood pressure, LDL cholesterol and body mass index were measured and it was examined whether the participants were abiding to the advised healthy habits (nonsmoking, physically active, good diet, regular use of medicaments according to the guidelines). Adjustment to the new lifestyle was measured with Likert scale (1-5) and the same scale was used to asses physicians satisfaction with transparency of electronic health record data. Results: 63.2% of participants had recommended values for blood pressure, 19.4% for LDL cholesterol and 25.3% had a normal body mass index according to the guidelines. 25.1% of participants continued to smoke and 43.2% continued alcohol consumption. In terms of diet, a change was observed in 63.7% and physical activity increase in 63.4% of participants. In most cases, after coronary incident, physician consulted them regarding lifestyle changes. Family medicine specialists were mostly pleased with the content and the amount of data in electronic health records, but not with their transparency and ease of use in everyday, usually time constrained, patient - doctor consultations. A software application Adobe Illustrator® was used to visually represent the relevant risk factors which could provide more effective control for conducting secondary prevention measures. Conclusion: The care for coronary artery disease patients in family medicine is very complex, and a part of it is related to providing effective measures of secondary prevention which are of crucial importance. Therefore it is imperative to plan ahead and allow sufficient consultation time to obtain control over the risk factors and make timely changes according to the guidelines. Research results have shown that not all risk factors are within recommended values and one of the reasons could be the lack of clear presentation in the electronic health record. Better quality of care could be achieved with the proposed visual solution using pictures that allows the family physician fast access to the patient’s “profile” and improves efficiency of every consultation despite its constrained duration in everyday conditions

Say it in Croatian - Croatian translation of the EGPRN definition of Multimorbidity using a Delphi consensus technique

Patients coming to their family physician (FP) usually have more than one condition or problem. Multimorbidity as well as dealing with it, is challenging for FPs even as a mere concept. The World Health Organization (WHO) has simply defined multimorbidity as two or more chronic conditions existing in one patient. However, this definition seems inadequate for a holistic approach to patient care within Family Medicine. Using systematic literature review the European General Practitioners Research Network (EGPRN) developed a comprehensive definition of multimorbidity. For practical and wider use, this definition had to be translated into other languages, including Croatian. Here presented is the Croatian translation of this comprehensive definition using a Delphi consensus procedure for Forward/Backward translation. 23 expert FPs fluent in English were asked to rank the translation from 1 (absolutely disagreeable) to 9 (fully agreeable) and to explain each score under 7. It was previously defined that consensus would be reached when 70 % of the scores are above 6. Finally, a backward translation from Croatian into English was undertaken and approved by the authors of the English definition. Consensus was reached after the first Delphi round with 100% of the scores above 6; therefore the Croatian translation was immediately accepted. The authors of the English definition accepted the backward translation. A comprehensive definition of multimorbidity is now available in English and Croatian, as well as other European languages which will surely make further implications for clinicians, researchers or policy makers

PALLIATIVE CARE OF PATIENT WITH GASTROINTESTINAL CANCER IN FAMILY MEDICINE

Palijativna skrb je potpuna skrb za bolesnika čiju bolest više nije moguće aktivno liječiti. Svrha palijativne skrbi je kontrola simptoma, produženje života uz postizanje najveće moguće kvalitete života za bolesnike i članove njihovih obitelji. U završnom razdoblju bolesti bolesnici 90 % vremena zadnje godine života provode u svom domu u skrbi obiteljskog liječnika i njegovih suradnika te obitelji bolesnika. Bolesnici koji boluju od raka u posljednja tri mjeseca života imaju prosječno 11,9 simptoma. Najčešće su prisutni simptomi probavnog trakta te bol. Rast i širenje raka kao i poduzeti terapijski postupci su najvažniji uzroci simptoma. Najčešći simptomi u bolesnika s rakom probavnog sustava su mučnina, povraćanje, konstipacija, bol, kaheksija i anoreksija te psihološki problemi. Ovi najčešći, ali i drugi simptomi bit će različitog intenziteta i pojavnosti ovisno o sijelu i agresivnosti raka probavnog sustava, oblika liječenja te kondicije bolesnika. Bolesnici s uznapredovalim rakom preživljavaju sve dulje i svi zdravstveni profesionalci uključeni u skrb bolesnika trebaju imati sve više znanja i vještina nužnih za učinkovito suzbijanje raznolikih simptoma. Koordinacija, organizacija i provođenje palijativne skrbi u obiteljskoj medicini kada se veliki dio skrbi pruža u domu bolesnika je jedan od najkompleksnijih zadataka liječnika obiteljske medicine Taj zadatak zahtijeva od liječnika obiteljske medicine specifi čna znanja i vještine kako bi znao i mogao učinkovito pomoći u kontroli brojnih simptoma te pružiti primjerenu potporu bolesniku i njegovoj obitelji. Komunikacija između liječnika i bolesnika koji boluje od uznapredovalog raka probavnog sustava je temeljni aspekt skrbi. Kvaliteta komunikacije značajno utječe na tok liječenja, dobrobit bolesnika i njegove obitelji, odluke o izboru liječenja i suradljivost u liječenju te na planiranje skrbi u budućnosti. U zbrinjavanju bolesnika s uznapredovalim rakom probavnog sustava liječnik obiteljske medicine treba osigurati holistički pristup te uvažavati bolesnika kao osobu i poštivati njegove odluke.Palliative care is defi ned as the care for patients whose disease is not responsive to curative treatment. The goals of palliative care are symptom control, life prolongation and enabling the best possible quality of life for patients and their families. For most patients with an advanced progressive incurable disease, 90% of care in their last year of life is provided at home by family physician and his team and patient family. Patients suffering from cancer have a mean of of 11.9 symptoms in the last three months of life. The most common symptoms are digestive tract symptoms and pain. The growth and spread of cancer, as well as the therapeutic procedures applied are the most important causes of symptoms. The most common symptoms in patients with cancer of digestive system are nausea, vomiting, constipation, pain, cachexia, anorexia, and psychological problems. These most common symptoms and many others will be of varying intensity and appearance depending on localization and aggressiveness of digestive system cancer, modality of treatment and patient condition. Patients with advanced cancer have longer survival and all health care professionals involved in the care of patients should have more knowledge and skills necessary to effectively treat various symptoms. Coordination, organization and implementation of palliative care in family medicine, when large part of care is provided at patient home, are one of the most complex tasks of family physician. This task requires a family practitioner with specifi c knowledge and skills to know how effectively control a number of symptoms and to provide adequate support to the patient and his family. Communication between doctor and patient suffering from advanced cancer of digestive system is a fundamental aspect of care. The quality of communication signifi cantly affects the course of treatment, the benefi t to patients and their families, the choice of treatment and adherence to treatment, as well as care planning. In the management of patients with advanced cancer of the digestive system, family physician should use holistic approach and respect the patient as a person and his decision

CARE QUALITY FOR PATIENTS WITH CORONARY ARTERY DISEASE IN FAMILY MEDICINE - GUIDELINE IMPLEMENTATION BY TAKING A GLANCE AT THE RISK FACTORS

Uvod: Bolesnici s koronarnom bolešću su velik izazov u skrbi liječnika obiteljske medicine (LOM) zbog brojnih komorbiditeta te primjene mjera sekundarne prevencije kojima se prate i istovremeno korigiraju rizični čimbenici koji se odnose na bolesnika, njegovu okolinu i stil života. Cilj: Istražiti uspješnost LOM-a u primjeni mjera sekundarne prevencije kardiovaskularnih bolesti i pronaći moguće rješenje za poboljšanje kvalitete skrbi. Ispitanici i metode: Opservacijsko istraživanje provedeno je 2017. godine u devet specijalističkih ordinacija obiteljske medicine diljem Hrvatske, a uključivalo je 169 bolesnika koji su ili preboljeli infarkt miokarda i/ili su bili podvrgnuti perkutanoj koronarnoj intervenciji i/ili operaciji aortokoronarnog premoštenja. Praćene su vrijednosti krvnog tlaka, LDL kolesterola i indeksa tjelesne mase, a ispitivano je pridržavanje poželjnih oblika ponašanja (nepušenje, tjelesna aktivnost, pravilna prehrana, redovno uzimanje dokazano djelotvornih lijekova) te prilagodba novom stilu života koja je mjerena Likertovom ljestvicom (1-5) kao i zadovoljstvo liječnika preglednošću elektroničkog zdravstvenog zapisa. Rezultati: Zadovoljavajuće vrijednosti arterijskog tlaka postignute su u 63,2 % ispitanika, razinu LDL kolesterola prema smjernicama imalo je 19,4 %, dok je 25,3 % ispitanika imalo uredan indeks tjelesne mase; 25,1 % ispitanika je i dalje pušilo, dok je 43,2 % ispitanika konzumiralo alkohol. Prehrambene navike promijenilo je 63,7 % ispitanika, a 63,4 % je povećalo svoju tjelesnu aktivnost. LOM je u većini slučajeva proveo savjetovanje oko promjene životnog stila nakon koronarnog incidenta. Liječnici su većinom bili zadovoljni sadržajem i količinom podataka u elektroničkom zdravstvenom zapisu, ali ne i njihove upotrebljivosti u svakodnevnoj, vremenski ograničenoj konzultaciji s bolesnikom. Osmišljeno rješenje u programu Adobe Illustrator® omogućilo bi i olakšalo bolju preglednost rizičnih čimbenika i time bi moglo imati utjecaja na učinkovitiju kontrolu provođenja mjera sekundarne prevencije. Zaključak: Skrb za bolesnike s koronarnom bolešću u obiteljskoj medicini je vrlo kompleksna, a dio kompleksnosti se odnosi na primjenu mjera sekundarne prevencije koje su od vitalne važnosti. Zbog toga je potrebno planirati i osigurati dovoljno vremena za konzultaciju s takvim bolesnicima kako bi se dobio uvid u kontrolu rizičnih čimbenika i pravovremeno učinile promjene sukladno važećim smjernicama. Rezultati istraživanja pokazali su da se u bolesnika svi rizični čimbenici ne nalaze unutar preporučenih vrijednosti te da je jedan od mogućih razloga tome što ne postoji njihov pregledan prikaz u elektroničkom zdravstvenom zapisu. Kvalitetnija skrb mogla bi se postići kada bi postojalo jasno vizualno rješenje stanja rizičnih čimbenika koje je u ovom radu osmišljeno i predloženo u obliku slika koje bi LOM-u dale brzi uvid u “profi l” bolesnika te poboljšale učinkovitost svake konzultacije s obzirom na njeno kratko vremensko ograničenje u svakodnevnim uvjetima rada u ordinacijama obiteljske medicine.Introduction: Patients with coronary artery disease represent a challenge in each family medicine practice because of many comorbidities and the application of secondary prevention measures which represent a tool for tracking and simultaneously correcting risk factors related to the patient, his surroundings and lifestyle. Objective: Explore the effectiveness of family medicine specialists in applying secondary prevention measures in cardiovascular diseases and to find a solution for improving quality of care. Participants and Methods: This observational study, was conducted in 2017. under nine specialised family medicine practices throughout Croatia and included 169 patients who suffered from myocardial infarction and/or underwent percutaneous coronary intervention and/or bypass surgery. Blood pressure, LDL cholesterol and body mass index were measured and it was examined whether the participants were abiding to the advised healthy habits (nonsmoking, physically active, good diet, regular use of medicaments according to the guidelines). Adjustment to the new lifestyle was measured with Likert scale (1-5) and the same scale was used to asses physicians satisfaction with transparency of electronic health record data. Results: 63.2% of participants had recommended values for blood pressure, 19.4% for LDL cholesterol and 25.3% had a normal body mass index according to the guidelines. 25.1% of participants continued to smoke and 43.2% continued alcohol consumption. In terms of diet, a change was observed in 63.7% and physical activity increase in 63.4% of participants. In most cases, after coronary incident, physician consulted them regarding lifestyle changes. Family medicine specialists were mostly pleased with the content and the amount of data in electronic health records, but not with their transparency and ease of use in everyday, usually time constrained, patient - doctor consultations. A software application Adobe Illustrator® was used to visually represent the relevant risk factors which could provide more effective control for conducting secondary prevention measures. Conclusion: The care for coronary artery disease patients in family medicine is very complex, and a part of it is related to providing effective measures of secondary prevention which are of crucial importance. Therefore it is imperative to plan ahead and allow sufficient consultation time to obtain control over the risk factors and make timely changes according to the guidelines. Research results have shown that not all risk factors are within recommended values and one of the reasons could be the lack of clear presentation in the electronic health record. Better quality of care could be achieved with the proposed visual solution using pictures that allows the family physician fast access to the patient’s “profile” and improves efficiency of every consultation despite its constrained duration in everyday conditions