Sixteen years of ICPC use in Norwegian primary care: looking through the facts

<p>Abstract</p> <p>Background</p> <p>The International Classification for Primary Care (ICPC) standard aims to facilitate simultaneous and longitudinal comparisons of clinical primary care practice within and across country borders; it is also used for administrative purposes. This study evaluates the use of the original ICPC-1 and the more complete ICPC-2 Norwegian versions in electronic patient records.</p> <p>Methods</p> <p>We performed a retrospective study of approximately 1.5 million ICPC codes and diagnoses that were collected over a 16-year period at 12 primary care sites in Norway. In the first phase of this period (transition phase, 1992-1999) physicians were allowed to not use an ICPC code in their practice while in the second phase (regular phase, 2000-2008) the use of an ICPC code was mandatory. The ICPC codes and diagnoses defined a problem event for each patient in the PROblem-oriented electronic MEDical record (PROMED). The main outcome measure of our analysis was the percentage of problem events in PROMEDs with inappropriate (or missing) ICPC codes and of diagnoses that did not map the latest ICPC-2 classification. Specific problem areas (pneumonia, anaemia, tonsillitis and diabetes) were examined in the same context.</p> <p>Results</p> <p>Codes were missing in 6.2% of the problem events; incorrect codes were observed in 4.0% of the problem events and text mismatch between the diagnoses and the expected ICPC-2 diagnoses text in 53.8% of the problem events. Missing codes were observed only during the transition phase while incorrect and inappropriate codes were used all over the 16-year period. The physicians created diagnoses that did not exist in ICPC. These 'new' diagnoses were used with varying frequency; many of them were used only once. Inappropriate ICPC-2 codes were also observed in the selected problem areas and for both phases.</p> <p>Conclusions</p> <p>Our results strongly suggest that physicians did not adhere to the ICPC standard due to its incompleteness, i.e. lack of many clinically important diagnoses. This indicates that ICPC is inappropriate for the classification of problem events and the clinical practice in primary care.</p

Toward unsupervised outbreak detection through visual perception of new patterns

<p>Abstract</p> <p>Background</p> <p>Statistical algorithms are routinely used to detect outbreaks of well-defined syndromes, such as influenza-like illness. These methods cannot be applied to the detection of emerging diseases for which no preexisting information is available.</p> <p>This paper presents a method aimed at facilitating the detection of outbreaks, when there is no a priori knowledge of the clinical presentation of cases.</p> <p>Methods</p> <p>The method uses a visual representation of the symptoms and diseases coded during a patient consultation according to the International Classification of Primary Care 2^ndversion (ICPC-2). The surveillance data are transformed into color-coded cells, ranging from white to red, reflecting the increasing frequency of observed signs. They are placed in a graphic reference frame mimicking body anatomy. Simple visual observation of color-change patterns over time, concerning a single code or a combination of codes, enables detection in the setting of interest.</p> <p>Results</p> <p>The method is demonstrated through retrospective analyses of two data sets: description of the patients referred to the hospital by their general practitioners (GPs) participating in the French Sentinel Network and description of patients directly consulting at a hospital emergency department (HED).</p> <p>Informative image color-change alert patterns emerged in both cases: the health consequences of the August 2003 heat wave were visualized with GPs' data (but passed unnoticed with conventional surveillance systems), and the flu epidemics, which are routinely detected by standard statistical techniques, were recognized visually with HED data.</p> <p>Conclusion</p> <p>Using human visual pattern-recognition capacities to detect the onset of unexpected health events implies a convenient image representation of epidemiological surveillance and well-trained "epidemiology watchers". Once these two conditions are met, one could imagine that the epidemiology watchers could signal epidemiological alerts, based on "image walls" presenting the local, regional and/or national surveillance patterns, with specialized field epidemiologists assigned to validate the signals detected.</p

Completion of fit notes by GPs: a mixed methods study

Aims: The aim of this study was to investigate the completion of fit notes by UK general practitioners (GPs). A series of actual fit notes issued to employed patients were examined, and their GPs’ reflections and experiences of fit note completion explored. Methods: A mixed-methods design was used. Data were collected from copies of 94 fit notes issued to employed patients by 11 GPs, and from 86 questionnaires completed by these GPs reflecting on the fit notes they had issued. Face-to-face interviews were then conducted with each GP. Results: Fit note completion is not meeting expectations for a number of reasons. These include the following: limited knowledge and awareness of the guidance in fit note completion; problems with the fit note format; lack of mandatory training in completing fit notes; lack of incentive to change practice; incomplete implementation of the electronic fit note; GPs’ lack of confidence in, and doubts about the appropriateness of performing this role. Conclusion: If UK GPs are to continue their contractual responsibility for completing fit notes, further consideration of their education and training needs is urgently required. Weaknesses in the design and format of the fit note and the availability of the electronic version also need to be addressed

One consensual depression diagnosis tool to serve many countries: a challenge! A RAND/UCLA methodology

Objective From a systematic literature review (SLR), it became clear that a consensually validated tool was needed by European General Practitioner (GP) researchers in order to allow multi-centred collaborative research, in daily practice, throughout Europe. Which diagnostic tool for depression, validated against psychiatric examination according to the DSM, would GPs select as the best for use in clinical research, taking into account the combination of effectiveness, reliability and ergonomics? A RAND/UCLA, which combines the qualities of the Delphi process and of the nominal group, was used. GP researchers from different European countries were selected. The SLR extracted tools were validated against the DSM. The Youden index was used as an effectiveness criterion and Cronbach’s alpha as a reliability criterion. Ergonomics data were extracted from the literature. Ergonomics were tested face-to-face. Results The SLR extracted 7 tools. Two instruments were considered sufficiently effective and reliable for use: the Hospital Anxiety and Depression Scale and the Hopkins Symptoms Checklist-25 (HSCL-25). After testing face-to-face, HSCL-25 was selected. A multicultural consensus on one diagnostic tool for depression was obtained for the HSCL-25. This tool will provide the opportunity to select homogeneous populations for European collaborative research in daily practice