Chronic patients: persons with diabetes frequent attenders in Croatian family practice

Chronic diseases cause high frequency visits and generate the long-term frequent attenders (FAs). The connection between frequent attendance and specific morbidities in the health care systems in transitional Europe has been underestimated. We investigated whether frequent visits of chronic patients in primary care are related to characteristic of chronic disease (diabetes mellitus) and whether this is influenced by the family practice in the transitional health care. We analyzed the number of visits a day time work for 490 persons with diabetes in the period 1997 to 2000. As the cut-off points between frequent attenders and non frequent attenders (NFAs) we used the value of the third quartile (Q3) of visits determined for the sex and age groups in the parallel study in the whole population. The analysis was performed for 23 variables: demographic characteristics of patients, disease characteristic and variables of physician. Logistic regressions were employed to identify the predictors of FAs/NFAs. 56.9% (in 1997) to 62.4% (in 2000) persons with diabetes were FAs, compared to 22.4% to 24.3% FAs patients in the whole population. Logistic regression analysis significantly differentiated the two group of visits with 68% accuracy. 4 variables are significant predictors for FAs/NFAs: diabetes as the main disease (p = 0.0005), diet-only-treatment (p = 0.0062), treatment by secondary care (p = 0.0116), and if glycated hemoglobin test (HbA1c) is determined (p = 0.0272). Understanding the similarities and differences of FAs/NFAs persons with diabetes may be important in improving the care and management of chronic diseases in family medicine in transitional health care systems

Quaternary prevention. Prediabetes: risk, disease or overdiagnosis? The diseases which are not of great danger should not be teased by medicines (Plato, 5th century BC)

Kvartarna prevencija suvremen je, kritički pristup moderne medicine. Usmjerena je na zaštitu pacijenata od medicinskih intervencija koje su suvišne pri zdravstvenoj zaštiti i mogu nanijeti više štete nego koristi. Kvartarna prevencija sastavni je dio svih triju prevencija: primarne, sekundarne i tercijarne. Cilj je zaštita pacijenta od mogućega suvišnog probira, suvišne dijagnoze bolesti, što pacijenta može uvesti u suvišnu medikalizaciju i postupke. Dijabetes je kronična, doživotna bolest s dijagnozom na temelju dogovorene točke razgraničenja kontinuirane varijable i pod visokim je rizikom od suvišnih postupaka. S druge strane, prepoznavanjem i intervencijom u graničnim području (u predbolesti) može se odgoditi nastanak bolesti. Izazov je prepoznati rizike i uvesti intervenciju samo ondje gdje su oni visoki, gdje je nastanak bolesti siguran, a odgovarajuća intervencija može ga odgoditi. Čini li se to za osobe niskog rizika od nastanka bolesti i komplikacija, pacijentu se ne mijenja prognoza, ali mu se dodaju suvišna dijagnoza i dodatni postupci te izaziva dodatni stres. O ovomu treba voditi računa na svim razinama zdravstvene zaštite, no poglavito u obiteljskoj medicini, što je prepoznala i Svjetska udruga obiteljskih liječnika (WONCA).Quaternary prevention is a contemporary critical approach to modern medicine. Its goal is the protection of patients from unnecessary medical intervention which can do more harm than good. Quaternary prevention is a part of all three preventions: primary, secondary and tertiary. Its aim is to protect a patient from overscreening and overdiagnosis which can lead to overmedicalization. As a life-long disease with diagnosis based on the agreed cutoff point of a continuous variable, diabetes is in a great risk of over-intervention. However, with a right intervention in pre-disease it is possible to postpone the disease. The challenge is to recognize the risks and intervene if they are high, the risk of disease progression is substantial, and appropriate intervention can diminish it. If the same is done for low risk it is a waste of energy and means, and the patient gains nothing but additional stress due to overdiagnosis. It has to be considered at all levels of health care, but mostly in primary care, which has been recognized by the international association of family physicians (WONCA)

Antibiotic Prescription Rate for Upper Respiratory Tract Infections and Risks for Unnecessary Prescription in Croatia

Overprescribing of antibiotics in primary care has been recognized as public health problem. We investigated visits prescription rate of antibiotics to patients with upper respiratory tract infections (URTI) and unnecessary prescribtion for tonsillopharyngitis, in Croatia. In prospective observational study in November 2007. 25 GPs in Croatia recorded all patients’ visits with URTI episode according ICPC-2. Clinical status of patients with tonsillopharyngitis were categorized according to Centor Criteria. 689 visits were analysed, 82% of visits were initial. Antibiotics were prescribed in 44.7% visits with URTI. There were no significant differences in antibiotic prescription rates regarding non–clinical factors. Antibiotics were prescribed to patients with tonsillopharyngitis in 62.2% visits. Unnecessary antibiotics were prescribed (Centor 1,2) in 49.6% visits with tonsillopharyngitis. Logistic regression analysis showed significant differences in unnecessary antibiotic prescription rates only with respect to the workday – Wednesday, CI (1.117–2.671), p=0.0139. Leading antibiotic was amoxicillin + clavulonic acid, second was amoxicillin, the third were macrolides, the fourth was narrow spectrum penicillin and fifth were cephalosporins. This study shows over prescription for URTI. Unnecessary prescription for tonsillopharyngitis depend on non clinical factor – day of the week. This should be futher explored and help to improved prescribe antibiotics

Chronic Patients – Persons with Diabetes Frequent Attenders in Croatian Family Practice

Chronic diseases cause high frequency visits and generate the long-term frequent attenders (FAs). The connection between frequent attendance and specific morbidities in the health care systems in transitional Europe has been underestimated. We investigated whether frequent visits of chronic patients in primary care are related to characteristic of chronic disease (diabetes mellitus) and whether this is influenced by the family practice in the transitional health care. We analyzed the number of visits a day time work for 490 persons with diabetes in the period 1997 to 2000. As the cut-off points between frequent attenders and non frequent attenders (NFAs) we used the value of the third quartile (Q3) of visits determined for the sex and age groups in the parallel study in the whole population. The analysis was performed for 23 variables: demographic characteristics of patients, disease characteristic and variables of physician. Logistic regressions were employed to identify the predictors of FAs/NFAs. 56.9% (in 1997) to 62.4% (in 2000) persons with diabetes were FAs, compared to 22.4% to 24.3% FAs patients in the whole population. Logistic regression analysis significantly differentiated the two grup of visits with 68% accuracy. 4 variables are significant predictors for FAs/NFAs: diabetes as the main disease (p=0.0005), diet-only-treatment (p=0.0062), treatment by secondary care (p=0.0116), and if glycated hemoglobin test (HbA1c) is determined (p=0.0272). Understanding the similarities and differences of FAs/NFAs persons with diabetes may be important in improving the care and management of chronic diseases in family medicine in transitional health care systems

Prescribing antibiotics to preschool children in primary health care in Croatia

The use of antibiotics depends on cultural and socioeconomic factors, physician's characteristics as well as on microbiological considerations. Aim of our study was to asses antibiotic prescription among preschool children in primary health care in Croatia in relation to socioeconomic factors, symptoms and diagnoses, and type of health care provider. Retrospective longitudinal survey was conducted in 7 teaching primary health care offices in the Croatian capital of Zagreb during 2004, among 1700 preschool children. Antibiotics were prescribed to 611 (46%) children. Significantly more antibiotics were prescribed to boys (66.7%, P = 0.024) and to children whose parents had lower educational level. Most frequently antibiotics were prescribed for the symptoms such as fever (32%), cough (32.5%), nasal discharge (12%), and for the diagnoses such as respiratory diseases (J00-J99) (40%), infectious and parasitic diseases (A00-A99) (31%), and diseases of the middle ear and mastoid (H60-H95) (15%). Logistic regression analyses also predicted correlation of antibiotic prescriptions with socioeconomic factors, symptoms and diagnoses and health care of pediatrician. Prescription of antibiotics for preschool children in primary health care in Croatia related to socioeconomic factors, type of health care provider, certain symptoms and diagnosis groups which should be taken into account when assessing and planning primary health care for preschool children

Early detection of diabetes mellitus in family medicine

Incidencija dijabetesa melitusa danas zauzima epidemijske razmjere. 90-95% bolesnika cine pacijenti s Tipom 2 dijabetesa. Bolest se sporo razvija, i ima dugu asimptomatsku fazu. Klinicki se otkrije nakon 5-10 godina trajanja. Bolesnik s dijabetesom, zbog komplikacija bolesti, umire ranije od svojih vršnjaka bez dijabetesa. Poznati su pozitivni ucinci ranog otkrivanja bolesti – probiranjem (skriningom). Još nisu nadeni idealni modeli provodenja probiranja za rano otkrivanje bolesti, za otkrivanje stadija povecane glukoze natašte i stadija oštecene tolerancije glukoze. Nisu dobiveni efinitivni odgovori ni na pitanja: tko ce provoditi skrining, gdje ce se provoditi i kako? Kako odrediti rizicne skupine? Kako provoditi probiranje u tranzicijskoj obiteljskoj medicini? Znanost i struka se u jednome slažu: obiteljski lijecnik ima kljucnu ulogu u ranom otkrivanju bolesti.The incidence of diabetes mellitus today precedes epidemic dimensions. 90-95% of diabetic patients have type 2 diabetes. The disease develops slowly, and it has a long asymptomatic phase. Clinical detection comes after 5-10 years of disease duration. Due to disease complications, diabetic patients die earlier than their peers without diabetes. Positive effects of early disease detection (screening) are well known. The perfect models of screening for early diseases detection high level fasting glucose stage and the impaired glucose tolerance stage detection haven’t been found yet. Definitive answers to the following questions haven’t also been found yet – Who will conduct the screening, where and how? How to determine the risk groups? How to conduct the screening in transitional family medicine? Science and profession concur in one thing: the family practitioner has the key role in early disease etection

New requirements of medical documentation in the area of chronic patients care in family medicine

Liječnik obiteljske medicine dužan je osigurati kontinuitet zdravstvene zaštite za populaciju u skrbi, što je moguće jedino uz kvalitetnu i preglednu medicinsku dokumentaciju iz koje je moguće na jednostavan i brz način prikupiti sve potrebne podatke. Podaci o pacijentu u njegovom elektronskom kartonu trebali bi biti raspoređeni u tri područja: listu epizoda zdravstvene zaštite, listu pacijentovih problema, te ostale informacije o pacijentu. Zabilježeni podaci se za liječenje kroničnih bolesti koriste po strukturiranom modelu: prevencija i rano otkrivanje bolesti, liječenje, rano otkrivanje komplikacija, te analiza kvalitete zaštite. Podaci također trebaju biti dostupni ostalim razinama zdravstvene zaštite, te se trebaju iskoristiti za nacionalne registre. Ovako zabilježeni podaci temelj su kvalitetnijega rada liječnika, te olakšavaju rad s kroničnim pacijentima, kako obiteljskom liječniku koji vodi populaciju, tako i ostalim liječnicima koji dolaze u kontakt s njegovim pacijentima.The family physician must ensure the continuity of health care for his patients, which is possible only using adequate medical documentation where a physician can find and collect all the necessary data. The data about a patient in his electronic medical record must be divided into three areas: list of episodes of care, list of patient\u27s problems and other information on the patient. Collected data are used for management of chronic diseases according to structured model:-prevention and early detection of diseases, treatment, early detection of complications and analysis of quality of care. The data must be available to other levels of health care and also be transferred automatically to national registers. The data thus collected make the work of the family physician with chronic patients easier, as well as the work of all other physicians who participate in the patient care process

QUATERNARY PREVENTION AS A BASIS FOR RATIONAL APPROACH TO THE PATIENT IN FAMILY PRACTICE

Kvartarna prevencija definirana je kao postupak identificiranja pacijenta rizičnog podlijeganju prekomjernoj medikalizaciji ali i zaštite pacijenta od nove medicinske invazije te predlaganja takvom pacijentu etički prihvatljivih intervencija. Njeno primarno mjesto je u obiteljskoj medicini zbog pozicije obiteljskog liječnika koji predstavlja prvu liniju kontakta s pacijentom te »voditelja« pacijenta kroz zdravstveni sustav. Veliko umijeće liječnika obiteljske medicine je odrediti kojem tjelesnom sustavu pripada simptom kojega prezentira pacijent, te odrediti optimalni daljnji postupak s pojedinim pacijentom. To je posebno složeno u situaciji kada pacijent ima tegobe, a liječnik ne nalazi bolest. U tim situacijama individualni pristup pacijentu, dobra komunikacija, balans između indiciranja odgovarajućih pretraga i utvrđivanja nužnih postupaka uz oslanjanje na medicinu temeljenu na dokazima čine kvartarnu prevenciju, koja postaje nužnost u vođenju pacijenta kroz suvremeni sustav zdravstvene zaštite.Quaternary prevention is an action taken to identify a patient at risk of overmedicalisation, to protect him from new medical invasion, and to suggest to him interventions which are ethically acceptable. It belongs mostly to family medicine because of the family physician’s position who is the first contact to the patient and »leader« of patient through health care system. Family physician must have a skill to locate the patient’s symptom to the proper organ system and also to find the appropriate procedure for the patient. This is very complex in a situation when the patient has symptoms and complaints and the physician doesn’t find the disease. In these situations individual approach to the patient, good communication, balance between finding appropriate procedures and defining neccessary procedures together with evidence based medicine make quaternary prevention, which becomes a neccessity in the process of leading the patient through modern health care system

Occurrence of type 2 diabetes in people with risk factors

Uvod. Sukladno preporukama Međunarodne dijabetičke federacije (engl. International Diabetes Federation, IDF) pacijentima s rizikom za obolijevanje od šećerne bolesti (ŠB) potrebno je provoditi oportunistički probir svakih 3-5 godina s ciljem otkrivanja bolesti u ranoj asimptomatskoj fazi. Cilj. Utvrditi udio pacijenata u skrbi liječnika obiteljske medicine (LOM) u dobi 45-70 godina s čimbenicima rizika (ČR) za nastanak ŠB koji u intervalu praćenja od tri godine razviju ŠB tipa 2. Metode. Retrospektivnim istraživanjem za razdoblje 1. siječnja 2014. – 1. siječnja 2017. godine obuhvaćeno je 840 pacijenata koji su na početku istraživanja imali normoglikemiju po parametrima: glukoza u plazmi (GUP), glikirani hemoglobin (HbA1c) i/ili test oralnog opterećenja glukozom (OGTT) te barem jedan ČR za nastanak ŠB: ITM≥ 25 kg/m², hipertenzija ili dislipidemija. Praćenjem vrijednosti GUP-a, HbA1c-a, i/ili OGTT-a kroz trogodišnji period pacijenti su sukladno IDF kriterijima svrstani u skupine: normoglikemija, preddijabetes ili ŠB tip 2. Elektronički medicinski zapis (engl. EMR) korišten je kao izvor podataka. Rezultati. Ukupna prevalencija ŠB na kraju istraživanja za dobnu skupinu 45-70 godina iznosila je 14,5% (4,5% novooboljelih kroz tri godine). Od 840 promatranih pacijenata, 9,1% je razvilo ŠB tip 2, 11,4% preddijabetes i 79,5% je bilo u normoglikemiji. U skupini pacijenata bez zabilježenih ČR, 8 je razvilo ŠB u promatranom razdoblju. Zaključak. Korištenjem EMR-a za praćenje bolesnika s ČR za nastanak ŠB, LOM može aktivnim probirom otkriti i započeti rano liječenje bolesnika s asimptomatskom ŠB.Introduction. According to the recommendations of the International Diabetes Federation (IDF), patients with risk of diabetes mellitus (DM) should undergo opportunistic screening every 3-5 years in order to detect the disease in the early asymptomatic phase. Aim. It is necessary to determine the proportion of patients in care of family doctors (FDs) aged 45-70 years with risk factors (RFs) for DM, who develop DM in the monitoring period of three years. Methods. Retrospective study for the period January 1, 2014 - January 1, 2017 included 840 patients who had normoglycemia by parameters at the beginning of the study : plasma glucose level (PGL), glycated hemoglobin (HbA1c) and/or oral glucose tolerance test (OGTT) and at least one RF for the development of DM: ITM≥ 25 kg / m², hypertension or dyslipidemia. By monitoring PGL, HbA1c, and/or OGTT values over a three-year period, patients were classified according to the IDF criteria in the following groups: normoglycemia, pre-diabetes or DM. Electronic medical record (EMR) was used as a data source. Results. Total prevalance of DM at the end of research period for age group 45-70 years was 14.5% (4.5% newly diagnosed). From 840 observed patients 9.1% developed DM, 11.4% had pre-diabetes, and 79.5% were normoglycemic. Eight patients without documented RFs developed DM in the monitoring period. Conclusion. Using EMR for follow up of patients with RFs for DM, FD can perform active screeninig and initaite early treatment for patients with asymptomatic DM

ACCUSTOMING TO HELICOBACTER PYLORI BACTERIUM IN FAMILY PRACTICE

Rezistencija bakterije Helicobacter pylori (HP) na antibiotike danas je globalno rasprostranjen problem. Liječnik obiteljske medicine donosi odluku o liječenju gastrointestinalnih bolesti bez direktnog endoskopskog nalaza i izolata eventualno prisutne bakterije, po principu „testiraj i liječi“. Prije donošenja odluke postavlja pitanja: ima li pacijent infekciju, treba li prisutnost bakterije odrediti, koji dijagnostički test izabrati, treba li propisati antibiotik, koji antibiotik propisati. Prikazane su tri kliničke slike pacijenata koje najčešće susrećemo u praksi: dispepsija, gastroezofagealna refl uksna bolest (GERB), ekstragastrične bolesti koje se vežu uz prisustvo HP. Prikazani su serološki testovi, test antigena HP u stolici i ureja izdisajni test. Zahtjevna je uloga obiteljskog liječnika u istodobnoj racionalizaciji propisivanja antibiotika i eradikaciji HP. Treba stalno imati na umu da je bolest rezultat odgovora nositelja/domaćina i čimbenika–bakterije u varijabli vremena i stupnja oštećenja što je bakterija eventualno izazvala.Today, antibiotic resistance of Helicobacter pylori (HP) is a worldwide problem. The ‘test and treat’ strategy is the recommended approach in family medicine, as family medicine doctors make decisions on treating gastrointestinal conditions without endoscopic fi ndings or HP testing. In treatment strategy, family medicine doctor has to answer several questions: whether the patient has HP infection, is it necessary to evaluate HP infection, which diagnostic test to use in evaluation of HP infection, should he proscribe antibiotic, and which antibiotic to prescribe. In this article, we present three common clinical cases to determine which approach to use in daily practice: dyspepsia, gastroesophageal refl ux disease (GERD), and extragastric diseases associated with HP infection. Serology test, stool antigen test and urea breath test are described. It is required from family medicine doctors not only to rationalize antibiotic prescription but also to eradicate HP infection at the same time. We need to have in mind that disease is a result of the host-agent (bacterium) interaction that varies in time and possible damage/impairment from the disease