BackgroundSkin cancer is believed to impose a heavy burden on healthcare services, but the burden of skin lesions suspected of malignancy on primary healthcare has never been evaluated. Therefore the aim of this study was to determine the demand for care in general practice due to these suspected skin lesions (i.e. lesions that are suspected of malignancy by either the patient or the GP).MethodsRegistry study based on data (2001–2010) from the Registration Network Groningen. This is a general practice registration network in the northern part of the Netherlands with an average annual population of approximately 30,000 patients. All patient contacts are coded according to the International Classification of Primary Care (ICPC). Consultations for skin lesions suspected of malignancy were selected according to the assigned ICPC codes. Subsequently, the number of consultations per year and the annual percent change in number of contacts (using the JoinPoint regression program) were calculated and analysed. Additionally, the percentage of patients referred to secondary care or receiving minor surgery within one year after the first contact were calculated.ResultsFrom 2001 onwards we found an annual increase in demand for care due to skin lesions suspected of malignancy of 7.3% (p < 0.01) and in 2010 the benign:malignant ratio was 10:1. In total 13.0% of the patients were referred and after 2006, minor surgery was performed on 31.2% of the patients. Most surgeries and referrals took place within 30 days.ConclusionsSuspected skin lesions impose an increasing burden on primary healthcare and most likely on healthcare costs as well. General practitioners should therefore be trained in diagnosing skin lesions suspected of malignancy, as a high diagnostic accuracy can save lives in the case of melanoma, and may also prevent unnecessary, costly, excisions and referrals to secondary healthcare.

BackgroundEarly detection and effective management of risk factors can potentially delay progression of chronic kidney disease (CKD) to end-stage kidney disease, and decrease mortality and morbidity from cardiovascular (CV) disease. We evaluated a specialist nurse-led intervention in the primary care setting to address accepted risk factors in a study sample of adults at ‘high risk of CKD progression’, defined as uncontrolled type II diabetes and/or hypertension and a history of poor clinic attendance.MethodsThe study was a non-controlled quality improvement study with pre- and post- intervention comparisons to test feasibility and potential effectiveness. Patients within two primary care practices were screened and recruited to the study. Fifty-two patients were enrolled, with 36 completing 12-months follow-up. The intervention involved a series of sessions led by the nephrology Nurse Practitioner with assistance from practice nurses. These sessions included assessment, education and planned medication and lifestyle changes. The primary outcome measured was proteinuria (ACR), and the secondary outcomes estimated glomerular filtration rate (eGFR) and 5-year absolute CV risk. Several ‘intermediary’ secondary outcomes were also measured including: blood pressure, serum total cholesterol, glycosylated haemoglobin (HbA1c), body mass index (BMI), prevalence of active smoking, a variety of self-management domains, and medication prescription. Analysis of data was performed using linear and logistic regression as appropriate.ResultsThere was a significant improvement in ACR (average decrease of −6.75 mg/mmol per month) over the course of the study. There was a small but significant decrease in eGFR and a reduction in 5 year absolute CV risk. Blood pressure, serum total cholesterol, and HbA1c all decreased significantly. Adherence to lifestyle advice improved with a significant reduction in prevalence of active smoking, although there was no significant change in BMI. Self-management significantly improved across all relevant domains.ConclusionsThe results suggest that a collaborative model of care between specialist renal nurses and primary care clinicians may improve the management of risk factors for progression of CKD and CV death. Further larger, controlled studies are warranted to definitively determine the effectiveness and costs of this intervention.Trial registrationAustralian and New Zealand Clinical Trials Registry number: ACTRN12613000791730

BackgroundPrimary care providers are an important source of information regarding appropriate alcohol consumption. As early presentation to a provider for alcohol-related concerns is unlikely, it is important that providers are able to identify at-risk patients in order to provide appropriate advice. This study aimed to report the sensitivity, specificity, positive predictive value and negative predictive value of General Practitioner (GP) assessment of alcohol consumption compared to patient self-report, and explore characteristics associated with GP non-detection of at-risk status.MethodGP practices were selected from metropolitan and regional locations in Australia. Eligible patients were adults presenting for general practice care who were able to understand English and provide informed consent. Patients completed a modified AUDIT-C by touchscreen computer as part of an omnibus health survey while waiting for their appointment. GPs completed a checklist for each patient, including whether the patient met current Australian guidelines for at-risk alcohol consumption. Patient self-report and GP assessments were compared for each patient.ResultsGPs completed the checklist for 1720 patients, yielding 1565 comparisons regarding alcohol consumption. The sensitivity of GPs’ detection of at-risk alcohol consumption was 26.5%, with specificity of 96.1%. Higher patient education was associated with GP non-detection of at-risk status.ConclusionsGP awareness of which patients might benefit from advice regarding at-risk alcohol consumption appears low. Given the complexities associated with establishing whether alcohol consumption is ‘at-risk’, computer-based approaches to routine screening of patients are worthy of exploration as a method for prompting the provision of advice in primary care.

BackgroundImproving the quality of care for patients with vascular disease is a priority. Clinical guidance has emphasised the importance of early identification and active management of chronic kidney disease (CKD) in primary care in order to maintain vascular health. However, awareness of stage 3 CKD amongst patients remains limited. We aimed to identify predictors of patient self-report of CKD to inform tailoring of conversations around CKD in primary care for diverse patient populations.MethodsWe conducted a cross-sectional analysis of baseline data from 436 patients with stage 3 CKD from 24 GP practices taking part in a randomised controlled trial (RCT) evaluating a complex self-management intervention, which aimed to support the maintenance of vascular health in patients with stage 3 CKD. Potential predictors of patient self-report of CKD included demographics, stage of CKD, cardiovascular risk, self-reported co-morbidities, health status, self-management ability, and health service utilisation.ResultsAround half (52%, n = 227) of patients did not self-report CKD. Self-report rates did not appreciably differ by practice. Multivariate analysis revealed that female patients (p = 0.004), and patients with stage 3b CKD (p < 0.001), and with higher anxiety levels (p < 0.001), were more likely to self-report CKD.ConclusionsSelf-report of kidney problems by patients on CKD registers was variable and patterned by sociodemographic factors. Although it cannot be assumed that failure to self-report indicates a lack of awareness of CKD, our data do suggest the need for greater consistency in discussions around kidney health, with meaningful and relevant clinical dialogue that is aligned with existing clinical encounters to enable shared decision making and minimise anxiety.

BackgroundOrganised follow-up is a common feature of several strategies at the primary health care level to promote health behaviour change, e.g. to increase physical activity. In Norway, municipal ‘healthy living’ centres run by health care personnel are established to offer counselling and organised follow-up of health behaviour change during a 12-week programme. We report the results of a systematic review commissioned by the Norwegian Directorate of Health concerning organised follow-up to improve physical activity.MethodsWe searched ten electronic databases up to June 2012, reference lists of included publications, and relevant journals. Study selection and quality risk of bias assessment were carried out independently. Data were synthesised narratively due to heterogeneity of measurements of physical activity. The GRADE approach was used to assess our confidence in the effect estimate for each outcome in each comparison.ResultsFourteen randomised controlled trials from seven countries and with a total of 5,002 participants were included in the systematic review. All studies were carried out in primary care or community settings. The interventions comprised referral to supervised group physical activity (2 studies), referral to local resources with follow-up (6 studies), and self-organised physical activity with follow-up (6 studies). The narrative synthesis, comprising a total of 39 comparisons, indicated effects of self-organised physical activity with follow-up (compared to both advice and no treatment) and referral to local resources with follow-up (compared to advice) in some of the comparisons where we rated our confidence in the effect estimates as moderate. However, the results indicated no difference between intervention and control groups for the majority of comparisons. Follow-up in the studies was mainly short-term with the longest follow-up 9 months post-treatment. We rated our confidence in the effect estimates as low or very low in most comparisons, both for positive and neutral results.ConclusionsThe results of this systematic review indicate considerable uncertainty concerning effects of organised follow-up during 10–14 weeks on physical activity. Major methodological problems concerning the measurement of physical activity are discussed.Trial registrationSystematic review registration: PROSPERO CRD42011001598.

BackgroundThe prevention of type 2 diabetes is a challenge for health institutions. Periodic blood glucose screening in subjects at risk for developing diabetes may be necessary to implement preventive measures in patients prior to the manifestation of the disease and to efficiently diagnose diabetes. Not only medical aspects, but also psychological and social factors, such as the perception of risk (the individuals’ judgment of the likelihood of experiencing an adverse event) influence healthy or preventive behaviors. It is still unknown if risk perception can have an effect on health behaviors aimed at reducing the risk of diabetes (glucose screening). The objective of study was to identify factors that influence glucose screening frequency.MethodsEight hundred randomized interviews, which were stratified by socioeconomic level, were performed in Mexico City. We evaluated the perception of risk of developing diabetes, family history, health status and socioeconomic variables and their association with glucose screening frequency.ResultsOf the study participants, 55.6% had not had their glucose levels measured in the last year, whereas 32.8% of the subjects reported having monitored their glucose levels one to three times per year and 11.5% had their levels monitored four or more times per year. Risk perception was significantly associated with the frequency of blood glucose screening. Having a first-degree relative with diabetes, being older than 45 years and belonging to a middle socioeconomic level increased the probability of subjects seeing a doctor for glucose screening.ConclusionsGlucose screening is a complex behavior that involves the subjects’ perception of threat, defined as feeling vulnerable to the development of diabetes, which is determined by the subject’s environment and his previous experience with diabetes.