An international glossary for general/family practice

Defining multimorbidity in people with HIV - what matters most?

PURPOSE OF REVIEW

Although multimorbidity (defined as the coexistence of multiple conditions) presents significant health challenges to people with HIV, there is currently no consensus on how it should be defined among this population. This review aimed to examine the definition of multimorbidity in existing studies among people with HIV ( n  = 22).

RECENT FINDINGS

Variation in the definition of multimorbidity (in terms of the number and nature of conditions included) across studies among people with HIV was observed, with less than half (45%) reporting a selection criteria for conditions. The number of conditions considered ranged from 4 to 65. Certain conditions (e.g. stroke, myocardial infarction and chronic kidney disease) and risk factors (e.g. hypertension) were more frequently included, while other symptoms (e.g. joint pain, peripheral neuropathy and sleeping problems) and mental health conditions (e.g. anxiety and panic attacks) were rarely included in the definition of multimorbidity.

SUMMARY

The definition of multimorbidity among people with HIV is highly variable, with certain conditions overlooked. We propose recommendations that researchers should consider when defining multimorbidity among this population to not only enable comparisons between studies/settings but also to ensure studies consider a person-centred approach that can accurately capture multimorbidity among people with HIV.

Patients in general practice share a common pattern of symptoms that is partly independent of the diagnosis

OBJECTIVE

To describe self-reported symptoms among patients in general practice and to explore the relationships between symptoms experienced by patients and diagnoses given by general practitioners.

DESIGN

Doctor-patient questionnaires focusing on patients' self-reported symptoms during the past 7 days and the doctors' diagnoses.

SETTING

General practices in urban and suburban areas in Southeast Norway.

SUBJECTS

Forty-seven general practitioners who included 866 patients aged ≥18 years on a random day in practice.

RESULTS

The most frequently reported symptoms were tiredness (46%), lower back pain (43%), neck pain (41%), headache (39%), shoulder pain (36%), and sleep problems (35%). Women had a significantly higher prevalence than men for 16 of 38 symptoms (p < 0.05). The mean number of symptoms was 7.5 (range, 0-32; women, 8.1; men, 6.5, p < 0.05). Regression analysis showed that patients who received a social security grant had 59% more symptoms than those who were employed and that people with asthenia and depression/anxiety had 44% and 23% more symptoms, respectively than those with all other diagnoses. The patterns of symptoms reported showed similar patterns across the five most prevalent diagnoses.

CONCLUSIONS

Patients in general practice report a number of symptoms and share a common pattern of symptoms, which appear to be partly independent of the diagnoses given. These findings suggest that symptoms are not necessarily an indication of disease.KEY POINTSPatients consulting general practitioners have a high number of self-reported symptoms.The most frequent symptoms are tiredness, lower back pain, neck pain, headache, shoulder pain, and sleep problems.Patients diagnosed with asthenia and depression/anxiety report the highest number of symptoms.Selected diagnoses show similar patterns in symptom distribution.Symptoms are not necessarily an indication of disease.

All-cause and cause-specific mortality rates of patients treated for alcohol use disorders: A meta-analysis

BACKGROUND

Although alcohol use disorders (AUDs) are known to increase the relative risk of all-cause and some cause-specific mortality, the absolute mortality rates of the AUD population are unknown. Such knowledge would benefit planners of the provision of services for this population, including in prioritizing the identification and/or treatment of diseases likely to cause their death.

METHODS

We conducted a systematic review of studies in English, reporting the cause-specific mortality rates among people treated for AUDs. Number of deaths by cause and total person-years of follow-up were extracted. All-cause and cause-specific mortality rates per 1000 person-years were meta-analyzed assuming random effects.

RESULTS

Thirty-one studies were included. Participants were mainly middle-aged males. The quality of studies was generally good. A total of 6768 all-cause deaths in 276,990.7 person-years of follow-up (36,375 patients) were recorded, and the pooled all-cause mortality rate was 27.67/1000 person-years (py) (95% confidence interval [CI]: 23.9, 32.04). The most common cause of death in the AUD population was cardiovascular disease (CVD) (6.9/1000 py; 95% CI: 5.61, 8.49), followed by gastrointestinal deaths (5.63/1000 py; 95% CI: 4.1, 7.74), unnatural deaths (4.95/1000 py; 95% CI: 4.01, 6.09)), neoplasms, respiratory diseases, and substance use disorders.

CONCLUSIONS

Patients with AUDs have increased rates of all-cause and cause-specific mortality compared with the general population. Like the general population, they are most likely to die of CVD. In contrast to the general population, gastrointestinal and unnatural deaths are the next most common causes of death. We believe these facts should be considered when planning health care services for patients with AUDs.

The effect of structured personal care on diabetes symptoms and self-rated health over 14 years after diabetes diagnosis

AIMS

To explore the effect of structured personal care on diabetes symptoms and self-rated health over 14 years after diabetes diagnosis while patients are gradually diagnosed with other chronic conditions (multimorbidity).

METHODS

Post hoc analysis of the Danish randomized controlled trial Diabetes Care in General Practice including 1381 patients newly diagnosed with type 2 diabetes. The effect of structured personal care compared with routine care on diabetes symptoms and self-rated health was analysed 6 and 14 years after diagnosis with a generalized multilevel Rasch model.

RESULTS

Structured personal care reduced the overall likelihood of reporting diabetes symptoms at the end of the intervention (OR 0.79; 95% CI: 0.64-0.97), but this effect was not explained by glycaemic control or multimorbidity. There was no effect of the intervention on diabetes symptoms after 14 years or on self-rated health after 6 years or 14 years.

CONCLUSIONS

Structured personal care had a beneficial effect on diabetes symptoms 6 years after diagnosis, but not on self-rated health at either follow up point. To optimally manage patients over time it is important to supplement clinical information by information provided by the patients.

Activation of professional and personal network relations when experiencing a symptom: a population-based cross-sectional study

OBJECTIVE

To describe patterns of disclosure of symptoms experienced among people in the general population to persons in their personal and/or professional network.

DESIGN

A population-based cross-sectional study. Data were collected from a web-based survey.

SETTING

The general population in Denmark.

PARTICIPANTS

100 000 individuals randomly selected, representative of the adult Danish population aged ≥20 years were invited. Approximately 5% were not eligible for inclusion. 49 706 (men=23 240; women=26 466) of 95 253 eligible individuals completed the questionnaire; yielding a response rate of 52.2%. Individuals completing all questions regarding social network relations form the study base (n=44 313).

PRIMARY AND SECONDARY OUTCOME MEASURES

Activation of personal and/or professional relations when experiencing a symptom.

RESULTS

The 44 313 individuals reported in total 260 079 symptom experiences within the last 4 weeks. No professional network relation was used in two-thirds of all reported symptoms. The general practitioner (GP) was the most frequently reported professional relation activated (22.5%). People reporting to have available personal relations were slightly less inclined to contact the GP (21.9%) when experiencing a symptom compared with people with no reported personal relations (26.8%). The most commonly activated personal relations were spouse/partner (56.4%) and friend (19.6%). More than a quarter of all reported symptom experiences was not shared with anyone, personal nor professional. The symptom experiences with the lowest frequency of network activation were symptoms such as black stool, constipation, change in stool texture and frequent urination.

CONCLUSION

This study emphasises variation in the activation of network relations when experiencing a symptom. Symptoms were shared with both personal and professional relations, but different patterns of disclosures were discovered. For symptoms derived from the urogenital or colorectal region, the use of both personal and professional relations was relatively small, which might indicate reticence to involve other people when experiencing symptoms of that nature.

Relation between health problems and sickness absence: gender and age differences

Women have higher long-term sickness absence rates than men, and higher rates of most health problems. The rates vary with type of problem and diagnosis. The objectives were to examine whether equal proportions of women and men had sickness absence when they had a given health problem, and if disparities were diagnosis specific. Prevalence of low-back pain, psychiatric disorders, and injuries was assessed in random samples of two populations in Norway. Prevalence of long-term sickness absence for the same diagnostic categories was estimated for the same time period (1990). For injuries, the prevalence ratios between a health problem and a sickness absence were equal for women and men. For psychiatric health problems, there were 1.7 more women than men behind each sickness absence. Low-back pain showed an intermediate gender ratio of 1.3, indicating that also for this condition women tended to have less sickness absence. Musculoskeletal and psychiatric health problems (fluctuating, chronic) may result in more gender-biased, subjective, and random assessment of work ability than injuries (acute health problem).

Being a psychiatric patient in the community- reclassified as the stigmatized "other' '

Aims: To explore the experiences of psychiatric patients living in six rural communities in Norway from a primary care perspective. Methods: A "Knowledge workshop'' (KW) was designed. It was a special kind of meeting between users of services for people with mental illness and service providers. The process and outcome were documented on fl ipcharts and audiotape and analysed by a qualitative method. Results: A main statement was constructed in order to capture the essence of meaning in the 10 main themes identified in the analysis. The statement is mainly about the process and state of being reclassified as a stigmatized "other'' , with serious consequences for both self-esteem and public esteem. The consequences include isolation and loneliness, low self-esteem, no paid work, lack of money, discrimination, and harassment. Other consequences include altered behaviour from others, lack of necessary conditions for empowerment, and the danger of becoming visible as mentally ill. Attitudinal change is called for. Conclusions: Although the stigma of mental illness is a well-known and much discussed fact, it has so far not really been included in the professional knowledge base. It is still practically absent from discussions of quality of care. In order for services to be relevant to people who need them, professionals can no longer ignore issues that are of major importance for users. Stigma must thus be included in the conceptual thinking about serving people with mental illness. The inclusion of stigma as an issue for quality of care could be a fruitful way forward.

The Danish Symptom Cohort: Questionnaire and Feasibility in the Nationwide Study on Symptom Experience and Healthcare-Seeking among 100 000 Individuals

Introduction. In order to develop strategies to prevent delay in diagnosis, it is important to gain knowledge of symptoms and healthcare-seeking processes in the population. This paper describes a combined survey and register-based study with (1) focus on development of a questionnaire concerning experience of symptoms and subsequent consequences and (2) feasibility of the study. Methods. The study is a nationwide cohort study of 100 000 individuals randomly selected from the Danish general population. A comprehensive questionnaire concerning experience of symptoms and subsequent consequences was developed. The methodological framework for the development included defining the domains to be measured, identification of previous items, scales and questionnaires in the literature, and pilot and field testing. Results. A total of five domains and 16 subdomains were defined covering the area of symptom experience, symptom characteristics, reaction in response to symptom experience, external factors, and personality characteristics with potential influence on the symptom experience. In total, 49 706 questionnaires were completed, yielding a response rate of 52.2%. Conclusion. We developed a comprehensive questionnaire used in a large combined survey and register-based study concerning experience of symptoms and subsequent consequences of symptom experiences. We succeeded in conducting a large survey providing the groundwork for The Danish Symptom Cohort.

Multiple perspectives on symptom interpretation in primary care research

BACKGROUND

Assessment and management of symptoms is a main task in primary care. Symptoms may be defined as 'any subjective evidence of a health problem as perceived by the patient'. In other words, symptoms do not appear as such; symptoms are rather the result of an interpretation process. We aim to discuss different perspectives on symptom interpretation as presented in the disciplines of biomedicine, psychology and anthropology and the possible implications for our understanding of research on symptoms in relation to prevalence and diagnosis in the general population and in primary care.

DISCUSSION

Symptom experiences are embedded in a complex interplay between biological, psychological and cultural factors. From a biomedical perspective, symptoms are seen as possible indicators of disease and are characterized by parameters related to seriousness (e.g. appearance, severity, impact and temporal aspects). However, such symptom characteristics are rarely unambiguous, but merely indicate disease probability. In addition, the GP's interpretation of presenting symptoms will also be influenced by other factors. From a psychological perspective, factors affecting interpretation are in focus (e.g. internal frame of reference, attention to sensations, illness perception and susceptibility to suggestion). These individual factors cannot stand alone either, but are influenced by the surroundings. Anthropological research suggests that personal experiences and culture form a continuous feedback relationship which influence when and how sensations are understood as symptoms of disease and acted upon.

SUMMARY

The different approaches to symptom interpretation imply that we need to be cautious and conscious when interpreting survey findings that are based on symptom prevalence in the general population or in primary care. These findings will reflect a variety of interpretations of sensations, which are not equivalent to expressions of underlying disease. Furthermore, if diagnosis of disease is based exclusively on the presence of specific symptom characteristics, we may risk reinforcing a dualistic approach, including medicalisation of normal phenomena and devaluation of medically unexplained symptoms. Future research in primary care could gain from exploring symptoms as a generic phenomenon and raised awareness of symptom complexity.

Higher incidence of common diagnoses in patients with low back pain in primary care

Most studies on comorbidity in low back pain (LBP) have been conducted in specialized settings with the use of self-reports. This study has an original design using data from family practices: the incidence of the most frequent diseases was compared in patients with and without LBP in 2004. The database includes data from 67 family physicians in 52 family practices in Flanders, Belgium. It contains data from 160,000 different patients with 1,500,000 diagnoses during the period 1994 to 2004. The incidence of the most frequent diagnoses is presented in patients with and without LBP in 2004. The diagnoses were coded according to the ICPC-2-classification. In 2004, the incidence of LBP was 51.4‰ (95% CI: 49.8 to 53.1) in patients aged 18 or older. The incidence was slightly higher in women than in men: 53.0‰ (95% CI: 50.7 to 55.4) vs. 49.9‰ (95% CI: 47.7 to 52.3). The highest incidence was recorded in the age group of 50 to 54 years. The most frequent "other" diagnoses in patients with and without LBP are comparable, but some were more frequent in patients with LBP. Respiratory infections and diseases of the locomotor apparatus (neck syndrome, bursitis) are more frequent in patients with LBP. Low back pain is one of the most frequent diagnoses in general practice. Striking is the relatively higher frequency of common self-limiting diseases in patients with a diagnosis of LBP during the same year. To the authors' knowledge, this is the first time that medical demands for non-LBP reasons in family practice have been reported in patients with LBP.

What went and what came? Morbidity trends in general practice from the Netherlands

BACKGROUND

Fourty years of morbidity registration in general practice is a milestone urging to present an overview of outcomes. This paper provides insight into the infrastructure and methods of the oldest practice-based research network in the Netherlands and offers an overview of morbidity in a general practice population. Changes in morbidity and some striking trends in morbidity are presented.

METHODS

The CMR (Continuous Morbidity Registration) collects morbidity data in four practices, in and around Nijmegen, the Netherlands. The recording is anchored in the Dutch healthcare system, which is primary care based, and where every citizen is listed with a personal GP. Trends over the period 1985-2006 are presented as a three year moving average. As an indicator for 20-year prevalence trends we used the annual percentage change (APC). We restricted ourselves to morbidity, which is presented to the family physician on a frequent basis (overall prevalence rates >1.0/1000/year).

RESULTS

The age distribution of the CMR population is comparable to the general Dutch population. Overall incidence figures vary between 1500/1000 ptyrs (men) and 2000/1000 ptyrs (women). They are quite stable over the years, whereas overall prevalence figures are rising gradually to 1500/2500 ptyrs (men) and 2000/3500 ptyrs (women). Increase in prevalence rates for chronic conditions is diffuse and gradual with a few striking exceptions.

CONCLUSION

For morbidity patterns, the CMR database serves as a mirror of general practice. Practice-based research networks are indispensable for the development and maintenance of general practice as an academic discipline.

Relationship Between Habitual Refractive Errors and Headache Complaints in Schoolchildren

PURPOSE

Refractive error (RE) is considered to be a possible cause for headaches. We aimed to gain insight into the relation between habitual RE (sphere and astigmatism) and headache complaints.

METHODS

In a cross-sectional study the habitual refractive state of 487 children, aged between 11 and 13 years, was measured using an autorefractometer (Topcon, RM-8000B). Headache complaints were measured using a questionnaire. Data were analyzed using Pearson correlation coefficients, bivariate analysis, and multiple logistic regression analysis.

RESULTS

For right eyes we found 15% habitual myopia < -0.50 D and 12% habitual hyperopia > +0.50 D; habitual astigmatism > 0.25 D was found in 33% of children. Pearson R between right and left eyes was 0.76 for the spherical component and 0.42 for the cylindrical. In the total group of children 70% reported the occurrence of headache in the last year. These headaches were reported as "often or frequent" by 37% of children, "severe" by 15%, "with long duration" by 45%, and "with severe burden" by 27%. In the total sample we found various associations between gender, sphere/cylinder components of habitual RE, and headache complaints. Headache was reported more in girls than in boys. Of the total variance of headache complaints in girls, the sphere component of habitual RE explained 4% of frequency, 6% of intensity, 2% of duration, and 2% of amount of burden. Of the total variance of headache complaints in boys the cylinder component of habitual RE explained 3% of frequency, and 4% in amount of burden.

CONCLUSION

Habitual RE and headache complaints are relatively common conditions in schoolchildren aged between 11 and 13 years. Headache complaints showed a small but statistically significant association with the sphere component of habitual RE in girls and the cylinder component of habitual RE in boys. The associations found between habitual RE and headache complaints indicate that habitual RE might be a risk factor for headache in children.

Review of performance assessment and improvement in ambulatory medical care

Health care plans often consider quality of care as a means of containing rising health costs. The assessment of physician and group practice performance has become increasingly widespread in ambulatory care. This article reviews the three main methods used to improve and assess performance: practice audits, peer-review groups and practice visits. The focus is on Europe - which countries use which methods - and on the following aspects: which authorities or bodies are responsible for setting up and running the systems, are the systems mandatory or voluntary, who takes part in assessments and what is their motivation, are patients views taken into account. Many countries run parallel systems managed by authorities working at different hierarchical levels (national, regional or local). The reasons that underlie the choice of a particular system are discussed. They are mostly related to the national health care system and to cultural factors.