South African Family Practice - Volume 50, Issue 4, 2008
Volume 50, Issue 4, 2008
Awareness and perceptions of published osteoporosis clinical guidelines - a survey of primary care practitioners in the Cape Town metropolitan area : original researchSource: South African Family Practice 50 (2008)More Less
Background : Despite the widespread production and dissemination of clinical practice guidelines, both worldwide and in South Africa, they have not resulted in the expected improvements in quality of care and patient outcomes. There are limited studies concerning the impact of South African-developed guidelines on local physician behaviour and knowledge. Awareness of a guideline is a necessary prerequisite for its successful implementation. This study aimed to survey primary care practitioners in Cape Town employed in both the private and state sectors on their awareness and perceptions of the Osteoporosis Clinical Guidelines, published in the South African Medical Journal in September 2000.
Methods : A descriptive, cross-sectional survey design was used. A telephonic survey of 150 randomised Cape Town primary care practitioners was conducted (100 private general practitioners and 50 public sector primary care practitioners). A survey instrument developed for the study was applied in a standardised manner. The respondents' levels of awareness and perceptions of the published guideline on osteoporosis were evaluated.
Results : A total of 18.7% (95% confidence interval 12.5-24.9%) of the respondents reported being aware of the clinical guidelines. Of the primary care practitioners who were surveyed, 12.7% (95% confidence interval 7.4-18%) reported having read the guidelines. There was no difference in reported awareness of the guidelines between doctors working in the private and public sectors. The respondents who had read the guidelines were generally well disposed towards them. Significantly fewer public sector primary care practitioners felt able to implement the guidelines than private general practitioners - organisational barriers were most commonly cited as barriers to implementation.
Conclusion : Passive dissemination of the Osteoporosis Clinical Guidelines resulted in low levels of awareness among the surveyed group. This result has implications regarding future clinical guideline dissemination and implementation in South Africa. Further attention needs to be focused on developing implementation and dissemination strategies of evidence-based guidelines in South Africa.
Multidisciplinary training of undergraduate students in the Faculty of Health Sciences : hypertension as a case study : original researchSource: South African Family Practice 50 (2008)More Less
Background : Healthcare students should be aware of the specific skills, knowledge and management options of other disciplines in order to achieve an effective and cohesive working relationship.
Aim : The aim of this study was to expose healthcare students at the University of the Free State to one another's domains, as related to hypertension management, during a formal didactic lecture attended by medical, physiotherapy and dietetic students, and to determine whether they could apply in practice the theoretical knowledge regarding blood pressure measurement and exercise, obtained during a multidisciplinary session. The perceptions of students regarding multidisciplinary sessions were also to be obtained.
Method : Students received a formal lecture on hypertension from a medical doctor, a dietitian, a physiotherapist and an occupational therapist and they then worked in multidisciplinary groups to demonstrate the physiological effect of exercise on blood pressure and pulse rate. Students had to report their findings and perceptions of the session by completing data forms.
Results : A total of 125 medical, physiotherapy and human nutrition students participated in the session. The students were able to demonstrate the influence of exercise on blood pressure and pulse measurements. They reported that they enjoyed the multidisciplinary session and gained information on the scope of practice of the domains of the other disciplines. Negative feedback was received on the size of the groups and lack of equipment.
Conclusion : The students could apply theoretical knowledge in practice and all gave positive feedback. The sessions will continue in the current format but attention will be given to smaller groups and the availability of more equipment.
Evaluation of breast cancer awareness among women presenting with newly diagnosed breast disease at Universitas Hospital (Bloemfontein, South Africa) : original researchSource: South African Family Practice 50 (2008)More Less
Background : This study aimed at assessing breast cancer awareness among women presenting with newly diagnosed breast disease at Universitas Hospital in Bloemfontein, South Africa. The breast cancer awareness of the women, in turn, was related to their screening practices and the stage of breast cancer at presentation. Recommendations to address the clinical implications of the findings of this study were then suggested.
Methods : Reports of data on the number of breast cancer awareness campaigns held and the number of people reached during the period April to June 2006 were acquired from the main campaign organiser, CANSA. Data were also obtained by means of interviewer-administered structured questionnaires, from consenting women (n = 56) presenting with newly diagnosed breast disease at Universitas Hospital during the period May 2006 to April 2007. The study was approved by the Ethics Committee of the Faculty of Health Sciences of the University of the Free State.
Results : Despite aggressive nationwide public education on breast cancer and on the benefits of screening by CANSA breast cancer awareness, the examination and screening practices of women presenting with newly diagnosed breast disease at the Universitas Hospital were generally low. Most of the women interviewed presented with advanced breast cancer (stage 2 and 3), and reported that their healthcare professionals never initiated clinical breast examinations or mammograms.
Conclusion : This study has revealed low breast cancer awareness among women presenting with newly diagnosed breast disease at the Universitas Hospital, and hence low rates of self- and clinical examinations of the breast and low mammographic screening rates. This may be attributed to a general lack of awareness of the rising incidence of breast cancer in the Free State among both the public and healthcare professionals.
Missed opportunities for cervical screening at Worcester Hospital and Worcester Community Health Centre, Worcester, South Africa : original researchSource: South African Family Practice 50 (2008)More Less
Background : Cervical cancer is the only gynaecological malignancy for which a screening modality is widely accepted and recommended for all women. Just as in other developed countries, the decline in deaths from cervical cancer in the white population in South Africa after the mid-1960s has been attributed to cytological screening. The purpose of this study was to determine the extent of missed opportunities for cervical cancer screening by the healthcare service at Worcester Hospital and the closely associated Worcester Community Health Centre (CHC) for patients 30 years and older who presented at these centres for reasons unrelated to cervical cancer screening.
Methods : A descriptive cross-sectional survey was conducted using a questionnaire that was administered through personal interviewing. A sample of 235 patients was selected from six sampling units. Sampling was done proportionately, according to the average numbers of patients normally seen daily at the various units.
Results : The mean age of the sample was 47, with 30 and 81 being the youngest and oldest patients respectively. The mean level of education for the sample was Grade 7 (Std 5). The overall rate for missed opportunities for cervical cancer screening was 93.2% (95% Confidence Interval (CI) 90%96%), as only 6.8% of patients were asked about cervical (Papanicolaou) smears during consultation. None of the patients that were seen at the medical, surgical and orthopaedic clinics and casualty were asked about whether they had had a cervical pap smear; 56.5% (95% CI 36%76%) of the patients that were seen at the gynaecology clinic were asked and 2.3% (95% CI 0.3% 4.8%) from Worcester Community Health Centre were asked whether they had had a cervical smear. A total of 15.7% [37/235: 95% CI 11%20%)] had never had a cervical smear, while 84.3% (198/235) had had a cervical smear previously. Of those who had had a cervical smear previously, 51% [101/198: (95% CI 44%58%)] had it performed at a local clinic, 40.4% [80/198: (95% CI 34%47%)] at a secondary hospital, 5.6% [11/198 (95%CI 2.3%8.7%)] privately and 3% [6/198: 995% CI 0.6%5.4%)] at a tertiary hospital. Of those patients who had a smear done before (198), 52% [103/19852% (95% CI 45%59%)] were not given an appointment to return for the results, 32% (95% CI 25.8%38.8%) did not receive their results and 78.3% (95% CI 72.5%84.0%) were not advised on further management in the future. It is noteworthy that only 2.1% (5/235) of the patients had personally requested a cervical smear from a doctor at Worcester Hospital and Worcester CHC. A total of 6.8% (16/235) patients were asked during the consultation whether they had had a cervical smear done before. On enquiry, a total of 99.2% (95% CI 97.9%100%) of the patients said that they would have preferred to have received information about a cervical smear from their doctor.
Conclusion : Opportunities for cervical cancer screening were missed in patients attending Worcester Hospital and Worcester CHC. Women 30 years and older should routinely be asked about whether they are up to date with their cervical smears, irrespective of their presenting complaint. If they are found not to be up to date, they should have a cervical smear done or be referred appropriately to their clinics to have a cervical smear performed. When a smear has been done, a follow-up appointment should be made for them to be given the results, as well as advice regarding when the next smear is due. All such interactions between the patient and the healthcare worker should be clearly documented in the patient's record.
Risk factors precipitating exacerbations in adult asthma patients presenting at Kalafong Hospital, Pretoria : original researchSource: South African Family Practice 50 (2008)More Less
Background : Research into asthma is proceeding at an unprecedented rate and yet we live with a disease that escalates in prevalence and severity, despite a greater understanding of its pathophysiology and the necessary therapy. The total prevalence of asthma is estimated to lie at 7.2% of the world's population (6% in adults, 10% in children). Data from Australia, Canada and Spain report that acute asthma accounted for 1 to 12% of all adult emergency department visits. The prevalence of asthma in South Africa lies at 5% for adults and 10% for children. Asthma is reported as taking up 1 to 2% of the total health budget in direct costs, with equally large indirect costs being incurred for time lost from work and reduced productivity. It has also been reported that approximately one-third of the direct care costs of asthma are attributable to emergency department visits and hospitalisations. In some cases, exposure may be unavoidable (for example exposures to cold air, exercise or the asthma-inducing effects of pregnancy). Many studies have been done in other countries on specific triggers, especially allergens and viral respiratory infections. However, circumstances differ in the public sector in South Africa and other factors such as compliance and under-treatment, which may be applicable, should be studied in contention.
Methods : A matched case-control study was undertaken matched on age and gender between December 2003 and May 2005. Known asthma patients with exacerbations presenting at Kalafong Hospital's emergency unit were chosen as cases. Controls were stable asthma patients recruited from the outpatient departments. A structured questionnaire was used to interview patients concerning their possible exposure to certain triggers and risk factors. Univariate and multivariate analyses with conditional logistic regression were done to determine any significant exposures. Participants were between 18 and 65 years of age.
Results : In total, 356 patients were evaluated. Fifty cases and 100 controls were enrolled. Cases were shown to be more non-compliant than controls (OR = 2.18; 95% Confidence interval (CI): 1.09 to 4.38, p = 0.03). Missing follow-up doctor's appointments for the last six months were statistically significant with an OR of 2.39 (95% CI 1.08 to 5.27) and p = 0.03.
Conclusions : Non-compliance was a strong predictor of exacerbations in adult asthma patients at Kalafong Hospital.
Choosing, changing or adhering to a registered doctor in a managed care plan : what will it take? A qualitative survey in rural Mpumalanga, South Africa : original researchSource: South African Family Practice 50 (2008)More Less
Background : The phenomenon of doctor shopping has not yet attracted the attention of managers in the South African healthcare sector. Satisfaction with services is known to be mediated by the personal connection inherent in interpersonal continuity with the provider. Such a connection hinges on the fulfilment of expectations of what a good doctor should be at a relational level. With the advent of managed care in South Africa, the restriction on doctor choice and use is being enforced. There is evidence that adherence to one doctor has clinical and financial benefits. Clinical benefits are related to continuity of care, whilst financial gains to the patient and the healthcare system are acquired mainly through better co-ordination of care to avoid inefficiency and wastages. This study explores the concept and context of a 'good doctor', a prerequisite for adherence to one doctor, among members of a health plan targeting the low income community in South Africa.
Methods : This qualitative enquiry of what constitutes a 'good doctor' took place in the form of focus group discussions and key informant interviews and was conducted among members of a managed care health plan in Piet Retief, South Africa. The plan was designed specifically for the employed but uninsured population, a population group of strategic importance in the South African healthcare market. The participants in this study were purposively sampled to include a wide range of opinions about the characteristics of a good doctor.
Results : The respondents looked for values in a doctor that range from fairness, lack of discrimination, autonomy, dignity, warmth and taking time to do a job properly. Generally, the participants expressed willingness to adhere to one registered doctor on condition that the doctor was a 'good doctor'. The definition of a good doctor as provided by the participants was not based on strict technical / clinical criteria, but rather on the patients' and the community's recent experiences of care under that particular doctor. The typical good doctor is a popular, friendly person who does not discriminate along racial lines, listens seriously to anything presented to him or her and examines the patient properly. He / she takes the patient's illness seriously, refers when necessary and gives sick leave that can be used to see a traditional healer. The determinants of the choice of doctor were practical (e.g. the cost), although many were humanistic and difficult to quantify (e.g. word of mouth from fellow patients; the attitude of the doctor toward people; the popularity of the doctor in the community). The specific needs of the respondents relating to traditional healing, migration and sick leave are not readily captured in a standard medical aid contract.
Conclusion : Some characteristics of a 'good doctor' that are particular to the study population include emphasis on a non-discriminative approach, the value of understanding the patient, acceptance of traditional healing and the provision of sick leave when needed. This has important implications for the training of doctors (e.g. to expand the curriculum to include humanistic competencies) and the nature of a managed care contract.
Author Gboyega A. OgunbanjoSource: South African Family Practice 50 (2008)More Less
By the time you receive this issue of the journal, the 14th National Family Practitioners' conference in Rustenburg North-West province would have ended. The theme of the conference is "Turning Evidence into Practice" and most of the articles presented in this issue adequately demonstrate this theme.
Healthy lifestyle interventions in general practice : part 1 : an introduction to lifestyle and diseases of lifestyle : CPDSource: South African Family Practice 50, pp 6 –12 (2008)More Less
Poor lifestyle choices including physical inactivity, adverse nutrition and tobacco use are strongly associated with heart disease, diabetes, respiratory disease and cancer. These four diseases are responsible for over 50% of mortality worldwide. Yet lifestyle intervention is under emphasised in the undergraduate training of doctors and other health professionals. This article reviews the lifestyle factors related to chronic non-communicable disease and suggests small but meaningful interventions for general practitioners to incorporate into daily practice. The upcoming series to be published in Family Practice regarding "lifestyle modification in chronic disease states" is introduced.
Type 2 diabetes : primary health care approach for prevention, screening and diagnosis in South Africa : CPDSource: South African Family Practice 50, pp 14 –20 (2008)More Less
We have reviewed large studies that demonstrate different methods that have been adopted to prevent or delay the progression to Type 2 diabetes in high-risk individuals. The principal interventions include behavioural modifications in diet and physical activity, use of insulin sensitisers such as metformin and glitazones, and alpha-glucosidase inhibitors.
Although there is no evidence of benefit in health outcomes from large-scale population screening for impaired glucose tolerance (IGT) or impaired fasting glucose (IFG), screening of high-risk individuals has merit. During prolonged periods of dysglycaemia that precede diabetes, individuals remain largely asymptomatic. These periods can be from 8-10 years as extrapolated from the United Kingdom Prospective Diabetes Study data. This phase of pre-diabetes is not innocuous, and is often associated with the concurrent development of complications, which highlights the importance of early detection and treatment of this 'silent killer' Although different methods for screening of diabetes are available, preferred techniques include measurement of fasting plasma glucose and 2 hr post-load plasma glucose. People should be encouraged to eat correct diets, be active, and maintain a healthy weight - these behaviours have other benefits in addition to preventing or delaying the onset of Type 2 diabetes. There are various diagnostic criteria used for the diagnosis of diabetes. In this article we have presented two sets of criteria, one from the World Health Organization (WHO) and the other from the American Diabetes Association (ADA).
Author F. GuidozziSource: South African Family Practice 50, pp 22 –24 (2008)More Less
Author E.M. IrusenSource: South African Family Practice 50, pp 28 –36 (2008)More Less
The medications used in asthma have been the subject of intense study over the last three decades. We now have extensive insights into their structure, regulation, receptors and mechanisms of action. Their intersection with the complexity of asthma inflammation has also been well characterised. In parallel, good quality pharmaceutical trials have informed national guidelines and patient-centered outcomes have been explored. With this therapeutic armamentarium the practitioner should aim to achieve the goals of asthma therapy that are focused on clinical and lung function parameters. The concept of complete asthma control is the current benchmark.
Airway inflammation is the fundamental problem in asthma and, logically, anti-inflammatory therapy in the form of inhaled corticosteroids is the single most important intervention. The importance of appropriate use of inhaler devices cannot be sufficiently emphasised. The clinician carefully titrates this treatment utilising additional medications for synergy and to modulate side-effects and costs. The contemporary standard of asthma care is a single inhaler with a combination of inhaled corticosteroids (ICS) and long-acting beta adrenoceptor agonists. The alternative is to add leukotriene modifiers to ICS therapy; there are special circumstances when this may be more appropriate. Poor inhaler use and concomitant allergic rhinitis are examples when supplementation with anti-leukotriene agents would be prudent. With whatever therapeutic strategy, regular education of the patient, tailoring of medication and monitoring of asthma are still crucial to ensure that the goals of asthma control are achieved and maintained in the long term.
Author J.L. RoosSource: South African Family Practice 50, pp 38 –43 (2008)More Less
Depressive disorder is the most common mental health problem in older people. Health professionals mainly come into contact with those who are most susceptible to depression, including older people who live in residential facilities and the frail with acute or chronic physical illness. Quite often, such individuals also exhibit multiple pathology. Under these circumstances, health professionals may have an exaggerated view of the extent of depression among the elderly, causing them to overlook depressive disorders that they may have developed. Organic factors, including alcohol and iatrogenic drugs, must be ruled out in the aetiology. Physical ill health must receive optimum treatment. The choice of antidepressant drug is based on the side-effect profiles and potential drug-drug interactions, rather than on the degree of therapeutic efficacy. Treatment should be multimodal and multidisciplinary, with the aim of complete recovery and not simple improvement. By using a range of treatments, most patients will recover, though keeping patients well is more difficult. Treatment should be continued for at least 12 months. Many patients who could benefit from long-term maintenance therapy do not receive it. With optimum management the prognosis is at least as good as that for any other stage of adult life.
An approach to the diagnosis, treatment and referral of tuberculosis patients : the family practitioner's role : CPDSource: South African Family Practice 50, pp 44 –50 (2008)More Less
The family practitioner in private practice is a key role player within the primary health care system and should play a bigger role in national tuberculosis (TB) control. TB training at medical undergraduate level is often not adequate and continuous medical education is necessary to develop capacity among private family practitioners. The Department of Health should also encourage the involvement of especially the private family practitioners in district TB control, which is a long overdue public-private interaction. This article discusses the role of the family practitioner to better diagnose, treat and refer tuberculosis patients.
Source: South African Family Practice 50, pp 52 –54 (2008)More Less
Undergraduate and postgraduate medical education entails acquiring and maintaining technical skills of various natures. Peripheral venous cannulation, splinting of fracture, wound suturing, venous cut-down and intra-osseous catheter placement for the most part, are considered minimally invasive procedures. The traditional way of skill acquisition could be summarised by the adage ''See one, do one, teach one''. Although the saying may be a misrepresentation of the reality, it should not be an optional educational approach. Patients undergoing a procedure under general anaesthesia are often not informed of the possibility that they could be used for ''ghost procedures'' - part or whole of the procedure is performed by a trainee. An attitude of ''don't ask, don't tell'' devalues patients' autonomy and the trainee's moral integrity. In view of the polarisation of the views about teaching, acquiring, and maintaining technical skills, institutions should consider and deliberate on these principles and reach consensus on a set of guidelines to clarify and limit the practice of learning technical skills on patients and on the newly dead. Informed consent procedures and requirements must be clearly established and communicated. The learning and proficiency practices should be restricted to the staff that can truly benefit from the experience. The practice of 'don't ask, don't tell' is not an option.
Author Pierre J.T. De VilliersSource: South African Family Practice 50 (2008)More Less
South Africa embarked on the road to establish family medicine as a medical specialty during the early 1990s. A special registration category of "family physician" was created to give recognition to practitioners who have completed postgraduate education in family medicine, such as the MFamMed or MCFP(SA). In 2000, a compulsory period of vocational training for registration in this category was introduced, which meant a period of supervised clinical training in an approved clinical training position. Applicants for registration in this category were screened and accredited by the Committee for Family Medicine (CFM) of the Medical and Dental Professions Board (MDPB).
Author D. LutchmanSource: South African Family Practice 50 (2008)More Less
The relationship between early wheezing and subsequent development of asthma is controversial; and the relationship between early childhood viral infection and atopic sensitisation is equally controversial. Additionally, accumulating evidence suggests that susceptibility to viral infection and atopy may derive from a common set of transient developmental defects in cellular immune functions operative during early infancy, which further complicate considerations of causal versus consequential interactions between these disease processes and how they impact on asthma development.
Setting the stage for risk-sharing agreements : international experiences and outcomes-based reimbursement : open forumAuthor J.L. CarapinhaSource: South African Family Practice 50, pp 62 –65 (2008)More Less
Background : Biological medicines are clinically effective but very expensive in South Africa. The business decisions of bio-logical manufacturers and payers (medical schemes) impact the access patient's have to biological medicines. This paper presents risk-sharing agreements as a means of managing the risk of introducing biological medicines into the healthcare market.
Methods : The paper critically reviews literature of some prominent international experiences with risk-sharing agreements and the nuances associated with such agreements. The paper also critiques the outcomes-based reimbursement of biological medicine and the structural necessities for its successful implementation.
Results : A risk-sharing agreement is a useful tool to manage the risk of introducing clinically effective and very expensive medicines into the healthcare market. It is also a tool that bridges the conflicting priorities of the manufacturer of biological medicine and the payer.
Conclusion : The application of risk-sharing agreements within an international context informs the local discussion. This paper is the first in a two-part series that serves to review the international experience with risk-sharing agreements and critique the outcomes-based reimbursement of biological medicines. The backdrop is set for a discussion of the application of risk-sharing agreements in South Africa, which is the purpose of the second paper in this series.
The UFS Faculty of Health Sciences Faculty Forum a critical evaluation by heads of department : letter : correspondenceSource: South African Family Practice 50, pp 72 –73 (2008)More Less
Source: South African Family Practice 50 (2008)More Less
Source: South African Family Practice 50 (2008)More Less