2008 Alexander S. Nadas Lecture—Repaired, Not Cured

Circulation ◽  
2008 ◽  
Vol 118 (suppl_18) ◽  
Author(s):  
Amnon Rosenthal
Keyword(s):  
Primary Care ◽  
School Health ◽  
Care Physician ◽  
Care Plan ◽  
Congenital Defects ◽  
Optimal Care ◽  
Term Care ◽  
Cardiac Defects ◽  
Number Of Patients ◽  
Medical Advances

A large number of patients with congenital cardiac disease have a repaired but not cured malformation. Although some mild cardiac defects may heal spontaneously, others persist or progress with advancing age. Among those with a major or complex defect repaired by interventional and/or surgical procedures, few are cured. Whereas major cardiac defects often occur as an isolated anomaly, many patients have serious extracardiac congenital defects, systemic syndromes, genetic abnormalities, or other handicaps. In caring for the patient, the pediatric cardiologist, in addition to directing cardiac therapy, is often called upon to coordinate the diverse care, plan, and guide for the patient’s future. It is a chronic disorder often recognized in the fetus, proceeding through infancy, childhood, and into adulthood, thus requiring long-term care. The medical and surgical therapy is usually provided by subspecialist colleagues within the field. However, delivery of appropriate, comprehensive, and optimal care requires a “quarterback” cardiologist concerned with diverse, frequently inevitable issues, such as prematurity, nutrition, growth, or genetic screening. Important concomitant problems may be related to associated extracardiac anomalies, exercise capacity, school, health or life insurance, employment, pregnancy, and family life. A primary care physician might be uncomfortable advising on many of these issues and the responsibility falls to the cardiologist. Anticipated medical advances may further impact the care and require yet greater coordination of services and close empathetic attention. These changes may include further cardiologist subspecialization, primary care provided by nurse clinicians, fetal cardiac intervention, increase in regionalization of specialty care, or more complex laboratory procedures—all not infrequently replacing the careful medical history and physical examination.

Primary care physician services and the frequency of comorbidities in patients with acute myocardial infarction

2021 ◽  
Vol 28 (Supplement_1) ◽  
Author(s):  
R King ◽  
D Giedrimiene
Keyword(s):  
Myocardial Infarction ◽  
Primary Care ◽  
Acute Myocardial Infarction ◽  
Primary Care Physician ◽  
Care Physician ◽  
Adverse Outcomes ◽  
Coronary Syndrome ◽  
Number Of Patients ◽  
Significant Difference ◽  
The Impact

Abstract Funding Acknowledgements Type of funding sources: None. Background The management of patients with multiple comorbidities represents a significant burden on healthcare each year. Despite requiring regular medical care to treat chronic conditions, a large number of these patients may not receive proper care. Significant disparities have been identified in patients with multiple comorbidities and those who experience acute coronary syndrome or acute myocardial infarction (AMI). Only limited data exists to identify the impact of comorbidities and utilization of primary care physician (PCP) services on the development of adverse outcomes, such as AMI. Purpose The primary objective was to analyze how PCP services utilization can be associated with comorbidities in patients who experienced an AMI. Methods This study was based on retrospective data analysis which included 250 patients admitted to the Hartford Hospital Emergency Department (ED) for an AMI. Out of these, 27 patients were excluded due to missing documentation. Collected data included age, gender, medications and recorded comorbidities, such as hypertension, hyperlipidemia, diabetes mellitus (DM), chronic kidney disease (CKD) and previous arrhythmia. Each patient was assessed regarding utilization of PCP services. Statistical analysis was performed in order to identify differences between patients with documented PCP services and those without by using the Chi-square test. Results The records allowed for identification of documented PCP services for 172 out of 223 (77.1%) patients. The most common comorbidities were hypertension and hyperlipidemia: in 165 (74.0%) and 157 (70.4%) cases respectively. The most frequent comorbidity was hypertension: 137 out of 172 (79.7%) in pts with PCP vs 28 out of 51 (54.9%) without PCP, and significantly more often in patients with PCP, p< 0.001. Hyperlipidemia was the second most frequent comorbidity: in 130 out of 172 (75.6%) vs 27 out of 51 (52.9%) accordingly, and also significantly more often (p< 0.002) in patients with PCP services. The number of comorbidities ranged from 0-5, including 32 (14.3%) patients without comorbidities: 16 (9.3%) with a PCP and 16 (31.4%) without PCP services. The majority of patients - 108 (48.5% of 223), had 2-3 documented comorbidities: 89 (51.8%) had two and 19 (34.6%) had three. The remaining 40 (17.9%) patients had 4-5 comorbidities: 37 (21.5%) of them with a PCP and 3 (10.3%) without, with a significant difference (p < 0.001) found for patients with a higher number of comorbidities who utilized PCP services. Conclusions Our study shows that the majority of patients who presented with an AMI had one or more comorbidities. Furthermore, patients who did not utilize PCP services had fewer identified comorbidities. This suggests that there may be a significant number of patients who experienced AMI with undiagnosed comorbidities due to not having access to PCP services.

scholarly journals Medical Cannabis for the Primary Care Physician

2019 ◽  
Vol 10 ◽  
pp. 215013271988483 ◽  
Author(s):  
Deepika Slawek ◽  
Senthil Raj Meenrajan ◽  
Marika Rose Alois ◽  
Paige Comstock Barker ◽  
Irene Mison Estores ◽  
...  
Keyword(s):  
Primary Care ◽  
Primary Care Physician ◽  
Primary Care Physicians ◽  
The United States ◽  
Care Physician ◽  
Chronic Health Conditions ◽  
Health Conditions ◽  
Efficacy And Safety ◽  
Medical Cannabis ◽  
Number Of Patients

Medical cannabis use is common in the United States and increasingly more socially acceptable. As more patients seek out and acquire medical cannabis, primary care physicians will be faced with a growing number of patients seeking information on the indications, efficacy, and safety of medical cannabis. We present a case of a patient with several chronic health conditions who asks her primary care provider whether she should try medical cannabis. We provide a review of the pharmacology of medical cannabis, the state of evidence regarding the efficacy of medical cannabis, variations in the types of medical cannabis, and safety monitoring considerations for the primary care physician.

scholarly journals Are Care Plans Suitable for the Management of Multiple Conditions?

2016 ◽  
Vol 6 (2) ◽  
pp. 103-113 ◽  
Author(s):  
Charlotte E. Young ◽  
Frances M. Boyle ◽  
Allyson J. Mutch
Keyword(s):  
Primary Care ◽  
Patient Preferences ◽  
Care Plan ◽  
Care Practice ◽  
Multiple Chronic Conditions ◽  
Comorbid Conditions ◽  
Care Needs ◽  
Care Plans ◽  
Number Of Patients ◽  
Multiple Conditions

Background Care plans have been part of the primary care landscape in Australia for almost two decades. With an increasing number of patients presenting with multiple chronic conditions, it is timely to consider whether care plans meet the needs of patients and clinicians. Objectives To review and benchmark existing care plan templates that include recommendations for comorbid conditions, against four key criteria: (i) patient preferences, (ii) setting priorities, (iii) identifying conflicts and synergies between conditions, and (iv) setting dates for reviewing the care plan. Design Document analysis of Australian care plan templates published from 2006 to 2014 that incorporated recommendations for managing comorbid conditions in primary care. Results Sixteen templates were reviewed. All of the care plan templates addressed patient preference, but this was not done comprehensively. Only three templates included setting priorities. None assisted in identifying conflicts and synergies between conditions. Fifteen templates included setting a date for reviewing the care plan. Conclusions Care plans are a well-used tool in primary care practice, but their current format perpetuates a single-disease approach to care, which works contrary to their intended purpose. Restructuring care plans to incorporate shared decision-making and attention to patient preferences may assist in shifting the focus back to the patient and their care needs.

Serial concept mapping: A tool to assess the evolution of medical student learning about cancer survivorship.

2018 ◽  
Vol 36 (7_suppl) ◽  
pp. 21-21
Author(s):  
Miklos C. Fogarasi ◽  
Roy P Eichengreen
Keyword(s):  
Primary Care ◽  
Critical Thinking ◽  
Concept Mapping ◽  
Primary Care Physician ◽  
Cancer Survivorship ◽  
Health Care Professionals ◽  
Care Physician ◽  
Care Plan ◽  
Survivorship Care Plan ◽  
Wide Range

21 Background: Concept mapping (CM) fosters meaningful learning yet its use in cancer education is rare. Serial CM as a learning tool may offer novel ways to promote critical thinking about complex medical issues. We introduced CM in our Cancer Survivorship (CS) elective to study the evolution of students’ conceptual learning, to offer feed-back and as a tool for inter-professional and team-based education. Methods: The study was funded by an institutional grant and received IRB exemption. Eleven 2nd year medical students and 2 pre-med students enrolled. Oncologist-lead classes were co-facilitated by a primary care physician, a survivor, caregivers or other health care professionals. Students were trained using cMAPTools on week 1 and applied domains of the Quality of Life (QoL)-CS tool by City of Hope to their CMs. Feedback given after each round of mapping assessed adequate use of CS concepts and creation of meaningful linkages. Results: Map #1 (week 1) tested baseline perceptions. These maps displayed a wide-range of complexity, a largely non-hierarchical structure with rare connections and a sense of overload by the scope of CS issues. Map #2 (week 4) explored physical and spiritual challenges of CS from a primary care physician and a cancer survivor. Here improved maps presented concepts more clearly but linear thinking with limited crosslinks was still observed. Map #3 (week 8) about social aspects of CS followed lively sessions with a social worker and family caregivers. Emerging cross-links reflected a deeper understanding of survivor issues. Final CMs will be based on interviewing a panel of survivors and should aid students in creating a thorough Survivorship Care Plan. Team-based and inter-professional maps were well received. Conclusions: Serial concept mapping exposes progressive understanding of Survivorship issues during a one-semester elective. CM facilitates the learning of relationships among complex survivorship topics. Inter-professional and team-based CM is feasible. By mapping issues to QoL domains, students practice patient-centered critical thinking. Challenges include low reproducibility due to changing concepts, and limited practicality once concepts grow too large.

Chronic Daily Headache with Medication Overuse: A Randomized Follow-Up by Neurologist or PCP

Cephalalgia ◽  
2009 ◽  
Vol 29 (8) ◽  
pp. 855-863 ◽  
Author(s):  
MG Bøe ◽  
R Salvesen ◽  
Å Mygland
Keyword(s):  
Primary Care ◽  
Medication Overuse ◽  
Medication Overuse Headache ◽  
Care Physician ◽  
Number Of Patients ◽  
Group A ◽  
Withdrawal Therapy ◽  
Daily Headache ◽  
Group B

Several studies have shown the benefit of withdrawal therapy when medication overuse headache (MOH) is suspected. Our aim was to compare the effect of withdrawal therapy in patients followed by a neurologist (group A, n = 42) and a primary care physician (PCP) (group B, n = 38). Patients were randomized to A or B, and follow-up was at 3, 6 and 12 months. Calculated mean headache (MH at 6 months + MH at 12 months)/2 (primary end-point) was similar; A 1.04 (0.87, 1.21) and B 1.02 (0.82, 1.21) ( P = 0.87). The number of patients with 50% improvement of headache days was also similar; 14/42 in group A vs. 12/34 in B ( P = 0.86) at 3 months, 15/42 vs. 11/33 ( P = 0.83) at 6 months and 15/42 vs. 14/38 ( P = 0.92) at 12 months. Days without headache during the last 9 months of follow-up were 123 (96, 150) in group A and 137 (112, 161) in B ( P = 0.62). After 3 months one-third were classified as MOH. Patients with MOH improved similarly in group A and B, and so did patients without MOH. Within 1 year 7/42 in A and 9/38 in B had recurrent medication overuse ( P = 0.43). In summary, there were no significant differences in follow-up results between the two groups.

scholarly journals General Practice Services in England During the COVID-19 Pandemic and Beyond: Patient Access and Barriers

2021 ◽  
pp. 70-77
Author(s):  
Pablo Millares Martin
Keyword(s):  
Primary Care ◽  
Age Groups ◽  
Careful Consideration ◽  
Care Physician ◽  
Readiness For Change ◽  
Health Needs ◽  
Online Information ◽  
Care Services ◽  
Primary Care Services ◽  
Number Of Patients

Background: During the coronavirus disease (COVID-19) pandemic, primary care services have been forced to operate differently, limiting face-to-face consultations and relying on telemedicine. This has impacted the care received by patients in need of primary care. The aim of this article was to assess the patient needs during the pandemic, their perspectives on current interactions with primary care, and the readiness for change in operating general practices in the future. Method: A survey was conducted among patients in Leeds, UK, that explored whether patients had health needs during the pandemic, the decisions that were then taken if so, their use of online information and resources, and their satisfaction with primary care website portals and consultations. Results: Over 75% of patients gathered information online before deciding to consult. The main effect of the pandemic was that among those whose health needs remained, 37% did not consult, preferring to wait to see if their symptoms resolved by themselves. There was a significant statistical difference depending on age groups: among those patients aged <30 years, 48% did not consult a primary care physician. Conclusion: The primary care response during the pandemic led to a large number of patients to withhold their concerns, and careful consideration is needed to access how to improve accessibility in future crises.

Optimal measures for primary care physician encounters after stroke and association with survival: a data linkage study

2021 ◽  
Author(s):  
David Ung ◽  
Yun Wang ◽  
Vijaya Sundararajan ◽  
Derrick Lopez ◽  
Monique F. Kilkenny ◽  
...  
Keyword(s):  
Primary Care ◽  
Primary Care Physician ◽  
Primary Care Physicians ◽  
Cox Regression ◽  
Information Criterion ◽  
Median Number ◽  
Care Physician ◽  
Composite Measure ◽  
Optimal Care ◽  
Clinical Registry

Background and Purpose: Primary care physicians provide ongoing management after stroke. However, little is known about how best to measure physician encounters with reference to longer term outcomes. We aimed to compare methods for measuring regularity and continuity of primary care physician encounters, based on survival following stroke using linked healthcare data. Methods: Data from the Australian Stroke Clinical Registry (2010-2014) were linked with Australian Medicare claims from 2009 2016. Physician encounters were ascertained within 18 months of discharge for stroke. We calculated three separate measures of continuity of encounters (consistency of visits with primary physician) and three for regularity of encounters (distribution of service utilization over time). Indices were compared based on 1-year survival using multivariable Cox regression models. The best performing measures of regularity and continuity, based on model fit, were combined into a composite ‘optimal care’ variable. Results: Among 10,728 registrants (43% female, 69% aged ≥65 years), the median number of encounters was 17. The measures most associated with survival (hazard ratio [95% confidence interval], Akaike information criterion [AIC], Bayesian information criterion [BIC]) were the: Continuity of Care Index (COCI, as a measure of continuity; 0.88 [0.76 1.02], p=0.099, AIC=13746, BIC=13855) and our persistence measure of regularity (encounter at least every 6 months; 0.80 [0.67 0.95], p=0.011, AIC=13742, BIC=13852). Our composite measure, persistent plus COCI ≥80% (24% of registrants; 0.80 [0.68 0.94], p=0.008, AIC=13742, BIC=13851), performed marginally better than our persistence measure alone. Conclusions: Our persistence measure of regularity or composite measure may be useful when measuring physician encounters following stroke.

scholarly journals Effects of discontinuation of chronic medication in primary care: a systematic review of deprescribing trials

2018 ◽  
Vol 68 (675) ◽  
pp. e663-e672 ◽  
Author(s):  
Sioe Lie Thio ◽  
Joana Nam ◽  
Mieke L van Driel ◽  
Thomas Dirven ◽  
Jeanet W Blom
Keyword(s):  
Systematic Review ◽  
Primary Care ◽  
Care Physician ◽  
Evidence Based ◽  
Chronic Medication ◽  
Primary Care Settings ◽  
Number Of Patients ◽  
The Mean ◽  
Randomised Controlled

BackgroundPolypharmacy is becoming more prevalent and evaluation of appropriateness of medication use is increasingly important. The primary care physician often conducts the deprescribing process; however, there are several barriers to implementing this.AimTo examine the feasibility and safety of discontinuation of medication, with a focus on studies that have been conducted in the community, that is, primary care (or general practice) and nursing homes.Design and settingThis systematic review included randomised controlled trials published in 2005–2017, which studied withdrawal of long-term drugs prescribed in primary care settings and compared continuing medication with discontinuing.MethodPubMed and EMBASE searches were conducted and the extracted data included the number of patients who successfully stopped medication and the number of patients who experienced relapse of symptoms or restarted medication.ResultsA total of 27 studies reported in 26 papers were included in this review. The number of participants in the studies varied from 20 to 2471 and the mean age of participants ranged from 50.3 years to 89.2 years. The proportion of patients who successfully stopped their medication varied from 20% to 100%, and the range of reported relapse varied from 1.9% to 80%.ConclusionOnly a few studies have examined the success rate and safety of discontinuing medication in primary care, and these studies are very heterogeneous. Most studies show that deprescribing and cessation of long-term use seem safe; however, there is a risk of relapse of symptoms. More research is needed to advise physicians in making evidence-based decisions about deprescribing in primary care settings.

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