The association between chiropractors’ view of practice and patient encounter-level characteristics in Ontario, Canada: a cross-sectional study

Background Chiropractors have diverse views of practice, but the impact on their patient profiles and treatment approaches remains unclear. We assessed the association between chiropractors’ view of practice (unorthodox versus orthodox) and patient encounter-level characteristics among chiropractors who practice in Ontario, Canada. Methods We conducted a cross-sectional study using Ontario Chiropractic Observation and Analysis STudy (O-COAST) data. In O-COAST, Ontario chiropractors were randomly recruited from a list of registered chiropractors in 2015 and recorded up to 100 consecutive patient encounters. We classified chiropractors’ response regarding their views of practice as unorthodox when viewing “vertebral subluxation as an encumbrance to health that is corrected to benefit overall well-being”; other views were considered orthodox. Patient encounter-level characteristics included: (1) non-musculoskeletal reason-for-encounter; (2) subluxation as diagnosis; (3) duration of encounter (log-transformed for modeling); (4) unimodal manipulative treatment; and (5) patient health characteristics (good health status, some activity limitations). We conducted multilevel logistic regression to assess the association between view of practice and aforementioned characteristics, accounting for potential confounders and clustering of encounters within chiropractors. The multilevel models had two levels (level 1—patient encounter level; level 2—chiropractor level), with level 1 patient encounters nested within level 2 chiropractors. Results We included 40 chiropractors (mean age = 43.4 years, SD = 11.5) and 3,378 chiropractor-patient encounters. The 2,332 unique patients identified had a mean age of 48.5 years (SD = 18.5). Chiropractors with unorthodox views had higher odds of having patients with a non-musculoskeletal reason-for-encounter (adjusted odds ratio (aOR) 16.5, 95% CI 3.2–84.0) and subluxation as diagnosis (aOR 63.0, 95% CI 4.2–949.1). Encounters of chiropractors with unorthodox views were 0.6 times shorter than those with orthodox views (95% CI 0.4–0.9). Chiropractor level explained 32%, 75%, and 49% of the variability in non-musculoskeletal reason-for-encounter, subluxation as diagnosis, and encounter duration, respectively. We observed no association between unorthodox view and unimodal manipulative treatment or patient health characteristics. Conclusions Chiropractors’ unorthodox view of practice was associated with treating non-musculoskeletal conditions, subluxation as diagnosis, and shorter duration of encounter. Chiropractor level explained a high proportion of variability in these outcomes. Findings have implications for understanding chiropractic practice and informing interprofessional collaboration.

P and Z ICPC2 classifications as reason for encounter for sex and age in central Portugal in 2016 and 2019

Background ICPC2 reasons for encounter classified in P (Psychological) and Z (Social) chapters are scarce in the medical literature. We aimed to verify the frequency of such reasons for encounter classified in P and Z ICPC-2 chapters, to perceive their association by sex and age in the post-economic 2011 to 2015 economic and financial Portuguese crisis, calculating its trends from 2016 to 2019. Methods Observational, cross-sectional study in 2020 comparing data from 2016 and 2019 using the application R of the software RStudio® version 1.3.1093, considering 100 random samples of 10.000 dimension random samples with replacement from the original one. Absolute and relative frequencies and classification trends of all items corresponding to the component signs and symptoms and Illnesses and diagnostics of chapters P and Z in total and by gender were calculated. Results Classified reasons for encounter in 2016 and 2019 presented statistically significant association by sex (P < 0.001) and age (P < 0.001) being more common in women (67.4% in 2016 and 66.8% in 2019) and in adulthood (51.6 years in 2016 and 51.5 years in 2019). P and Z of components 1 and 7 reasons for encounter decreased in both chapters (Δ = -7.3% in component 1 and Δ = -2.3% in component 7 of P; Δ = -0.9% in component 1 of Z) between 2016 and 2019. Conclusions The P and Z ICPC-2 chapters classified as reasons for encounter presented statistically significant association by sex and age and were more frequent near to the crisis years, in the female sex and in those older than 50 years.

Prevalence, aetiologies and prognosis of the symptom cough in primary care: a systematic review and meta-analysis

Background Cough is a relevant reason for encounter in primary care. For evidence-based decision making, general practitioners need setting-specific knowledge about prevalences, pre-test probabilities, and prognosis. Accordingly, we performed a systematic review of symptom-evaluating studies evaluating cough as reason for encounter in primary care. Methods We conducted a search in MEDLINE and EMBASE. Eligibility criteria and methodological quality were assessed independently by two reviewers. We extracted data on prevalence, aetiologies and prognosis, and estimated the variation across studies. If justifiable in terms of heterogeneity, we performed a meta-analysis. Results We identified 21 eligible studies on prevalence, 12 on aetiology, and four on prognosis. Prevalence/incidence estimates were 3.8–4.2%/12.5% (Western primary care) and 10.3–13.8%/6.3–6.5% in Africa, Asia and South America. In Western countries the underlying diagnoses for acute cough or cough of all durations were respiratory tract infections (73–91.9%), influenza (6–15.2%), asthma (3.2–15%), laryngitis/tracheitis (3.6–9%), pneumonia (4.0–4.2%), COPD (0.5–3.3%), heart failure (0.3%), and suspected malignancy (0.2–1.8%). Median time for recovery was 9 to 11 days. Complete recovery was reported by 40.2- 67% of patients after two weeks, and by 79% after four weeks. About 21.1–35% of patients re-consulted; 0–1.3% of acute cough patients were hospitalized, none died. Evidence is missing concerning subacute and chronic cough. Conclusion Prevalences and incidences of cough are high and show regional variation. Acute cough, mainly caused by respiratory tract infections, is usually self-limiting (supporting a “wait-and-see” strategy). We have no setting-specific evidence to support current guideline recommendations concerning subacute or chronic cough in Western primary care. Our study presents epidemiological data under non non-pandemic conditions. It will be interesting to compare these data to future research results of the post-pandemic era.

Do Women With Severe Persistent Fatigue Present With Fatigue at the Primary Care Consultation?

Recent studies have shown underdiagnosis of severe persistent fatigue in primary care. To study how patients with severe persistent fatigue present in primary care and whether they differ from patients with less severe fatigue and patients with no fatigue. A 4-year retrospective database study combined with a questionnaire, including all female patients 25–50 years ( n = 917) who are registered in one primary care group practice. Based on the results of a validated self-administered questionnaire, patients were divided into three groups: patients with severe persistent fatigue ( n = 42), patients with fatigue ( n = 174), and patients with no fatigue ( n = 246). Data on frequency of consulting, reason for encounter, and diagnoses from 2009 to 2013 were obtained from the electronic medical health record. Data were analyzed using odds ratios. Women with severe persistent fatigue more often were unemployed and had lower education. They visited the general practitioners (GP) more often than other women. However, more than half of the women with severe persistent fatigue did not visit their GP with fatigue as reason for encounter at all during the 4 years of study. A minority of the women with severe persistent fatigue received a psychological diagnosis or social diagnosis (36% and 19%, respectively) during these 4 years. Underdiagnosis of severe persistent fatigue is partly a consequence of patients not presenting or reporting this to their GP. The reasons for this behavior are not clear.

Reliability and validity of ICPC-2-R encoding by medical students

Objective: To estimate how reliably and validly can medical students encode reasons for encounter and diagnoses using the International Classification of Primary Care, revised 2nd edition (ICPC-2-R). Methods: For every encounter they supervised during an entire semester, three family and community physician teachers entered the reasons for encounter and diagnoses in free text into a form. Two of four medical students and one teacher encoded each reason for encounter or diagnosis using the ICPC-2-R. In the beginning of the study, two three-hour workshops were held, until the teachers were confident the students were ready for the encoding. After all the reasons for encounter and the diagnoses had been independently encoded, the seven encoders resolved the definitive codes by consensus. We defined reliability as agreement between students and validity as their agreement with the definitive codes, and used Gwet’s AC1 to estimate this agreement. Results: After exclusion of encounters encoded before the last workshop, the sample consisted of 149 consecutive encounters, comprising 262 reasons for encounter and 226 diagnoses. The encoding had moderate to substantial reliability (AC1, 0.805; 95% CI, 0.767–0.843) and substantial validity (AC1, 0.864; 95% CI, 0.833–0.891). Conclusion: Medical students can encode reasons for encounter and diagnoses with the ICPC-2-R if they are adequately trained.

Self-rated worry in acute care telephone triage: a mixed-methods study

BackgroundTelephone triage is used to assess acute illness or injury. Clinical decision making is often assisted by triage tools that lack callers’ perspectives. This study analysed callers’ perception of urgency, defined as degree of worry in acute care telephone calls.AimTo explore the caller’s ability to quantify their degree of worry, the association between degree of worry and variables related to the caller, the effect of degree of worry on triage outcome, and the thematic content of the caller’s worry.Design and settingA mixed-methods study with simultaneous convergent design combining descriptive statistics and thematic analysis of 180 calls to a Danish out-of-hours service.MethodThe following quantitative data were measured: age of caller, sex, reason for encounter, symptom duration, triage outcome, and degree of worry (rated from 1 = minimally worried to 5 = extremely worried). Qualitative data consisted of audio-recorded telephone calls.ResultsMost callers (170 out of 180) were able to scale their worry when contacting the out-of-hours service (median = 3, interquartile range = 2–4, mean = 2.76). Degree of worry was associated with female sex (odds ratio [OR] 1.98, 95% CI = 1.13 to 3.45) and symptom duration (>24 hours: OR 2.01, 95% CI = 1.13 to 3.45) (reference <5 hours), but not with age or reason for encounter. A high degree of worry significantly increased the chance of being triaged to a face-to-face consultation. The thematic content of worry varied from emotions of feeling bothered to feeling distressed. Callers provided more contextual information when asked about their degree of worry.ConclusionCallers were able to rate their degree of worry. The degree of worry scale is feasible for larger-scale studies if incorporating a patient-centred approach in out-of-hours telephone triage.

Is it possible to register the ideas, concerns and expectations behind the reason for encounter as a means of classifying patient preferences with ICPC-2?

BackgroundFamily practice aims to recognize the health problems and needs expressed by the person rather than only focusing on the disease. Documenting person-related information will facilitate both the understanding and delivery of person-focused care.AimTo explore if the patients’ ideas, concerns and expectations (ICE) behind the reason for encounter (RFE) can be coded with the International Classification of Primary Care, version 2 (ICPC-2) and what kinds of codes are missing to be able to do so.MethodsIn total, 613 consultations were observed, and patients’ expressions of ICE were narratively recorded. These descriptions were consequently translated to ICPC codes by two researchers. Descriptions that could not be translated were qualitatively analysed in order to identify gaps in ICPC-2.ResultsIn all, 613 consultations yielded 672 ICE expressions. Within the 123 that could not be coded with ICPC-2, eight categories could be defined: concern about the duration/time frame; concern about the evolution/severity; concern of being contagious or a danger to others; patient has no concern, but others do; expects a confirmation of something; expects a solution for the symptoms without specification of what it should be; expects a specific procedure; and expects that something is not done.DiscussionAlthough many ICE can be registered with ICPC-2, adding eight new categories would capture almost all ICE.

General practice encounters for young patients with autism spectrum disorder in Australia

This study compared the patient demographics and reasons for encounter in general practice for patients <25 years with and without an autism spectrum disorder identified as a reason for encounter and/or problem managed. The Bettering the Evaluation and Care of Health programme collected information about clinical activities in Australian general practice. Each year, the programme recruited a random sample of 1000 general practitioners, each of whom collected data for 100 consecutive consultations (encounters). Encounters with patients <25 years, where at least one autism spectrum disorder was recorded as a reason for encounter and/or a problem managed (n = 579), were compared with all other encounters (n = 281,473) from April 2000 to March 2014 inclusive. Data were age–sex standardised. Patients at autism spectrum disorder encounters (compared to non-autism spectrum disorder encounters) were more likely to be younger and male. There was a dramatic rise in the number of general practitioner consultations at autism spectrum disorder encounters from 2000 to 2013. More reasons for encounter were recorded at autism spectrum disorder encounters than at non-autism spectrum disorder encounters (156.4 (95% confidence interval: 144.0–168.8) and 140.5 (95% confidence interval: 140.0–141.0), respectively). At autism spectrum disorder (vs non-autism spectrum disorder) encounters, there were more psychological, general and unspecified, and social reasons for encounter and fewer preventive and acute health reasons for encounter. People with an autism spectrum disorder have complex health care needs that require a skilled general practice workforce.