Family Medicine Update

Predictive value of history taking and physical examination in diagnosing arrhythmias in general practice.

Fam Pract. 2007 Nov 6;

Authors: Hoefman E, Boer KR, van Weert HC, Reitsma JB, Koster RW, Bindels PJ

BACKGROUND: Palpitations and light-headedness are common symptoms that may be indicative of cardiac arrhythmias. Effective triage by the GP might prevent delayed treatment or inappropriate referrals. The aim of this study was to determine the capability of GPs to assess the presence of cardiac arrhythmias and which signs and symptoms are used in predicting the presence of arrhythmias and which actually are related to the presence of arrhythmias. METHODS: A consecutive cohort of 127 patients presenting with palpitations and/or light-headedness to 41 GPs in the Netherlands underwent physical examination, patient history and standard electrocardiogram. The GPs’ estimation of the probability of patients having an arrhythmia was compared with the diagnostic result of 30 days of continuous event recording (CER). We assessed discriminating factors that can assist a GP in diagnosing an arrhythmia. RESULTS: No correlation was found between the GPs’ assessment of risk and actual diagnoses. GPs were more likely to predict an arrhythmia in patients who suffer from hypertension (P = 0.049) or patients with a history of cardiovascular disease (P = 0.006). Vasovagal symptoms [odds ratio (OR) = 2.91, 95% confidence interval (CI) 1.1-7.6] and bradycardia (OR = 4.2, 95% CI 1.3-14.0) were significantly more common in patients with a CER diagnosis of arrhythmia. CONCLUSION: Prediction of arrhythmias by GPs based on history taking and physical examination alone is not accurate. These parameters are insufficient to decide which patients need further diagnostic evaluation. A diagnostic facility with low threshold for GPs is essential for an adequate diagnostic process in patients with palpitations and light-headedness.

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Responding to a colleague who neglects best practices.

Am Fam Physician. 2007 Oct 1;76(7):1043-4

Authors: Pfifferling JH

17956076

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Behind-the-Scenes of Patient-Centered Care: Content Analysis of Electronic Messaging Among Primary Care Clinic Providers and Staff.

Med Care. 2007 Dec;45(12):1205-1209

Authors: Stiles RA, Deppen SA, Figaro MK, Gregg WM, Jirjis JN, Rothman RL, Johnston PE, Miller RA, Dittus RS, Speroff T

BACKGROUND:: Transitions to patient-centered health care, the increasing complexity of care, and growth in self-management have all increased the frequency and intensity of clinical services provided outside office settings and between visits. Understanding how electronic messaging, which is often used to coordinate care, affects care is crucial. A taxonomy for codifying clinical text messages into standardized categories could facilitate content analysis of work performed or enhanced via electronic messaging. OBJECTIVE:: To codify electronic messages exchanged among the primary care providers and the staff managing diabetes patients at an academic medical center. RESEARCH DESIGN:: Retrospective analysis of 27,061 electronic messages exchanged among 578 providers and staff caring for a cohort of 639 adult primary care patients with diabetes between April 1, 2003 and October 31, 2003. SUBJECTS:: Providers and staff using locally developed electronic messaging in an academic medical center’s adult primary care clinic. MEASURES:: Raw data included clinical text message content, message ID, thread ID, and user ID. Derived measures included user job classification, 35 flags codifying message content, and a taxonomy grouping the flags. RESULTS:: Messages contained diverse content: communications with patients, families, and other providers (47.2%), diagnoses (25.4%), documentation (33%), logistics and support functions (29.6%), medications (32.9%), and treatments (28.9%). All messages could be classified; 59.5% of messages addressed 2 or more content areas. CONCLUSIONS:: Systematic content analysis of provider and staff electronic messages yields specific insight regarding clinical and administrative work carried out via electronic messaging.

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