Jueves 2 de Octubre / Thursday 2, October

18:00:00 a/to 19:30:00

Moderador/Chairperson:

Robert West y Jesús de Pedro

203 EFFICACY OF PSYCHIATRIC CONSULTATION FOR PATIENTS WITH SOMATOFORM DISORDER IN PRIMARY CARE

Christina M. Van der Feltz-Cornelis, Patricia Van Oppen, Richard Van dyck

Dept. of Psychiatry, Free University Medical Center, Amsterdam, The Netherlands.

Introduction: Patients with medically unexplained symptoms, or somatoform disorder, generally resist psychiatric referral, suffer from concomitant anxiety or depressive disorders and disability, and burden health care with their high and inappropriate use of health care services. The objective of this study was to evaluate the efficacy of a psychiatric consultation model for patients with somatoform disorder in primary care.

Methods: Randomized controlled trial performed in primary care practices. 81 patients with serious somatoform disorder were selected by the primary care practitioners (PCP's) according to pre-set criteria and completed the study. Selection criteria were ongoing medically unexplained symptoms for which diagnostic referral yielded no pathological substrate, combined with fulfillment of ICD-10 criteria in a baseline self-rating questionnaire. 36 PCP's cooperated. Blockwise randomization between primary care practices was performed. 'PC' practices received psychiatric consultation by a psychiatrist in the presence of the PCP in the primary care practice setting; in 'CAU' practices the PCP delivered care as usual to the selected patients. Outcome measures were physical and psychiatric symptoms, social functioning and level of health care utilization. Follow-up measurements were performed by selfrating questionnaire 6 weeks and 6 months after inclusion.

Results: Analysis by a General Linear Model revealed that in the 'PC' group all outcome measures improved significantly. Utilization of health care services diminished in the 'PC' group but increased substantially in the 'CAU' group.

Conclusions: Psychiatric consultation in the primary care setting is an effective intervention in the treatment of serious somatoform disorder. A further (cost)-effectiveness study is needed.

204 ACCESS TO GENERAL PRACTITIONER SERVICES: DISABLED ELDERLY INDIVIDUALS LAG BEHIND IN UNDERSERVED AREAS

Basile Chaix*, Paul J. Veugelers**, Pierre-Yves Böelle*, Pierre Chauvin*

*Research Unit in Epidemiology and Information Sciences, National Institute of Health and Medical Research, Paris, France. **Department of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada.

Introduction: Various European studies have reported that the access to general practitioners (GP) in areas where the availability of such services is low was particularly limited for the elderly. After confirming that the availability of GPs had a stronger impact on consultation patterns among the elderly, we examined whether the entire group of elderly individuals, or only those with an impaired mobility, had a restricted access in underserved areas. Refining the identification of the type of individuals who are put at risk of underconsultation is greatly needed to target more efficiently intervention programs.

Methods: We used survey data collected in 1999 by the French National Institute for Prevention and Health Education. The sample included 12 405 individuals aged 18-75, representative of the French population. We used multilevel Poisson models adjusted for several sociodemographic and health factors to investigate the impact of the availability of GPs on the self-reported number of GP consultations over the previous 12 months. The availability of GPs, expressed as the number of GPs per 100 000 inhabitants in the broad area of residence, was first used as a categorical variable, and then as a continuous variable. Inclusion of interaction effects into the model and stratified analyses were used to examine if the availability effect increased with age, and if it was stronger among disabled individuals

Results: After adjustment, interaction effects indicated that the availability effect was stronger among individuals aged 60-69 than among those aged under 60, and still stronger among those aged 70-75. Moreover, a stronger availability effect for disabled vs. non disabled individuals was only found among people aged 70-75. Finally, the number of consultations was significantly higher in high vs. low availability areas only among disabled individuals aged 70-75 (+236%, 95% confidence interval= +74%, +546%). Among them, the number of consultations increased by 96% (95% confidence interval= +21%, +216%) for an increment of 50 of the number of GPs per 100 000 inhabitants.

Conclusions: Despite the fact that French general practitioners are geographically more evenly distributed than other healthcare services, and provide a high proportion of their consultations to patients at homes, a stronger positive association between availability of GPs and utilization was found among the elderly, and this effect increased further with age even past 60. Among the elderly aged 60-75, the availability effect was mainly attributable to the oldest (70-75) disabled individuals.

As care cannot be made equivalent regardless of geographical location, home visiting programs along with the use of provider-initiated telephone calls and telemedicine should be enhanced in underserved areas to improve access to primary care for disabled elderly (who are particularly faced with transportation difficulties). This is an increasingly important issue in industrialized countries due to ageing populations.

205 ASSESSMENT OF CARE AND OUTCOMES IN PATIENTS WITH THROMBOSIS PROPHYLAXIS

Bernd Brüggenjürgen*, Doreen Mcbride*, Stephanie Roll*, Burkhard Raming**, Stefan N. Willich*

*Institute of Social Medicine,Epidemiology & Health Economics, University Hospital Charité, Humboldt University of Berlin, Berlin, Germany. **AstraZeneca, Wedel, Germany.

Introduction: Venous thromboembolism, particularly deep vein thrombosis (DVT), is a significant complication following surgical interventions. The primary aim of the ASClOT (ASsessment of Care and Outcomes in Thrombosis prophylaxis) study is to determine health care utilisation and costs associated with thrombosis prophylaxis following elective hip and knee replacement surgery. Patient quality of life (QoL) and identification of possible risk factors for DVT are also assessed.

Methods: In a multi-centre, prospective cohort study in 21 hospitals and associated ambulatory settings, 309 patients were studied over a 3-month post-operative period. The patients completed pre-operative baseline questionnaires including generic QoL (SF-36). Patient risk factors, nature and course of the thrombosis prophylaxis in hospital were documented from patient charts. Follow-up patient questionnaires at one and three months post-surgery, including the SF-36, identified the "natural course" and potential complications of thrombosis prophylaxis, associated costs, possible medication interactions with anticoagulants, socio-economic factors, patient quality of life and treatment satisfaction. Information obtained in the 1-month follow-up patient questionnaire was validated and complemented if necessary by the attending physician.

Results: Statistical examination will address the costs of thrombosis prophylaxis, resource consumption, risk factors for thrombosis, patient quality of life, and therapy satisfaction. Full results of the study are expected in April 2003.

Conclusions: This therapeutic and economic analysis of DVT in Germany will provide a basis for further development of optimal treatment guidelines for thrombosis prophylaxis to improve patient outcomes and implement maximum utilisation.

206 USE OF HEALTH CARE AND OUTCOME OF MODERATELY IMPAIRED STROKE PATIENTS IN MADRID AND STOCKHOLM

Milagros Jimenez Muro*, Jesús De Pedro Cuesta**, Javier Almazán Isla**, Lena von Koch***, Lotta Widen Holmqvist***

*Servicio de Rehabilitación, Hospital 12 de Octubre. CAM, Madrid, Spain. **Área de Epidemiología Aplicada, Centro Nacional de Epidemiología, ISCIII, Madrid, Spain. ***Div. of Neurology. NEUROTEC, Huddinge University Hospital. Karolinska Institute, Stockholm, Sweden.

Purpose: To compare the function and use of health care of two selected groups of patients with moderate impairments after stroke in South Madrid and in Southwest Stockholm County.

Methods: Twenty seven Spanish and 38 Swedish stroke patients with first or recurrent stroke, Mini Mental State Exam >23, continent and independent in feeding according to Katz ADL Index, and impaired motor capacity assessed one week after onset, were included. They were evaluated at 5-7 days, 3 and 6 months after stroke using a protocol which encompassed clinical and socio-economic data, assessment of impairment, function and activity, and use of hospital, rehabilitation and community services.

Results: The Madrid patients, four years younger, exhibited significantly lower motor capacity, and were more disabled at baseline but the differences between the groups decreased with time. The frequency of social activities before stroke and at 6-months was lower among the Spanish patients. All the Swedish patients were hospitalized in neurological, rehabilitation and geriatric wards, while the Spanish patients were mainly admitted to other wards, 66%, more recurrently hospitalized and had a similar proportion receiving rehabilitation, considerably higher average number of out-patient visits to therapists during 6-months, 47.5 vs 7.6, and lower use of home adaptation.

Conclusion: Hospital admitted patients after stroke in Madrid were more disabled at baseline, had a higher impact in health-related quality of life at 3 months, and had a different recovery pattern than patients at Stockholm with similar moderate impairment at baseline. It would appear that there is a space for rational improvement of care, particularly hospital-acute, community rehabilitation and home adaptation, for moderate stroke patients in Madrid.

207 SURVEY OF GENERAL PRACTITIONERS IN GERMANY REGARDING CONTINUING EDUCATION

Christoph Trautner*, Rafael Bernt**, Burkhard John***

*Department of Public Health, University of Applied Sciences of Braunschweig/Wolfenbuettel, Wolfsburg, **Department of Social Sciences and Public Health, University of Applied Sciences of Magdeburg, Magdeburg, Germany. ***Association of Office-Based Physicians, Magdeburg, Germany.

Introduction: To plan continuing education best adapted to the needs of general practitioners (GPs), we surveyed their experience and perceived needs in this field. In particular, we wanted to know to which extent GPs in the middle or the second half of their career in the former Eastern part of Germany are interested in Evidence-Based Medicine (EBM) and in using electronic media and the internet for their education.

Methods: In preparation of polling a representative sample of GPs, a pilot study was carried out. During two meetings for continuing education, the participating GPs in the German state of Saxony-Anhalt were polled by questionnaire. Relative frequencies were calculated. In addition, the participants were asked how confident they felt with respect to certain aspects of their professional practice. Using Likert scales, mean confidence scores were calculated.

Results: n=60 questionnaires were filled in and returned. 9 participants did not give their personal characteristics. Of the remaining, 31 were women, 20 men. 43 had finished their studies before 1989, 8 after 1989. (In 1989, the reunification of Germany brought about major changes in health care and education). Over 90% reported that they had used journals, books and oral presentations for continuing education in the past, 40% had participated in case conferences. 20% had used CD-ROM and the internet. 18% planned an increased use of journals and books, 30% of case conferences, 33% of CD-ROM, and 43% of the internet for their education. The main topic of interest was useful and cost-effective pharmacotherapy. 51% had participated in continuing education in this field over the last 5 years, 25% planned to do so within the next year. 36% had participated in training on methods of EBM, 31% on the application of EBM on specific diseases. 24% planned to participate within the next year. 78% had participated in quality circles. Main topics were the discussion of specific medical problems and useful and cost-effective pharmacotherapy. 68% were overall satisfied with their participation in quality circles. Mean confidence scores (highest confidence:6, lowest:1) were: Patient-oriented drug therapy 4.9. Life-saving procedures 3.8. Communication with "difficult" patients 4.3. Diagnosis and therapy of psychosomatic disorders 4.4. Organisation of the office 4.3. Use of computers and the internet 3.4

Conclusions: In this pilot study, useful and cost-effective prescription of drugs was the focus of interest both in the past and for future education. The participants felt already most confident in this field, compared with all other fields covered in this questionnaire. Most of the participants were relatively advanced in their career. Nevertheless, their interest in using electronic media and the internet was great. Interest in EBM was higher than expected.