Family Practice Advance Access originally published online on June 22, 2005
Family Practice 2005 22(5):520-522; doi:10.1093/fampra/cmi041
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Combined training of GPs and practice-assistants on peripheral arterial disease: positive effects after six months
a Atrium Medical Centre, Department of Surgery, Division of Vascular Surgery, PO Box 4446, 6401 CX Heerlen, The Netherlands, b University Medical Centre Utrecht, Julius Centre for Health Sciences and Primary Health Care, Stratenum: 6.107, PO Box 85500, 3508 GA Utrecht, The Netherlands, c Gezondheidscentrum West, Koenendelseweg 9, 5222 BG Den Bosch, The Netherlands, d Department of Internal Medicine, Division of Vascular Medicine, Academic Medical Centre, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands and e Department of Epidemiology, University of Maastricht/KEMTA, P. Debeyelaan 25, 6229 HX Maastricht, The Netherlands
Correspondence to Joep AW Teijink; Email: j.teijink{at}atriummc.nl
Received 8 September 2004; Accepted 27 January 2005.
Willigendael EM, Teijink JAW, Bartelink M-L, Langenberg M, Welten RJthJ, Büller HR and Prins MH. Combined training of GPs and practice-assistants on peripheral arterial disease: positive effects after six months. Family Practice 2005; 22: 520–522.
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Abstract |
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Objectives. To improve the use of the ankle-brachial index (ABI) measurement, and management of patients with peripheral arterial disease (PAD) a combined training, targeting GPs and practice assistants (PAs) was developed. To measure the effect of the combined training on the management of patients with PAD, a cross-sectional study was performed.
Methods. Fifty consecutive patients referred by GPs to a vascular surgery out-patient clinic were analysed. Six months after the training an additional fifty patients were included. In all patients the ABI measurement, risk factor management, and treatment as performed by the GP, prior to referral, were analysed.
Results. The measurement of the ABI significantly increased from 10% before the training to 53% after the training (GPs with training: 83%, GPs without training: 35%; P: 0.001). The referral of patients with actual PAD significantly increased from 32% before the training to 70% after the training (GPs with training: 83%, GPs without training: 59%; P: 0.05). The presence and treatment of risk factors did not differ between the groups.
Conclusions. Within the limitations of a before and after study the combined training of GPs and PAs appears to be an effective method to increase ABI measurements and significantly improve adequate diagnostics.
Keywords. Ankle-brachial index, diagnostic, intermittent claudication, peripheral arterial disease, training.
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Introduction |
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In the Netherlands, the GP is the physician that is primarily responsible for the diagnosis and conservative treatment of patients with peripheral arterial disease (PAD). However, there were strong indications that the management of patients with PAD was unsatisfactory.1,2 In an effort to improve this, a combined training on PAD for GPs and practice assistants (PAs) was developed. The purpose of the study was to measure the effect of this training on frequency of ankle-brachial index (ABI) measurement, secondary risk factor management, and conservative treatment of patients with PAD referred by GPs to a vascular outpatient clinic.
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Methods |
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To investigate the effect of a combined training, a baseline measurement was conducted in fifty consecutive patients before the start of the training. Six months after completion of the training sessions for GPs and PAs, an additional fifty consecutive patients were included in the same region.
Training methodology
The four-hour training started with a plenary introduction on PAD. After this session a parallel session started with a theoretical introduction on PAD and the ABI measurement for the PAs and introduction and training in performing an ABI for GPs. In the next parallel sessions this was reversed. PAs focussed on practical skills in measuring an ABI under supervision of two vascular technicians. The GPs received a theoretical course on PAD diagnosis, treatment, and vascular risk factor management given by a vascular surgeon and a GP. All participants received the course book and a CD with ABI instructions on video. The course was accredited by the Dutch College of General Practitioners.
Patient evaluation
All included patients were referred by a GP to the vascular out-patient clinic for the treatment of PAD. The patients were evaluated on the basis of criteria developed by the Dutch College of General Practitioners guideline on symptomatic PAD.3 If the GP had measured the ABI prior to referral, as is prescribed in the guideline, the GP's outcome 'normal' or ‘abnormal’ as described in the referral letter was noted as correct if the outcome corresponded with the ABI measurement at the vascular laboratory. The presence and treatment of vascular risk factors were assessed in every patient during the first visit, with a twice-measured blood pressure, and a fasting blood sample was taken for total cholesterol, glucose, and HbA1c. Information on the by the GP initiated conservative treatment of PAD, smoking cessation and exercise therapy, was evaluated with the aid of the accompanying referral letter and, if necessary with additional information from the patient.
Analysis
The effect of the training was assessed with logistic regression analysis, using the before training group of 50 GPs as the comparator. GPs from a medical centre of which one or more of the practice members and PAs had followed the training were analysed as part of the training group.
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Results |
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The 50 included patients before the training had an average age of 66 years (SD: 12) (males: 26) and had been referred by 41 GPs. The 50 patients included after the training had an average age of 66 years (SD: 11) (males: 27) and had been referred by 37 different GPs. Seventeen GPs had participated in the training, and referred 24 patients. Twenty GPs had not participated in the training and referred 26 of the included patients.
In total 53 GPs of the total number of 126 regional GPs (42%) and 65 accompanying PAs had participated. With an additional 29 GPs and 31 PAs from outside our region the four training sessions reached 82 GPs and 96 PAs. After these four regional training meetings, the training was launched nationwide and currently over 1000 GPs and over 1200 PAs have participated.
The number and accuracy of ABI measurements and the actual presence of PAD improved significantly after the training (Table 1). The presence of vascular risk factors at the outpatient clinic was high and did not differ between before and after the training (Table 1). The difference in treatment of all three risk factors between the groups was not significant (Table 1). With respect to the conservative treatment of PAD, there was no significant difference in smoking cessation strategies (Table 1). Exercise therapy was more prescribed after the training, but there was no difference between trained and untrained GPs. One GP from the training group supplied the patient with the exercise therapy brochure. No referrals to a physiotherapist for exercise therapy did take place.
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Discussion |
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After the training the number of patients referred for PAD to the vascular out-patient clinic with a (correct) ABI measurement performed prior to referral increased almost six fold. Concomitantly, the ability to refer patients with actual PAD, showing an improvement in the GPs diagnostics, more than doubled. The similarities between both groups with respect to the prevalence of vascular risk factors show a homogenous population. The training did not result in a difference in treatment of these risk factors. Difficulties with the implementation of guidelines with respect to the detection and adequate treatment of risk factors in the primary care setting have been described earlier.4,5 Some studies have shown an improvement after educational interventions.6 We could not repeat these results after the training. A possible explanation could be that the training offered no additional tool for risk factor management to aid the implementation of the Dutch College of General Practitioners guidelines.
Multiple studies have shown that conferences, printed educational materials, and audits have little or no effect on changing the daily practice of GPs. Practice-based interventions, workshops, and outreach visits have shown positive effects.7–9 By providing a PAD course for GPs and PAs, an attempt was made to improve the management of patients with PAD by increasing the theoretical background of the GP in combination with a PA who is able to perform the ABI. This combined training concept was to our knowledge innovative for The Netherlands. Within the limitations of a before and after study the combined training of GPs and PAs appears to be an effective method to increase the diagnostic ABI meas-urement. Whether these results are durable should be analysed in a follow-up study. The expected spin off towards vascular risk factor management in general and the conservative treatment did not occur.
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Declaration |
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Funding: not applicable.
Ethical approval: not applicable.
Conflicts of interest: none.
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References |
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1 Simons PCG, Graaf van der Y, Banga JD, Eikelboom BC, Algra A. Screenen op asymptomatische vaatziekten en risicofactoren bij hoogrisicopatiënten: de huidige praktijk. NTvG 1998; 142: 1096–1099.
2 Willigendael EM, Teijink JAW, Bartelink ML, Boiten J, Büller HR, Prins MH. Peripheral arterial disease; closing the gap between common practice and The Dutch College of General Practitioners guideline. Eur J Gen Pract 2004; 10: 109–110.[Medline]
3 Bartelink ML, Stoffers HEJH, Boutens EJ et al. NHG-Standaard Perifeer Arterieel Vaatlijden. Huisarts en Wetenschap 2003; 46: 848–858.
4 McBride P, Schrott HG, Plane MB, Underbakke G, Brown RL. Primary care practice adherence to national cholesterol education program guidelines for patients with coronary heart disease. Arch Int Med 1998; 158: 1238–1244.
5 Short D, Frischer M, Bashford J, Ashcroft D. Why are eligible patients not prescribed aspirin in primary care? A quality study indication measures for improvement. BMC Fam Pract 2003; 1471–2296/4/9.
6 Bero LA, Grilli R, Grimshaw JM, Harvey E, Oxman AD, Thomson MA. Getting research findings into practice; closing the gap between research and practice: an overview of systematic reviews of interventions to promote the implementation of research findings. Br Med J 1998; 317: 465–468.
7 Davies DA, Thomson MA, Oxman AD. Changing physician performance, a systematic review of the effect of continuing medical education strategies. J Am Med Assoc 1995; 274: 700–705.
8 Beaulieu M-D, Rivard M, Hudson E, Beaudoin C, Saucier D, Remondin M. Comparative trail of a short workshop designed to enhance appropriate use of screening tests by family physicians. C Med Assoc J 2002; 167: 1241–1246.
9 Margolis PA, Lannon CM, Stuart JM, Fried BJ, Keyes-Elstein L, Moore DE. Practice based education to improve delivery systems for prevention in primary care: randomised trial. Br Med J 2004; 328: 388.
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