Continental-Mediterranean and rural-urban differences in cardiovascular risk factors in Croatian population.

AIM: To compare the distribution of cardiovascular disease (CVD) factors between continental and Mediterranean areas and urban and rural areas of Croatia, as well as to investigate the differences in achieving treatment goals by the general practitioners (GP) in different settings. METHODS: A multicenter prospective study was performed on 2467 participants of both sexes ≥40 years old, who visited for any reason 59 general practices covering the whole area of Croatia (May-July 2008). The study was a part of the Cardiovascular Risk and Intervention Study in Croatia-family medicine (CRISIC-fm) study. Patients were interviewed using a 140-item questionnaire on socio-demographics and CVD risk factors. We measured body mass index (BMI) and waist circumference and determined biochemical variables including blood pressure, total, high-density lipoprotein-, and low-density lipoprotein-cholesterol, triglycerides, glycemia, and uric acid. RESULTS: Participants from continental rural areas had significantly higher systolic and diastolic blood pressure (P<0.001), obesity (P=0.001), increased waist circumference (P<0.001), and more intense physical activity (P=0.020). Participants from coastal rural areas had higher HDL-cholesterol, participants from continental rural and coastal urban areas had higher LDL-cholesterol, and participants from rural continental had significantly higher BMI and waist circumference. CONCLUSION: Prevalence of CVD risk factors in Croatian population is high. Greater burden of risk factors in continental region and rural areas may be partly explained by lifestyle differences.

[Referring process in family medicine--contribution assessment]. / Upucivanje iz ordinacije obiteljskog lijecnika--procjena doprinosa.

AIMS: The aim of the study was to follow and analyze patient referrals from general practice (GP) to diagnostic procedures and specialist consultations. Data on the kinds of diagnostic procedures, specialist consultations and requests for referrals were collected. Specific aim was to assess the contribution of referring for definitive diagnosis and to compare the frequency and contribution of first and repeat consultations. METHODS: This prospective study was conducted in the course of one month at six GP practices (three urban and one rural practice in inland area, and one urban and one rural practice in coastal area of Croatia). Patient sociodemographic data (age and sex), referral request (by patient, GP, GP and specialist in agreement, specialist only) and kind of visit (first, follow-up) were collected. The contribution of referrals was assessed by GPs using modified Likert's scale (1-markedly significant, 2-significant, 3-undetermined, 4-small and 5-insignificant). On comparison of frequencies chi square test was used. Statistical analyses were done by use of licensed software (SAS Institute Inc, Cary, NC, USA). RESULTS: During one month, 1815 patients were referred, 979 for diagnostic procedures and 836 for specialist consultation (mean age 55.25 +/- 19.70; male 56.30 +/- 19.10, female 54.50 +/- 20.30). Most frequent diagnostic procedures requested were biochemical laboratory in primary health care setting (n = 331; 33.41%) and secondary care (n =1 18; 12.05%), basic radiology (n=106; 10.83%), ultrasonography (n=87; 8.80%) and microbiological laboratory (n = 68; 6.95%). The contribution of diagnostic procedures was mostly assessed as significant (54.84%). When GP and specialist indicated diagnostic procedure concordantly, its contribution was mostly assessed as significant (61.90%) and markedly significant (10.12%). Specialist consultations were used as follows: physical medicine in 131 (19%), surgeon in 90 (13%) and psychiatrist in 69 (10%) patients from inland area, cardiologist in 53 (37%), psychiatrist in 17 (12%) and oncologist in 12 (8%) patients from coastal area. Both in rural and urban practices in inland and coastal area surgeon consultations were assessed as markedly significant. Urban GPs assessed the contribution of first and follow-up check ups as undetermined or small more often than rural GPs (first check ups Xchi =21.66; P<0.0001; follow-up check ups chi2 = 196.38; P < 0.0001). Rural GPs assessed the contribution of first check ups more often as undetermined or small than significant (chi2 = 12.02; P = 0.0005), with the same tendency recorded for follow-up check ups (Xchi =32.01; P < 0.0001). CONCLUSION: GP should maintain the gatekeeping role to assure good quality of care and rationality in using available resources. Cooperation between GPs and specialists is essential to achieve good quality of care. GPs should restore role in indicating follow-up check ups.

Burnout in European family doctors: the EGPRN study.

INTRODUCTION: The aim of this study was to determine the prevalence of burnout, and of associated factors, amongst family doctors (FDs) in European countries. Methodology. A cross-sectional survey of FDs was conducted using a custom-designed and validated questionnaire which incorporated the Maslach Burnout Inventory Human Services Survey (MBI-HSS) as well as questions about demographic factors, working experience, health, lifestyle and job satisfaction. MBI-HSS scores were analysed in the three dimensions of emotional exhaustion (EE), depersonalization (DP) and personal accomplishment (PA). RESULTS: Almost 3500 questionnaires were distributed in 12 European countries, and 1393 were returned to give a response rate of 41%. In terms of burnout, 43% of respondents scored high for EE burnout, 35% for DP and 32% for PA, with 12% scoring high burnout in all three dimensions. Just over one-third of doctors did not score high for burnout in any dimension. High burnout was found to be strongly associated with several of the variables under study, especially those relative to respondents' country of residence and European region, job satisfaction, intention to change job, sick leave utilization, the (ab)use of alcohol, tobacco and psychotropic medication, younger age and male sex. CONCLUSIONS: Burnout seems to be a common problem in FDs across Europe and is associated with personal and workload indicators, and especially job satisfaction, intention to change job and the (ab)use of alcohol, tobacco and medication. The study questionnaire appears to be a valid tool to measure burnout in FDs. Recommendations for employment conditions of FDs and future research are made, and suggestions for improving the instrument are listed.

[Characteristics of depression in Otocac ten years after the war]. / Obiljezja depresije u Otoccu deset godina nakon zavrsetka domovinskog rata.

BACKGROUND: Depression is an important public health problem today. In the primary care setting, a high percentage of patients with depression present exclusively with physical symptoms; depression can often go undiagnosed in these patients. Another challenge for primary care doctors is the treatment of patients with depression and somatic comorbidity. When faced with demands to treat multiple chronic diseases, physicians may give depression less priority. The consequences of exposure to war stress on mental health have been constantly explored. Posttraumatic stress disorder and depression have been identified as the most common psychopathological consequences of exposure to war stressors. The 1991-1995 war in Croatia left deep psychosocial scars and affected self-perceived health, physical ability and mental health of the entire Croatian population stricken by war. Otocac is one of the areas that were more severely affected by war. OBJECTIVES: The aim of the study was to evaluate the prevalence and characteristics of depression in general practice patients in Otocac, Croatia, ten years after the war in Croatia. METHODS: In March 2005, 300 patients aged 18 and older were systematically selected from the patient list of a general practitioner in Otocac, Croatia. These patients were assessed for depression and classified as having a mild, moderate, severe or severe depressive episode with psychotic elements, according to the criteria of the ICD-10 classification of Mental and Behavioral Disorders, Croatian edition. Data were also collected on psychosomatic complaints, chronic diseases, sociodemographic characteristics, participation in war actions, refugee status, comorbid psychiatric diseases in patients and their family members. Differences in the characteristics of depressive and non-depressive patients were tested by chi2-test and Fisher's test. The level of significance was set at p < 0.05. The collected data were analyzed using the SPSS statistical software package, version 12.0.0. RESULTS: A total of 147 (49.0%) patients (65 male and 82 female) met ICD-10 criteria for depressive episode. Distribution of severity of depression showed the majority of depressive patients to meet the criteria for moderate (38.8%) and severe (39.5%) depressive episode. There was a statistically significant difference in the presence of all psychosomatic complaints between depressive and nondepressive patients. Unemployed patients were more often depressed (p = 0.002), and so were divorced and widowed patients (p < 0.001). There was no statistically significant sex difference in the frequency of depressive symptoms. Depression showed no correlation with the patient refugee status, but there was significant correlation with the presence of psychiatric diseases in a patient family member (p = 0.0001). Correlation between depression and the patient chronic somatic diseases was statistically significant for hypertension, cardiac diseases and malignant diseases. CONCLUSION: The results of our study indicated a high prevalence of depression in the group of general practice patients in Otocac, Croatia, ten years after the war in Croatia. Severe and moderate depressive episodes predominated, without sex difference in the frequency of depressive symptoms. Long-term psychological consequences of exposure to war stress as well as other characteristics of the post-war period in the area affected by war may in part explain these findings.