Pre ven ti ve Practices of General Practi tioners

in Torino, 1 taly

S tef ana Rosso

Department of Epidemiology and Biostatistics

McGill University, Montreal

A Thesis submitted to the

Faculty of Graduate Studies and RGsearch

in partial fulfillment of the requirements

for the degree of

Master of Science

@S. ROSSO, 1989

ACKNOWLBDGMENTS

The author is grateful to Professors Renddo N. Battista, J. Ivan Williams and

Samy Suissa for their assistance through every stage of this wCJrk and for making

available aIl the necessary resources from the Division of Clinical Epidemiology of the

Montreal General Hospital. The author is also indebted to Dr. Nereo Segnan, who

initiated this study, and to several colleagues from Torino who were involved in its

execution.

Appreciation is expressed to Dr. N.J.B. Wiggin, Ms. Cynthia Palmer and Ms.

Jeannie Haggerty for their valuable and thoughtful comments on earlier drafts of this

manuscript.

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ABSTRACT

This thesis comprises a review of studies on the diffusion of recommended

guidelines on preventive practices and three papers evaluating the preventive practke

patterns of general practitioners in Torino, Italy.

The first paper presents estimates of preventive practices and perceived

effectiveness of preventive interventions. Patterns of practice were found to be

consistently similar to those in other studies.

The second and third papers explore an array of determinants for ten primary

and secondary preventlve interventions.

An analysis of determinants indicates that complex patterns of behaviours are

rather condition-specifie, while the application of techniques is influenced to a varying

extent by organizational and attitudinal factors.

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Résumé

Cette thèse contient une rewe des études sur le niveau d'intégration

d'activités préventives dans la pratique clinique des médecins, ainsi que trois articles

traitant des pratiques préventives des généralistes à Turin.

Le premier article décrit les pratiques préventives des médecins et leur

perception de l'efficacité de certaines interventions. Nos résultats sont comparables

à ceux ra.pportés par d'autres chercheurs.

Les deuxième et troisième anicles examinent un ensemble de déterminants

pour dix interventions en prévention primaire et secondaire.

Une analyse des déterminants nous indique que les comportements de

pratique varient selon les entités cliniques et que l'utilisation de techniques données

est influencée par les attitudes des médecins et un ensemble de facteurs liés à

l'organisation de leur pratique.

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NOTICE

" The Candidate has the option, subject ta the approval of the Department,

of including as part of the thesis the tex! of an original paper, or papers, suitable for

submission ta learned joumals for publications. In this case, the thesis must still

conform to aIl other requirements explained in Guidelines Concemini Thesis

Preparation, (available at the Thesis Office).

Additional material (experimental and design data as weIl as descriptions of

equipment) must be provided in sufficient detail ta allow a clear and precise

judgement ta be made of the importance and originality of the research reported.

Abstract, full introduction and conclusion must be included, and where more than

one malluscript appears, connecting texts and common abstracts, introduction and

conclusion are required. A mere collection of manuscripts is not acceptable; nor

can reprints of published papers be accepted. "

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TABLE OF CONTENTS

Section

Acknowledgments ............................................. i

Abstract ••.•.....•••••..•••.•••.•.......••.•...•....••••...•...•• ii

R ... isumi ...........•......•..........•...............•..........• 111

N . • otlCe ..••••..••..•••••.•••••••••••.•••.••.••.•.••.•.• •••.••.•.••• IV

Table of Contents •......•.••........... 1" •••••••••••••••••••• v

Introouction .....•..•.•....••.•.......•.•...........•.•.....•...• 1

Literatl~re Review ••.......•..•...•..............•.......•...• 3

M ~thods of assessing practice patterns ....•.• 4

Primary preventive interventions ............... 6

Secondary preventive interventions ............ ll

Determinants of preventive practice .......... 13

The Health Care System in Italy ........................ 16

The Current Study ........................................... 0 19

References .........................................•........... 26

Tables ............................................................ 33

Paper 1 : "Preventive Practices of General

Practitioners in Torino, Italy"

Presentation .........•.....................• ,I ........ 39

Paper ..................•.......•.........•.....•........ 40

References ............•.......••..•.........•......... 52

Tables ..•...•..•..•••.••....•..•....•.•....•..•••....... 55

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Paper 2: "Determinants of Primary Preventive Practices

of General Practitioners in Tarino, Italy"

Presentation ....•........................•........... 63

Paper .......•......••••......•..............•........... M

References ......•.•.. Il •••••••••••••••••••••••• tt •••• 74

Tables ...•.•......••••....•.•.............••• ". " ...... 78

Paper 3: "Determinants of Cancer Barly Detection

Practices of General Practitioners in Torino,Italy"

Presentation ......•... It •••••••••••••••••••••••• 1, ••• 86

Paper ................. Il Il ••••• Il' tt •••••••• Il ••••••••• 87

References ••...•••••. tt. ft ••••••• , •••••••• Il .t' .. , ••• 96

Tables ..•.•••....••••••....•••.•.•••.....••...•.......• w Conclusion .................................................... 103

Appendix ....................................................... 107

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INTRODUCTION

The integration of preventive and curative approaches has become a standard

expectation for high quality health care. A key assumption is that the traditional clinical

encounter gives the physician an opportunity to promote health behaviours and to détect

disease early in its asymptomatic stage regardless of the primary reason for the

patient's visit (Easson, 1974; Frei, 1978; Smith, 1979).

From the 192O's l atil relatively recently, all patients weI e offered an

undifferentiated pack~ee of diagnostic procedures and laboratory tests as part of an

annual physical examination. This approach to annua! check-up was critically evaluated

during the 1970's (Frame, 1975) and was shown to be ineffective and mis!eading

because it neither reached appropriate groups at risk nor offered them techniques

proven to be effectivf'.

ln the late 1970's, Breslow and Somers (19n), the Institute of Medicine (IOM,

1978) and the Canadian Task Force on the Periodic Health Examination (1979)

proposed a new approach focused on preventable and serious diseases and on ~ubjects

who were at high risk for these diseases.

Three approaches were used to develop the new strategy.

The first approach was to differentiate primary from secondary prevention. The

object of primary prevention is to identify and modify risk factors in order to reduce

the likelihood of a disease or a disorder developing in a person wherl:as that for

secondary prevention is to identify the presence of disease in a pre-symptomatic stage

when effective therapies are available.

The second approach was to select conditions according to precise criteria of

social relevance, mortality, and morbidity and subsequently assess the effectiveness of

preventive interventions by examining the performance characteristics of early

detection procedures and the efficacy of early treatment.

Finally, effective preventive interventions were arplied to age- and sex-specific

risk groups to enhance the efficiency of the periodic health examination. This

innovative approach to preventive clinicat services bas now replaced the annual check­

up as the standard procedure.

The V.S. Preventive Services Task Force, in collaboration with the Canadian Task

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Force on PHE, refined and ~ùopted the above rules in the formulation of its own

recommendations for the integration of preventive interventions into clinical practice

(Goldbloom, 1986; Lawrence, 1987).

The National Institutes of Health (NIH) (Pink, 1984; Jacoby, 1985; Mullan, 1985; Perry, 1980) employed other methods reflecting their own particular concern~ and

perspectivf3 in the making of recomkoendations at "{',onsensus Conferences" ore:anized

by them; so have such other organizations as The American Academy of Pediatrics,

1978; The American College of Physicians, 1981; and The American Hospital

Associatirn, 1981. Problems arise, however, when conflictin~ recommendations for

practices are circulated among physicians.

The implementation of recommendations by physicians is determineti by such

factors as awareness of recommendations, practice structure, and medical training. A

study of these determinants is the subject of t}>js thesis.

The diffusion and implementation of recommendations have been studied mainly in

countries with a fee-for-service system, but their comparison with what happens

within a capitation system could generate new suggestions for increasing the use of

effective strategies in prevention.

These issues were examined in a survey of general practitioners in Torino,

Italy, that estimated the extent to which published guidelines on prevention were

included in GPs' practices within the Italian National Health Service. Associations

between physicians' practice behaviours and their attitudes, knowledge, lifestyles,

organizational models, and socio-demographic characteri5Hcs were a~.~0 investigated as

a means of idp'ltifying strategies for promoting eff~ctive interventions in clinical

practice.

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LITERATURE REVIEW

This review is limited ta articles appearing in print after plJbIication of a set

of recommendations for systematic prev~ntion in primary car,: in the first report of

Th~ C~m~Jmn Task Forr.e on The Periodic Health Examina'~ion (1979). The

bibliographie seareh included M'2DLINE (key words: primary care, praetice

assessment, generai praetice, counselling, early detection), Index Medicus, recent

reviews by Lewis (1988), Bass (1988), and Green (1988), and the bibliographies of

selected articles.

Beca\lse sur.h studies are plagued by variations in subject matter, sampling

techniques, and the questialls posed, a section discussing the methods used in the

surveys !s inc1uded. Table 1 presents a sytlthesis of the survey methods used ill the

studres eonsidered in this literature review.

The lite rature on the preventive activities of primary care physicians can be

broadly divided inta descriptive articles about the i!nplementation of recommended

practices, and analytic articles concerning the deterrninants of their adoption.

The picture that emerges from this literature review is that the degree ta

which preventive mterventions are implemented varies within individua 1 l'ractices and

is influenced by a complex pattern of organizationai and attitudinal factors inc1uding

method of reimbur~~ment, availability of a given technique, appropriate knowledge

and training, and perceived effectiveness of tde intervention. Tables 2 and 3

summarize the frequencies of implementation of preventive activities in rifferent

studies.

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Methods of assessing practice patterns.

The different approaches to ascertaining "what do physicians do about

prevention?" make it very difficult ta compare studies. Even the definition of

preventive practices varies among studies. While it is relatively simple to compare

practices such as "prescription of mammography", what anti-smoking counselling

entails is less clear.

Physicians' counse1ling procedures cover a wide range of activities. Most surveys

asked: "do you counsel patients about [target problem] ?It, but sorne used a proxy

question, such as "do you ask the patient about [target problem] ?" or Hdo you usually

bring up the issue of [target problem] with a11 patients ?" that implied life-style history

taking is the first step in counselling.

Sorne authors (Battista, 1983; Romm, 1981) addressed their questions ta specifie

recommended practices and focused on the type of clinical encounter during which

counselling is carried out and the type of patient groups targeted for the intervention.

Data were gathered by means of structured or semi-structured questionnaires

administered by mail, by telephone, or by trained interviewers during face-to-face

interviews. Most of the studies were local in scope, but sorne were province-wide

(Battista, 1983, 1985).

Physicians overestimate their preventive practices because they have difficulty

in recalling the exact procedure performed in each clinical situation and tend ta give the

desired response. Validation of their estimates is partially possible for reimbursed

procedures, but the reimbursement system seldom covers counselling interventions and

they are not always inc1uded in patient medical records.

Different recording procedures rnake it difficult to compare studies based on

medical records, particularly when physicians claim that the intervention was provided

although not recorded (Lewis, 1988).

Surveys in which patients are asked ta recall what their physicians did or said

provide indirect validation of preventive practices. Although such reports are also

subject to recall problerns, the answers give sorne indication of what the patient retains

frorn the doctor's intervention and are important in understanding the effect of

counsdling on patients (Lewis, 1988).

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Because several studies found that training and specialization influence

physicians' behaviours and attitudes towards prevention, modifications to continuing

education programs have been suggested. It must always be remembered, however, that

suggested interventions are not alwajs applicable in health systems that differ from

those in which the studies were conducted.

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Primary preventive interventions.

Anti-smoking counselling

Anti-smoking counselling involves giving individuals information about the

effects of smoking on their health and advising them to quit smoking. Counselling can

be supplemented by self-help mate rials and local community programs, but the most

effective strategy is to plan "support or reinforcement" visits during the first months

following cessation of smoking (Kottke, 1988). Recent recommendations issued by the

U.S. Preventive Services Task Force (1988) suggest that aIl patients who smoke,

regardless of the amount they smoke, be exposed to a variety of interventions delivered

by both physicians and other health professionals.

Physicians' consensus about the value of anti-smoking counselling is quite high,

and most physicians claim they provide it. The proportion of physicians reporting anti­

smokirJg counselling ranges from 98~ in the Quebec study to a low of 52% in Lewis'

study (American Cancer Society, 1985; Battista, 1983, 1985; Gemson, 1986; Goldstein,

1987; Lewis, 1986; McAlister, 1985; Orleans, 1985; Radecki 1986; Rosen, 1984; Valente,

1986; Wechsler, 1983; Wells, 1984). Similar results wcre found in studies done in

lreland and England where primary care structures differ (Catford, 1984; Daly, 1980).

Other studies showed that 41% of aIl smokers (Cummings, 1987), and 42% of

male smokers to 48% of female smokers (Rigotti, 1985) recalled being counselled by

their physicians. Rates of anti-smoking counselling recorded on medical charts were

61% (Mandel, 1982); 63% (Kosecoff, 1985); and 56 to 72%, depending on patient age,

(Romm, 1981).

Few studies have considered the types of clinical encounter in which counselling

was offered, or whether advice was offered, according to the published guidelines, to

aIl smokers; to "heavy" smokers; or only to smokers with symptoms attributable to

smoking (Battista, 1983, 1985; Wells, 1986). Generally speaking, anti-smoking

counselling is offered more frequently to heavy smokers and to patients with health

problems related to smoking. This finding implies sorne difficulties in fully

implementing the recommendation that counselling be offered to each smoker

regardless of quantity smoked or health status.

Internists and residency-trained family physicians seem to offer anti-smoking

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counselling more frequently than general practitioners do (Attarian, 1987; McAlister,

1985; Valente, 1986; Wechsler, 1983). Physicians who specialize in organ systems

adversely affected by smoking ( i.e. cardiologists, pulmonary specialists and

nephrologists) counsel more than do their colleagues in other specialties (Wells, 1986).

The Wessex study (Catford, 1984), which included an examination of the role of

other professionals, found that 57% of the general practitioners studied thought

counselling about smoking was a responsibility they shared with health yisitors who

provide and support health promotion (Fry, 1986); 65% thought it was a responsibility

they shared with health education officers, whose introduction into the Community Care

Services in Great Britain was intended to reduce length of stay in hospital and to

manage more patients in the community.

A few studies looked at physicians' personal smoking behaviours and found a

negative association between smoking by practitioners and their anti-smoking

counselling practice ( Lewis, 1986; McAlister, 1985;

Maheux, 1987). In a study of physicians' habits and attitudes in Pordenone, Italy, 64% of

current smokers versus 74% of non-smokers and 80% of ex-smokers provided anti­

smoking advice to their patients (Franceschi, 1986).

Despite the high importance rating given by physicians to anti-smoking

counselling, only a small minority (3% in Wechsler, 4% in Valente, 12% in Wells and

30% in Goldstein) believe their counselling is effective. This perception of low

effectiveness is corroborSlted by a recent meta-analysis of 39 controlled trials on

smoking cessation interventions. The average success rates for counselling were

13.1% after 6 months, and 3.8% after one year (Kottke, 1988).

~1cohol-abuse counselling

The primary problem in counselling those who abuse alcohol is distinguishing

between prevention of alcoholism and prevention of the long term effeets of a

high/moderate daily alcohol intake (mainly chronic liver damage). While the first

aspect is quite straightforward, no clear recommendations are available as to what

daily intake of alcohol is considered safe, although an intake of two drinks a day is

generally regarded as harmless.

Recommendations for detection and treatment of problem drinking consider

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active case finding followed by counselling to reduce alcohol consumption. Interviews,

questionnaire, biomarkers or presence of clinical signs can help physicians in detecting

problem drinking; although no single instruments has shown optimal accuracy,

approaches may be combined sequentially to increase either sensibility or specificity.

There is also good evidence that counselling and monitoring of progress reduce the

amount of alcohol consumed (Canadian Task Force on PHE, 1989).

The proportion of physicians who advise against excessive alcohol intake varies

from 94% in one study (Gems:)n, 1986) to 34% in the INSURE Project, a 3-year

feasibility study to develop and test a clinical model of preventive health services in

primary care, including patient education, as a form of insu rance bene fit (Rosen,

1981). Onlya small minority (3% in Valente), however, viewed their counselling

activities as being effective. Again, internists offer advice egainst alcohol abuse more

often than general practitioners do (Wechsler, 1983).

Validation of results by surveys of patients' health practices showed that 9% of

men and 6% of women who consumed >3 drinks/day had been counselled hy their

physicians (Rigotti, 1985). Medical chart reviews found that data on alcohol

consumptinn were recorded for on1y 18% of patients in one study (Mandel, 1982) and

47% in another (Romm, 1981). Data from a study of the medical records of North

Carolina physicians showed a 57% to 41% compliance with recommendations for alcohol

abuse counselling, depending on patient age groups (Romm, 1981).

Accidents in the home among the elderly

The first ~eport of the Canadian Task Force (1979) stated "An important

proportion of accidents occur at home, where young children and the elderly are

particularly at risk" and recommended "the use of PHE's scheduled for other

purposes to encourage safety in the home and the community". The Report gave no

suggestions about specifie techniques or approaches physicians could use in encouraging

safety in the home.

More recently, sorne authors have proposed a more complex approach and have

suggested precise maneuvers physicians may perform du ring visits. This approach

encompasses a careful history taking about medication and substances affecting balance

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(Kennedy, 1987), a clinical test for early detection of balance impairment (Wolfson,

1985), and a check list for assessing environmental hazards (Tideiksaar, 1986), but

there have been no controlled trials to evaluate the efficacy of such interventions.

Influenza vaccination for the elderly

Studies have demonstrated the efficacy of influenza vaccination for high risk

groups (LaForee, 1987: Recommendation of the Public Health Service Advisory

Committee on influenza practice, 1977; Williams, 1973), and the maneuver has been

included in the Periodic Health Examination, annually, for persans over 65 years of

age.

In New York City (Gemson, 1986), physicians c1aim they offer influenza

vaccine to 68% of their patients over 65. The same study also investigated the

acceptance of a recommendation for a general package of five immunizations published

in the American College of Physicians' "Guide for adult immunization" (1985). The

package included an annual influeIl2.a vaccination for patients over 65; a periodic tetanus

vaccination for aIl patients; and pneumococcal vaccination for elderly 1 chronically m, immuno-suppressed, and asplenic patients. The results showed that younger and board­

certified physicians were more likely to agree with these recommendations.

Reviews of medical charts have shown that compliance with recommendations

varies from a low of 3% to 8% (Cohen, 1982; Dietrich, 1984; Lurie, 1987), to a high of

30% (Kosecoff, 1985).

Prevention of unwanted pregnancies

Recommendations for the prevention of unwanted pregnancies cite good evidence

for the effectiveness of contraceptive eounselling in the prevention of second

pregnancies, but there is less evidence for the effectiveness of counselling in

preventing first pregnancies (Canadian Task Force on PHE, 1979, 1988). Th~ impact

of physicians' counselling in reducing unwanted pregnancy rates has not been

demonstrated, but there is sorne evidence that primary health care providers, through

teaching, counselling, and providing contraceptive agents, May be successful in

increasing the level of knowledge, the use of contraceptives, and the postponement of

first intercourse in adolescents (Forrest, 1981; Zabin, 1986).

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Physicians usually provide information on contraception to prev~nt unwanted

pregnancies. North Carolina physicians recorded offering advice on contraception in

23% of the m~dical records examined (Romm, 1981). In the INSURE project,

approximately 30% of physicians "usually bring this subject up for aIl patients" and 53%

"only for high-risk patients" (Rosen, 1984).

In a patients' survey carried out in a North London practice, where a preventhoe

package of five interventions was offered to women 17-30 years of age, a review of

medical records showed that 86% of the women were counselled on contraception in the

first year and 91% in the second (Page, 1983).

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Lung cancer

Secondary preventive interventions.

- early detection of cancer -

Chest x-ray and sputum cytology are the current screening procedures for lung

cancer. Neither has been declared suitable for inclusion in periodic health examinations

by the Canadian Task Force on The Periodic Health Exan".nation, the U.S. Preventive

Services Task Force or The American Cancer Society.

Nevertheless, the number of physicians ordering chest x-rays for this purpose

ranges from 42% in The American Cancer Society study (1985) to 71% in the Quebec -

New Brunswick study (Battista, 1983, 1985). Internists tend to use chest x-ray more

often than general practitioners - possibly because they see more symptomatic patients

(American Cancer Society, 1985).

Physicians order sputum cytology less frequently; the reported rates vary from

19% of physicians in New York (Gemson, 1986) to 41% in Quebec (Battista, 1983).

Breast cancer

Annual mammography has been widely recommended as an effective early

diagnostic procedure for women 50 years of age and older, but the effectiveness of

mammography for women between 40 and 49 is questionable. The proportion of

physicians recommending mammography for asymptomatic women 50 years of age and

over ranges between 3% (New Brunswick study) and 42% (American Cancer Society,

1985; Albant.s, 1988; Basset, 1986; Battista, 1983, 1985; Cummings, 1983; Gemson,

1986). The low rate in New Brunswick could be due to the scarcity of radiology

centers rather than a negative physician attitude.

Gynecologists reported the regular use of mammography for early detection of

breast cancer in women 50 and over more often than other physicians (American

Cancer Society, 1985; Albanes, 1988).

Radiation hazard (Gemson, 1986) and expensiveness (American Cancer Society,

1985) were the reasons most commonly given for not recommending mammography .

Breast self-examination (BSE) is still controversial and is not included in the

Canadian and U.S. Task Forces' guidelines (Canadian Task Force on PHE, 1986; US

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Preventive Services Task Force, 1987) although The American Cancer Society (1980)

recommends its performance, monthly, by women over 20. Almost ail physicians in

Quebec (96%) and New Brunswick (m) reported teaching BSE whereas only 48% of

physicians in New York City and 41% of those in the INSURE project adhere to The

American Cancer Society's recommendations.

Cervical cancer

The Papanicolaou smear is a well accepted practice, but there is continuing

discussion about its most effective frequency of use and who is at high risk.

Compliance with the recommendation for its use as an early detection maneuver varies

from 75% in the American Cancer Society study to 92% in the New York City study.

Reviews of medical charts reveal that the procedure was performed for 68% of

patients aged 30 to 39 years (Ro:Dm, 1981).

When types of clinical encounter are considered, orny 52% of physicians in

Quebec perform pap smears du ring visits for non-gynecological problems. Apparently,

a significant number of physicians still use pap smears more often in symptomatic than

asymptomatic patients.

Gynecologists prescribe pap tests more often than general practitioners and

internists; so do female and salaried physicians compared with male and fee-for­

service practitioners (Battista, 1983). If only fee-for-service physicians are

considered, higher rates of pap test prescription are associated with better knowledge

and younger age of physicians (Battista, 1986).

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Determinants of preventive practice

General conceptual frameworks for the determinants of preventive practices are

being developed (Battista 1986; Green, 1988; Lewis, 1986; Wells 1984).

Green suggests the use of three categories of determinants: predisposing, enabling,

and reinforcing factors. Predisposing factors induce physicians to take action and

inc1ude knowledge, beliefs, and skills. Enabling factors, such as type of

reimbursernent, incentives for preventive activities, availability of techniques and the

means of applying them, favour the introduction of new practice behaviours by

motivated physicians. Reinforcing factors, such as visibility of results, peer support

from colleagues and feed-back from patients, help to sustain new practice behaviours.

Although this classification is stimulating and interesting, the determinants are

not mutually independent and are difficult to put into operational terms.

Physicians' confidence in the effectiveness of an intervention, and their

"perceived self-efficacy" exert significant influences on their behaviour.

Although clinical training and continuing education are important in the diffusion

of preventive practices, the effectiveness of con!inuing medical education prograrns in

changing current practices is controversial (Haynes, 1984; Lomas, 1988). The impact

of training and specific educational programs in improving physicians' performance is

evident in such specialities as family and internaI medicine where better training in

disease prevention is associated with higher rates of use of preventive practices

compared with other speciaities (Attarian, 1987; Dietrich, 1984; Kosecoff, 1985; McPhee, 1986; Radecki, 1986; Wells, 1986; Woo, 1985).

Perceived effectiveness and clinical training are related to what physicians

actually know about the scientific rationale for preventive interventions. Sorne studies

have measured the association between knowledge and practice (Battista 1986), and

have found that it varies across diseases and interventions.

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Other "limiting factors" or "barrier~" can be grouped into physician-, patient-,

and system-related barriers (Battista, 1986). Time constraints and lack of

inclmtives/reimbursement are physician-re!ated barriers while low compliance,

accl~ssibility to primary care services, and patients' time constraints are patient­

re]ated barriers. System-related barriers range from scarcity of resources and the

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availability of a technique under a health insu rance plan to the existence of competing

services offering similar preventive interventions.

Motivation to counsel, perceived risk of smoking, physicians' skill in

counselling, ar.d perceived associated costs and benefits of counselling have been

aggregated in tht. general category of "attitude" and measured as sub-scales of the

"Multi-items Att~tude Scale" tested by Wells et al (1984) for anti-smoking counselling.

This scale has also been used (Lewis et al, 1986) to evaluate smoking and alcohol

abuse counselling, weight control, and exercise promotion. Perceived importance of

preventive practice, physicians' skill, and barriers (costs) were shown to play

differing roles in determining counselling behaviours. The most pervasive

determinants for the majority of counselling and health promotion interventions

appeared to be the physicians' specialties and personal preventive behaviours. Thi!.'

finding bas been ::onfirmed in a study by Maheux (1987) in which physicians' personal

health practices and role model orientation accounted for most of the variation in their

preventive practice behaviours.

Female physicians seem to be more oriented toward prevention, particularly for

gynaecologic cancer and contraception. Sorne authors 5uggest that this may be

attributable to a better doctor-patient relationship for female physicians (Gray, 1982;

Hopkins, 1967; Preston-Whyte, 1983). Gender disapp,~ars as a determinant of

preventive practice behaviours, however, when it is considered in conjunction with

other factors (Maheux, 1987).

Mode of reimbursement has been considered one of the important factors

"facilitating" physicians' preventive practices and various types of health insu rance

plans have been studied with different results (Contandriopoulos, 1980; Lurie, 1987;

McPhee, 1987; Manning, 1984; Pineault, 1976; Rice, 1983). In general, salaried

physicians are more prevention-oriented than fee-for-service physicians (Battista,

1986), but physicians paid on a capitation basis, as in the United Kingdom. are not

(Fleming 1981).

A major problem in evaluating the findings on determinants of preventive and

clinical practice arises when the complex mechanisms of interaction among the

attitudes, characteristics, and practice settings of physicians are considered. Type of

reimbursement has been cited as a main modifying factor in physicians' attitude and

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practices (Battista, 1986). Exploring how determinants are causally linked in a

capitation system, such as that in Italy, is a useful complement to previous analyses.

The picture that emerges from this literature review is that preventive

behavio~rs follow complex patterns and are rather condition-specifie. No group of

systematically adopted interventions is recognizable. Instead, the application of

techniques is influenced by complex and differing patterns of such organizational and

attitudinal factors as method of reimbursement, availability of given techniques,

appropriate knowledge and training, and perceived effectiveness of an intervention: the

adoption of each intervention is made independently from the adoption of similarly

recommended interventions for other conditions.

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THB HEALTH CARE SYSTEM IN IT ALY

Although the National Health Service (tlServizio Sanitario Nazionale -SSN~) in

Italy was only founded in 1978 (Legge 833), health insurance (tlCasse Sociali per

malattiatl ) bas been in existence since 1919 and has been controlled by government since

1966. AIl workers and their families were enroled in health insu rance plans based on

the worker's type of activity, and special plans \Vere provided to the unemployed.

Trade unions participated in the administration of these plans. Although the system

covered the whole ltalian popuiation, persistent inequalities in services and public

concern, during the 1970's, triggered a movement that led to the creation of the SSN and

the enactment of laws concerning prevention.

In 1978, a law was also enacted for the prevention of unwanted pregnancied

("Legy,e per la procreazione responsabile lt). It allowed legal abortior. and led to the

creation of services (tlconsHltori") tailored to preventive activities in family planning,

gynaecological disorders and sexual counselling. Further evidence of a broadening of

the concept of health and an increasing emphasis on health education and promotion is

provided by landmark environmentallegislation during the 1970's.

Until the early 1980's, health promotion stategy relied primarily on mass campaigns

and advertisements, but criticisms of this approach (Morosini, 1984), prompted mainly

by its failure to reach social groups with the greatest needs, led to its reexamination.

The organization of the Italian SSN is based on Lccal Health Authoriti~s

("Unita' Sanitaria Locale" - USL-) whose boards are elected by municipalities. Each

USL provides health services for 50,000 to 200,000 inhabitants and is administered by

the Local Health Authority in accord with national and regional policies. The

administrative resources of USLs are provided, through the Regional Councils, by tl:e

central government according to demographic indicators (population size and

proportions of people in specifie age groups), previous year's budgets, the inflation

rate, and specifie interventions required by the local authorities. The Regional

Councils distribute the funds among the USLs, which are eharged with achieving the

goals defined by central and regional eouncils. AlI public hospital care, family

medicine (encompassing general and paediatric practiee), public health, occupational

medicine, and environmental control faU within the jurisdiction of the USL. Social

16

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Services, such as home care, bousekeeping help, and "meals on wheelstt for elderly and

disabled people are supported directIy by the municipality which coordinates these

activities with USL administrators.

General practitioneI sare entitled ta provide free and accessible primary care

and ta aet as "gatekeepers" ta specialized and hospital care. Patients who go directly

to specialists have ta pay for their services, themselves. Few exceptions are made ta

this rule since patients may go directly to vaccination centers and clinics ("consultoritt)

specializing in famiiy planning, gynecological disorders and sexual counselling.

Everyone over 14 years of age is enroled in the GP rosters: those under 14 are

enroled in the pediatrician rasters. Before the institution of the SSN, GPs were

allowed any number of patients: subsequent ta its creation, they were invited to reduce

the number, gradually, to an upper limit of 1500. This rule has not been strictly

enforced and a small minority of GPs exceed the limit, slightly. GPs can undertake

other activities within the SSN, provided the number of patients they have is reduced in

accordance with the amount of working professional time they de vote to sueh activities.

GPs are paid on a capitation basis and are limited to a maximum Dumber of

patients according ta the mix of professional activities they engage in, such as hospital

appointments, emergeJlcy wards, and private activity. They run their own practices,

but the sharing of office facilities, nurses, and receptionists' services is inereasingly

common. GPs are responsible for providing, equipping and staffing their practices

from their capitation payments.

Any physician with a degree recognized I~: ille Italian Ministry of Education (i.e.

from a11 Italian Universities and, recently, frOl:' aIl universities of the European

Community Countries - after a language test), can apply for registration on the rosters

of a USL.

As the result of a discussion of the preventive role of GPs in Italy, a generic

statement about the health promotion and preventive activities to be provided by the GPs

was included in the 1985 Contract ("Convenzione per la Medicina Generale") signed by

the Government and the Physicians' Professional Organizations. Despite this

statement, no concrete action for inc1uding precise interventions or maneuvers in

clinical practice has been endorsed.

The Qnly training in prevention received by physicians, in medical sehool, is a

17

course on bygiene, propbylaxis and prevention; no special programs in family medicine

are offered. Physicians who want to specialize in family medicine take a three-year

degree in bygiene and community medicine. A proposaI to reorganize medical school

programs to meet the standards set by the European Corn munit y and the new challenges

ot the Health Reform is being considered by Parliament. It would introduce specifie

courses in medical schools and a four-year degree in corn munit y medicine.

The growing interest among Italian physicians in a more active role in promoting

patient bealth bas become apparent in sorne surveys (ArdigcS, 1982; Piperno, 1980).

The opportunity to introduce a strategy similar to the Periodic Health Examination is

evident in the high annual rate of patient visits, given that about 80% of the practice

population see their GPs once a year (ISTAT, 1980,1983), and sorne authors recognize

this as a favourable premise for the diffusion of preventive interventions by GPs

(Coen, 1983).

Unfortunately, GPs are often more willing to refer their patients to vaccination

centers, "consultori", and tuberculosis prevention services provided within the USL

than they are to carry out the interventions themselves. From a public policy pomt of

view, offering the same maneuver from different points within the same health

organization, with the attendant danger of duplication, may incur significant but

unnecessary costs. Proceeding further in the development of preventive services

separate from primary care, would ooly increase the costs, complexity, and

coordination difficulties of the system.

These problems and increasing concern about costs and monetary constraints

have recently led to a reconsideration of health reform in Italy. The need for a better

understanding of the effectiveness of interventions, the efficiency of proposed

organizational solutions, and the diffusion of innovations among health professionals,

has convinced authorities to fund researcb in primary care. The work reported in this

thesis was undertaken in the context of this new interest in prevention.

18

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THE CURRBNT STUDY

Objectives and justification of the study

Since most reported studies of the diffusion and "penetration" of preventive

practices among physicians were conducted in countries with a fee-for-service or

mixed fee-for-service/salary system, exploring and comparing practice behaviours in a

capitation system could be very enlightening. Since no official recommendations

and guidelines have been published by an Italian organization, the focus of the study was

to estimate the extent to which Italian GPs offer a broad range of preventive

interventions. C\

We also asked questions about specifie preventive strategies addressed locally by

the USL of Torino (the study site), including social services for the elderly, prevention

of disability, and reaction to the introduction of laws making the use of car seat belts

and motorbike crash helmets mandatory

Questions on determinants were selected and included on the basis of results in

other studies. Organizational factors related to the work environment, as cited by

most authors, supplemented by those typical of primary care in Italy, were also

examined.

In addition, we gathered information on preventive interventions having a

potential effect on morbidity and mortality in Italy (Costa, 1984; Rosso, 1984), including

interventions for the elderly and prevention of unwanted pregnancies, sinee they were

targeted by the new social services introduced by the USL and municipality of Torino.

19

j , . "

Specifie aims and research questions

The goal of this research was to answer the following questions:

1) How Many GPs in Torino perform/offer counselling for the following

preventive interventions:

- smoking cessation;

- anti-alcohol abuse;

- accident reduction at home among the elderly;

- flu vaccination for patients over 65 years of age;

- contraception;

- weight control;

- physical exercise;

- oral hygiene;

- the use of crash helmets by motorbikers and seat belts by car

drivers and passengers;

- early detection of lung cancer (chest x-rays and sputum cytology);

- early detection of breast cancer (physical examination, mammography

and breast self- examination);

- early detection of cervical cancer (Papanicolaou smear).

2) How much confidence do the physicians have in the ability of these interventions

to reach the proposed goals?

3) How much agreement is there with the published guidelines of optimal practice?

4) What are the factors influencing physicians' preventive behaviours?

5) How do the organizational features of primary care in Italy affect practice

patterns?

6) Relative to the adequacy of explanatory models emerging from our analyses,

what initiatives can he undertaken to improve physicians' performances.

Sampling Method

The reference population cOl1sisted of physicians who provide primary care. In

the Italian Health Service, this definition includes physicians enroled in the roster of

General and Paediatric practice in each USL. Physicians who offer primary care

exclusively on a private basis outside the SSN form a minority (about 10%) which was

20

,

(

excluded because of problems of accessibility and confidentiality of information.

Pediatricians were excluded because their preventive practices were the subject of a

separate study.

A systematic sample of full- and part-time GPs was drawn from the GP file of

the USL of Torino, after the file had been stratified by sex, age, and maximum number

of patients. Age and sex were selected as variables for stratification since they had

been shown to influence preventive practice behaviours of physicians in other studies

(Battista, 1986; Lurie, 1987; Maheux, 1987). We assumed that practjce size (number of

patients) could affect the amount of time spent by physicians in updating, collaborating

with colleagues, and gaining professional experience in other services.

In May 1986, we systematically selected 1 out of every 5 physicians to obtain a

sample of 225 from 1158 GPs that was proportionate by age, sex, and practice size.

Development of the Survey instrument: Questionnaire

We chose to administer a structured questionnaire during face-to-face

interviews, primar-ily because of the higher response rates achieved with this method in

other studies (Table 1). Other survey techniques were excluded because

confidentiality precluded the use of medical records and a patient survey would be too

expensive.

Ta develop our questionnaire, we first reviewed others used for estimating the

attitudes, knowledge and behaviours of physicians. Most studies asked questions on

limited aspects of practices and their perceived effectiveness; only the Quebec study by

Battista et al. (1983) offered a complete framework for addressing the factors of

interest. Battista's survey was limited to the early detection of four types of cancer,

but its precision made it possible to detect discrepancies from recommended guidelines

based on type and frequency of clinical encounter, and targeted population.

Accordingly, we selected items of interest from the Quebec and New Brunswick

studies and added the interventions ta be used in our survey following the same scheme.

Ta make each interviewas brief as possible, we gathered such information as

address, time-table of patients' visits, practice size, year of graduation, and age from

USL sources. Two general practitioners, who were not included in the sample, helped

us during the formulation of questionnaire items.

21

A pretest, conducted on 10 volunteers not inc1uded in the final sample, enabled us

to optimize subsequent response by: 1) informing physicians that the study was

sponsored by the Physicians' Federation and the USL of Torino within initiatives for

continuing education; 2) guaranteeing the personal involvement of the project director

for soli citation procedures; and 3) allowing the physicians to decide the time and place

for the interview.

The final version of the questiorinaire was sent to officiaIs of the USL of

Torino and the local chapter of the Physicians' Federation (Ordine dei Medici della

Provincia di Torino) for their approval. They granted it without change.

Questionnaire Structure

The first of the questionnaire's nine sections dealt with the management of the

practice. The next seven sections eovered interventions for lung cancer; alcohol

abuse; hypertension; cervical and breast cancer; prevention of disability among the

elderly; prevention of traffie accidents; and unwanted pregnancies. The last section

dealt with the physician's lifestyle - e.g. smoking habits.

Practice behaviors were assessed with questions about the frequency of adoption

of a given intervention scaled on four levels - "Do you adopt this intervention always,

often, seldom, never?" When recommended guidelines suggested such precise patterns

of praetice as frequency of intervention and targeted population, we inc1uded them.

Because we wanted to understand the determina~ts of physicians' practices, we

tried to uncover their attitudes towards prevention with questions on knowledge and

attitudes. Knowledge about prevention was measured by asking physicians to score the

evidenee of association between risk factors and diseases for smoking, alcohol abuse,

and breast and cervical cancer on a four level scale - strong, fair, poor, or no

evidence. Table 4lists the items for each issue. Physicians were also asked to grade

the perceived effectiveness of interventions on a four level seale - very, rather,

somewhat, or never effective.

A list of factors that could hamper the offering of anti-smoking and anti-alcohol

abuse counselling was also presented to physicians with a request that they indicate,

for each item, whether they considered the barriers to be important limiting elements.

22

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,~. 3! i))iL ,',' '\', }Ji \ 1 t. "

The list includes: lack of training, time constraints for the physician, time constraints

for the patient, lack of monetary incentives, difficult access to the technique,

availability of the technique, lack of reimbursement, and poor compliance from

patients.

In Ita] y , other primary care services offer preventive interventions and patients

have access to them directly, or through their GPs. Physlcians were asked whether

they refer thelr patients to the available centers in the community or carry out

interventions personally, e.g. for flu vaccination in the elderly or contraception advice.

We also asked GPs to rate their satisfaction with the referral services and with

consultant physicians on a four level scale - excellent, good, fair, or poor.

Field work

Interviewers were trained, for the specifie task, before and during the pilot

phase. The training included interview scheduling, making appointments, dealing with

refusais, presenting the questionnaire, and face-to-face interview techniques. Three

interviewers administ(~red the questionnaire to random subsamples of physicians.

A letter introducing the study was sent to each physician two weeks before an

interviewer telephoned to make an interview appointment. Physicians who requested

more information, or declined, were contacted personally by the project director in

order to maximize participation.

Questions missed by interviewers, and mistakes, were identified by a day-by­

day checY. of the completed questionnaires. The research assistant contacted the

physicians from whom additional information was needed.

The questionnaires were then sent for key-punching, the entry of data into the

computer, and checking for logical-formal errors (impossible, or out of range values)

and completeness by editing programs.

Most questions were coded using a system that differentiated between "don't

know", "don't remember", and "refuse to answer" categories.

Scale construction

The scales we devised for practice behaviours and their determinants were

analyzed by multtvariate statistical techniques. The questions used to construct the

23

various sC,ales are described below, for each variable studied.

Outcome variables

Patterns of counselling for ,smoking and alcohol abuse were identified by the

type of clinical encounter in which it was done (first visit, periodic check-up, or visit

for symptoms unrelated to the risk factor); frequency (always, often, seldom or

never); and patients targeted (ail patients at risk, at high risk, or only those with

symptoms). An overall score was computed for each type of counselling. The highest

score coincided with the recommended guidelines (aIl smokers during visits for

symptoms not related to the risk factor, and advice repeated more than once).

Adoption of early detection techniques for lung and cervical cancer was assessed

by type of clinical encounter; criteria for defining risk groups (family history, age,

lifestyle); frequency of intervention (once a year, every two years etc.); and follow­

up. The highest score indicated compliance with the recommended guidelines.

Mammography and breast examination were to be performed yearly for v!omen aged 50 to S9 years; breast self-examination yearly for women 40 and over.

Che st x-rays and sputum cytology were included, although tlley are not

recommended as early detection techniques. Their scales had bimodal distributions and

were dichotomized.

Scales for measuring adoption of counselling on accident prevention at home

among the elderly, flu vaccination for the elderly, and contraception were based on a

four-level item and were diehotomized for analysis.

Independent variables

Knowledge indexes for smoking, aleohol, cervical and breast cancers were

computed by assigning a positive score for every right answer, and summing positive

scores for each topic. This procedure led to four knowledge indexes. Table 4

displays the criteria used in judging the appro!,riateness of answers.

Seales of barriers to anti-smoking and anti-alcohol abuse cJunselling were

~omputed by summing the barriers considered important by physicians, after chee king

Cronbach's alpha.

In data reduction, "don't know" and "don't remember" (,'ite~ories were assigned

24

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the lowest value (usually zero). While this is appropriate for knowledge indexes,

because it represents a failure in knowledge as well as a wrong answer, it is

questionable for belief scales, since it would indicate a mid- or uncertainty point. In the analysis, we found that the preventive behaviour of physicians in !his category (low

score) was similar to that of physicians with the lowest belief score. We dècided,

therefore, to recode the "don't know" category as low score.

Response rate

We experienced only 16 refusaIs (7.1%). The remaining GPs participated with

great enthusia&îO and without declining to answer any questionnaire items.

Control of information bias

To check the possibility that information bias was introduced by interviewers,

we computed the expected frequencies of answers, by interviewer, from the total

marginal distributions of selected items. Observed-expected difference was tested

with a chi-square statistic. No statistically significant differences among response

patterns by interviewers were detected.

Because the capitation system in Italy does not require recording of the clinicat

encounter and applied interventions, we were unable to validate estimates of practice

patterns given by physicians (probably biased in the direction of overestimation) from

administrative data. The introduction of information bias by physicians waSt

therefore, a possibility.

25

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74. Rice T. The Impact of changing medicare reimbursement rates on physicians'

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75. Rigotti NA, Calkins DR, Gordon NP, Cleary PD. Do Physicians advise patients

about health practices, and does it make a difference? Clinical Research

1985;33:73-85.

76. Romm F J, Fletcher SW, Hulka BS. Periodic health examination: comparison of

recommendations and internists' performance. So Med Journal 1981;74:265-271.

n. Rosen MA, Logsdon DN, Demak MM. Prevention and health promotion in primary

care: baseline results on physicians from the INSURE project on life-cycle

preventive health Services. Prev Med 1984;13:535-548.

78. Rosso S, Segnan N, Colombo A, Costa G, De Maria M, Faggiano F. Stato di

salute della popolazione a Torino:: ~ttivita' sanitaria degli ospedali di Torino.

Unita' Sanitaria Locale 1/23 Torino. Torino 1984.

79. Smith A, Alvarez CA (eds). Cancer control. Advances in Medical oncology,

research and education. England: Pergalu.on Press, 1979.

BO. Tideiksaar R. Preventing faUs: home hazard checklist to help oIder patients

protect themselves. Geriatries 1986;41:26-28.

81. Valente CM, Sobal J, Muncie HL, Levine DM, Antlitz M. Health promotion:

physicians' beliefs, attitudes and practices. Am 1 Prev Med 1986;2:82-88.

82. U.S. Preventive Services Task Force. Recommendations for breast cancer

screening. lAMA 1987;257(16):21%.

31

,1

83. U.S. Preventive Services Task Force. Recommendations for smoking cessation

counselling.jAMA 1988;259(9):2882.

84. Wechsler Ht Levine St Idelson RK. Rohman M, Taylor JO. The physician's role

in health promotion: a survey of primary care practitioners. N Eng J Med

1983;308(2):97-100.

85. Wells KB, Lewis CE, Leake B, Ware JE j r. Do physician preach what they

practice? JAMA 1984;252:2846-2848. 86. Wells KB, Ware JE, Lewis CE. Physicians' attitudes in counselling patients

about smoking. Med Care 1984;22(4):360-365.

87. Wells KB, Lewis CE, Leake B, Schleiter MK, Brook RH. The practices of

general and sub-speciality internists in counseling about smoking and exercise.

Am j Public Health 1986;76(8):1009-1013.

88. Williams MC, Davignon L, Mc Donald jC, et al. Trials of aequos killed

influenza vaccine in Canada 1968-69. Bull WHO 1973;49:333. 89. Wolfson LO, Whipple R, Ammerman P, Kaplan j, Kleinberg A. Falls and the

elderly: gait and balance in the elderly, two functional capacities that link

sensoryand motor ability to faUs. Clinics Ger Med 1985;1:649-659.

90. Woo Bt Woo B, Cook EF, Weisberg M, Goldman L. Screening procedures in the

asymptomatic adult: comparison of physicians' recommendations, patients'

desires, published guidelines, and actual practice. JAMA 1985:254(11):1480-1484.

91. Zabin LS. Evaluation of pregnancy prevention programs for urban teenagers.

Fam Plann Persp 1986;18:119-126.

32

"

TAllE 1 ca.p.rllon of Methodlin !krvtys of Preventive PrllCtica

~ A - Physlc111l ~v'YI

VEAR lnforwtlon st:! ~l. Scope Method Resp. , aize of rate Source Popu atton

JOIe ....,Ung

fMllr Goldste1n Total "'die ne 1978 1116 Local Population 71 •• Telephone PrICt1tloners

Ireland Dall General 198 29S Regional Syst_tic ". MaU PrlCtltloners

l'Iassachussets fMnvi Internai

Wechsler Genera 1985 427 Regional RandOIII 76. Man Practltionerl'

New York State f.nr CuIIIIings Medic ne 19" 2711 Reglonal RandoM 6~ Man PrlCtlt10ners

Quebee Face-to Pri.,.V Battista face Care 198' ·.,11 Regional RandOftl 95_ Intervll!W Physlcl.ns

INSlIIE PriB'y Rosen Convenient Care 1984 61 Regional SMple NA MaU Physic1ans

Wessex Catford General lq84 '8~ Local RandOftl 9". "-11 PrlCtltioners

Merlcan Ceneer prl .. y Society (ACS) Cere 1985 111'5 National RandOftl 91. Telephone Physiciens

_rican ftedical Association (NIA) F·llr Orleans Medie ne 1985 618 National RandOftl 5n "-11 Practltloners

Boston Face~to Patients, Woo Total face Generel 1985 88 Local Population NA lntervil!W Pract1t1oners

New-Brunsw1ek Face-ta Pri ... y Battista fare Cere 1985 265 Regional RandOlll 95. Intervll!W Physiciens

TllCas fMnYi Internai

McAl1ster Genere 1985 442 Regional RandOlll ••• "-11 Practit10ners

Merlcan f'edlcal Association (NIA) Radecki Cllnical 1986 '655 Natlonal RandOIII .~ . MaU Encounters

Le: Mgeles Total A11 State Basset

1986 886 Regional Population 21. Mail ",yslelMS

JIlaryland Pri ... v Valente Care 1986 111411 Regional RandOlll 65. Mail Physiciens

New YorK City FMUYi Internai GeMson Genera 1986 1211 Local SystetIIIItic 9~ Telephone Prectitioners

Pennsylvania Internai Wells fledlc:1ne 1986 628 National RandOIII 7~ • NA Residents

Western USA Pri ... y Lewis Care 1986 281 Local RandOIII 76_ l'eU PhyslclMS

North Ceroline General, Attar1an F.Ur 1987 195 Regional RandOlll 6" ""11 Prect tioners

Pennsylvania Prl ... y Albanès Care 1988 663 Regional RandOll 6'. Mail PhysiclMS

"' ' ~} .. ,)

TABlE 1 (cont'd)

STlIlVI AUTtKRI VEAR

B - Revlews of Medical Records

~le Scope Method Resp. Information Studr slze of rate Source Papu ,tion

5..,11ng

North Cero11na Revlew of Patients 0' ROM ftledieal general 1981 86 Locel NA NA records preetices

OKford Revlew of Patients of Fleming Conventent ftledlcal general 1981 8522 Locel s..,le NA records practlce

London Revlew of Patients 'ra. Paae ftledlcal a~al ln 246 Local Random 67~ • records prlctict

USA Revlew of Patients of Koseckoff IM!dical hosp'ital 1985 1532 National Random 98~ records .... iis

Toronto Review of Patients of Bor~iel Convenient ftledicel fallUr 198 21 locel sample ,~ records preet ces

C - Patient Surveys

USA Riaottl 195 198' National Random NA Telephone

AsmtOMtlc Pa ients

Buffalo Face-to s.okers in a CUmllngs Total face fallnr 1987 '" Local Population 6~ • interview preet ces

USA Health Lurie Insurances General 1987 '829 National Random NA records Population

• Percentage. have been recalculated frOll! the data avaUable ln the rUcle

34

c

STlIlV/ AUTttCII/ VEAR

101008 Goldste1n 1978

Irelend DIIly 19811

PlIIssachussets Wechsler 19S' ~bec Battista 198'

INSlRE Rosen 1984

Wessex C8tford 1984

ACS

1985

N'A Orleans 1985

New Brunswick llettista 1985

Texes McAl1ster 1985

Maryland Val ente 1986

New York City Gealson 1986

Pennsylvania Wells 1986

Western USA Lf!W1s 1986

North Caroline ROIIIIII 1981

USA Koseckoff 1985

USA RigQttt 19~

Buffalo ClMings 1987

A - Physicien S\ryeys _ of Physiciens WlO cOWlSel thelr patients on:

SIIoking Alcohol ebuse

98

94

911 85

98

81

97

88

97

66 59

97 87

97 94

97

52 56

B - Reviews of Medical Records _ of Records reportlng antl-SlCklng and Ilcohol abuse counselllng

72-56-61 57-41-47 (accordlng to Ige groups)

C - Patients SUryeys _ of Patients recalling being counselled by their physiciens

42 (.en) 9 48 (WOMen) 6

41

STIJlVI AU1lOV VEAR

OJebec Blttista 198' New Brumwiclc Blttista 1985

ACS

1985

New York City GeMon 1986

London p;ue 1 ,

New York St.te CunI\Ilngs 198' Los Angeles Basset 1986

Pennsylvania Albanes 1988

IlKford Fllllling 1981

North Caroline ROIIIII 1981

USA Koseckoff 1985

NSPHPC Rigotti 1985

HIE Lurie 1987

, Il,

TABlE , SulMry of results for cancer urlV detectlon practlcel

A - Physicien Survey

_ of P1iïSicians WlO prescribe early detecUon techniques

Luna Cancer Cervical Cancer êhëst sputlIII x-ray cYtology

Breast Cancer mammogrlph~ Breast

lXMIinetlon Breast Pep lelf exaginetion test

77 41 8 99 96 91

77 49 , 98 92 98

58 11 811 98 7S

49 19 211 811 48 92

65 •

8

11

42 69 94

B - Reviews of Medical Records , of Records reportlng early detection techniques

56

85-77-78 68-64-59 (accordlng to age groups)

511

C - Patient surv~s , of Patients screened with early etection techniques

72 69

8

• Percentage has been recalculated frOM the data available in the article

36

.~. l , ; ,i

TMIlE 4 , IteMS for evaluatlng physlclllll' knawledge on association batween rlsk factors end dl_es.

ItelllS on SIIoklng Correct answer ItelS on alcohol abuse Correct An...,.

Lung cancer yes Coronary Hart Disesse yes l1ver Clrrhosis ye. Atherosclerosls yes Esophaglt1s ye. Chronlc Bronch1t1s yes Pancrlltit1s yes 8ladder Cancer yes Psychosis )'1' L .. ynK Cancer yls Pol yneuropathy yes MouthCancer yls Cardiomyopathy yes Pancreas Cancer no Anemia yes Colon Cancer no Esophaglll Cancer yes CerVical Cancer no Pancrlltic Cencer yll ThrOlllboangUtls yes Llver Cencer yes

Stomach Cancer yes 81adder Cancer no !bAth cancer yu

ItelS on cervical 1 teInS on breast cancer Correct answer cancer Correct 1Il5Wer

Dral Contraceptives no Dlet no ""er of sexuel Familial Predisposition yes partners yes Overwelght yes Parity yes low P .. ity yes First sexuel intercourse Dral Contraceptives no at young age yes Late Flrst pregnancy yes POOl' Personal Hygiene yes Early Menarche ylS Law Social Class yes Late Menopause )'II Veneres! Diseases yes 10nlzlng Radiations no Herpes Genitalis yes Cigarette SIIIoking ylS

( 37

PREVENTIVE PRACTICES OF GENERAL PRACTITIONERS

IN TORINO. IT ALY

38

l' '" , \ V'

PRESENTATION

This paper reports the descriptive analysis of the data collected on an array of

preventive practices and attitudes.

Reported practices are compared with published recommendations. We paid

particular attention to the implementation of interventions designated as objects of

special policy by the Local Health Authority of Torino, such as social services for the

elderlyand sexual education for prevention of unwanted pregnancies.

This paper WBS written in collaboration with Dr Nereo Segnan, director of the

Area di Epidemiologia of Torino, Dr Renaldo N. Battista, thesis supervisor, and Drs

Antonio Ponti, Daniela Aimar and Carlo Senore who are researchers at the Ares di

Epidemiologia of Torino. The author of this thesis contributed the literature review,

methods assessment, analysis, and writing of the corresponding sections.

39

, , \'"' - "

PREVENTIVE PRACTICES OF GENERAL PRACTITIONERS

IN TORINO, ITALY

Key wards:

Running head: Preventive Practices in Torino

Primary prevention, secondary prevention, general practice

Nereo Segnan, M.D., M.Sc.* Renaldo N. Battista, M.D., Sc.D.**

Stefano Rosso, M.D.*,** Antonio Ponti, M.D., M.P.H.*

Carlo Senore, M.D* Daniela Aimar, M.Sc.*

* From the Area di Epidemiologia, Unita Sanitaria Locale 1, Torino, Italy

** From the Department of Epidemiology and Biostatistics, McGill University and the Division of Clinical Epidemiology, Montreal General Hospital, Montreal, Canada. Dr. Battista is a Research Scholar of the National Health Research and Development Program, Ottawa, Canada.

Address Reprint requests ta: Dr. Nereo Segnan Area di Epidemiologia, Unita' Sanitaria Locale Tarino l, Via San Francesco da Paola 31, Torino, Italy 10123 Tel.:(l1) - 835386

(11) - 832004

40

~' (,

f. ~,

t ~.

c

"'; ':_l,.-tt{' r~"",t~~"~"" vl.::1~~.~~ .' ,

ABSTRACT

Health care reforms introduced in Italy in the Iate 1970's triggered a profound

rethinking of the role of general practitioners in prevention. Two hundred and

nine general practitioners registered in the Torino area were interviewed to delineate

their beliefs, attitudes, and practice patterns in relation to prevention. An array of

primary and secondary preventive interventions were examined, including influenza

vaccination of the elderly; counselling activities related to smoking, alcohol

consumption, accidents, contraception, safety helmets and seat-belts; and early

detection of hypertension and lung, cervical, and breast cancers. Although progress bas

been made in areas where guidelines for preventive practices are weIl accepted, there

is still room for improvement in their full implementation. Features of the

organization of medical practice in Italy that impede the integration of preventive

interventions are examined and compared with the situation in North America.

41

, ,/

t

INTRODUCTION The raIe of physicians in providing preventive services is now recognized1

-,..

The approach proposed by the Canadian Task Force on the Periodic Health

Examination3 and by Breslow and Somers2 is based on a set of age- and sex-related

health protection packages. Offering ease-finding and primary prevention activities to

patients who consult their physician for episodic care is at the heart of this strategy,

which makes any patient visit an opportunity for prevention6-

7•

Studies of the extent to which preventive activities have been integrated into

clinical practice in the USA8-

16 and Canada'8-22 show that, although sorne

implementation of the preventive strategies is occurring, the full benefits have not been

realized. Few studies have explored the patterns of preventive practice among primary

care physicians in Europe, but one by Pipern023 documents such activities among

general practitioners in Italy.

The organization of the Italian National Health Service (Servizio Sanitario

Nazionale -SSN-) is based on Local Health Authorities ("Unita Sanitaria Locale" -

USL -) whose administrators are elected by the municipal government. The USLs are

population based and each of them provides health services for SO,OOO to 200,000 inhabitants. The Local Health Authorities administer the services according to the

national and regional policies. Resourees for the administration of USL are provided

by the central government to each Region, according to demographic indicators, previous

year budget, inflation rate, and specifie interventions required by the local authorities.

AlI public hospitals, family medicine services, which encompass general and

pediatric practice, public health programs, occupational medicine, and environmental

control activities are under the jurisdietion of the USL. Adults (over 14 years of age)

are enroled in the rosters of GPs while children under 14 years of age are enroled in

the pediatricians' rosters. Patients can freely choose their general practitioners and

pediatricians within the rosters of USL.

Funds for health care are provided by indirect taxation and most medical

interventions are freely provided to aIl citizen;1 with sorne exceptions, sueh 8S dental

treatment.

Physicians with or without a specialization, operating within the SSN, May be:

1) full time general practitioners,

42

2) 3)

part-time general practitioners with hospital duties.

full time hospital physicians.

)iI .,", LU U ' ,

or

Any physician with a degree recognized by the Italian Ministry of Education can

apply for being registered on the rosters of USL as a general practitioner. GPs are

paid on a per capita basis and practiee within the SSN, which aHows tbem a maximum

number of patients that takes into account any other professional commitments they

may have. A general practitioner is allowed a maximum of 1,500 patients; a

pediatrician, BOO, the disparity being due to different workload required by the two

clinical situations.

Before the institution of the SSN, there were no patient quotas for GPs.

Physicians were subsequently invited to gradually reduce the number of patients to the

upper limit mentioned before. This rute was not strictly enforced and there is a smalI

minority of GPs with slightly more than 1500 patients.

GPs provide free and accessible primary care and Act as "gatekeepers" to

consultants and hospital care. Path~nts who go directly to specialists pay for their

services. There are few exceptions to the rule as patients may go directly to

~accination centers and clinics specialized in family planning, gynecological disorders

and sexual counselling called "consultori" without paying.

The object of our survey was to study the attitudes and practice behaviours of

general practitioners about preventive medicine practices recommended by the Canadian

Task Force on the Periodic Health Examination3.24-27 and the US Preventive Services

Task Force28-

31• We colIected information on an array of primary and secondary

pre'/entive interventions inc1uding influenza vaccination of the elderly; counselling

related to smoking, alcohol consumption, accidents, contraception, safety helmets and

seat belts; and early detection of hypertension and cancer of the lu' &, cervix, and

breast. '''le were also interested in gathering data on smoking cessation and anti­

alcohol a'lUse interventions other than counselling for which scientific evidence of

effectiveness and c1ear recommendations do not yet eX'lSt.

Tables A.1 and A.2 in Appendix provide a summary of the practices

recommended in the Reports of the Canadian Task Force on The Periodic Health

Examination and methodological guidelines used by the working group3.24-27.

43

!

METHODS

We selected a systematic sample of 225 full- and part-time physicians from the

roster of 1,158 SSN-registered general practitioners in the Torino area after

stratification for sex, age and maximum number of patients allowed - variables

believed to influence preventive behaviour. One in five physicians was sampled. This

method gave us a sample proportionate by age, sex, and practice size. We interviewed

209 of the physicians sampled, as 16 refused (7.1%) to partit.pate in the study. Table 1

illustrates our sampling method and the negligible effects of non-respondents on the

final group of physicians interviewed.

Three trained interviewers asked them questions about:

1) Physicians' patterns of preventive practices including primary preventive

practices (smoking cessation and, anti-alcohol abuse interventions, counselling on

accidents in the home among the elderly, flu vaccination for the elderly, and

contraception) and secondary preventive practices (early detection of long, cervical,

and breast cancers and of hypertension);

2) physicians' perceptions of the effectiveness of these primary and secondary

preventive interventions;

3) specifie features of. the organization of their medical practices including

their mode of reimbursement and the actual structure of their clinical practice; 4)

personal habits of physicians such as smoking.

The questionnaire used in this study consisted of close-ended questions that

forced physicians to make choices. Perceived effectiveness of preventive practices

was rated on a scale ranging from "very effective" to "not effective" and perceived

use of a practice on a similar scale going from "al ways used" to "never used".

A pretest of the questionnaire was conducted on ten physicians not included in the

final sample. Results were examined for information bias. Interviewers did not

introduce any significant bias in collecting and recording answers.

44

RESULTS

O!]!snization of MedicaI Practice

General practitioners in Torino usually run their own medical practice, and they

have to provide offices and support staff. Fifty-six percent had an assistant who, in

20% of cases, was a nurse.

The offices of 50% of physicians were 10cated in buildings where other GPs and

specialists practiseQ~ n% regularly availed themselves of the opportunity to exchange

opinions and discuss cases with other physicians and the specialists operating in the

same facility. Of the physicians who exchange opinions, 21% periodically met with

colleagues and 11% shared office facilities and receptionist services.

Primary prevention

Smoking

Even though 10% of the physicians believed that the risk of contracting lung

cancer is no lower for ex-smokers than for those who continue smoking, aImost aIl

physicians perceived quitting smoking as "very" or "rather important" for promoting

health ('17.6%), and 98% of them claimed to have provided counselling to their patients.

Their advice varied according to patients' smoking habits. Sixt y percent of GPs

counselled aIl their patients smokers, but 37% provided counselling to those whom they

regarded as heavy smokers, i.e. at least 10 cigarettes per day.

Physicians were also questioned about the perceived effectiveness and stated use

of severa! smoking cessation interventions as shown in (Table 2). There was

substantial agreement regarding the effectiveness of mass media advertisir.g (74%) and

regular counselling (72%). Various types of psychotherapy (individual - 56%; psychotherapy in clinics - 43%; and group therapy - 41%) were considered effective to

varying degrees. Although psychotherapy as a whole had considerably high credibility,

the lack of adoption may be explained by the lack of payment for this technique by the

SSN. Acupuncture is not covered by the SSN, but was perceived as effective and was

used. In addition, it must be emphasised that from 15% to 36% of GPs admitted to

having no knowledge or opinions about the interventions discussed, except for mass

media advertising and counselling.

45

Counselling practice appeared ta be influenced by the physician's own smoking

habits. Seventy-four percent of non-smokers compared to 47% of smoking physicians

and 58% of ex-smokers counselled their patients who smoke to quit. This finding was

confirmed by several studies32-

33 although no relationship was found by other

studiesll,34. It is WOI th noting that the percentage of physicians who smoke is quite

high (36.8%) in comparison to other western countries, and approaches the proportion

of smokers in Torino (38.4% between 25 and 74 years of age). Similar findings have

been reported in Pordenone, ltaly35.

The most important limiting factors in implementing smoking cessation

intelventions were perceived to be the low patient compliance (rated important by 67%

of GPs) and the cost of the techniques (rated important by 47% of GPs). Restrictive

legislation and increasing the price of cigarettes are perceived as moderately effective

strategies by 48.3% and 30.6% of physicians, respectively.

AlcoJtol

A distinction can be made between alcohol abuse and a moderate intake of

:0 alcoholic beverages, but general practitioners in the Torino area fail ta agree on the

level of alcohol consumption considered safe (Table 3). The results are comparable with

those from a survey oi health care workers in England36.

Contrary to the opinions expressed regarding the effectiveness of measures to

help smokers quit, 77% of physicians main tain that psychotherapy is the most effective

treatment for alcohol abuse and 61% recommend it. Smaller perceJtage~ of physicians

belil'!ved in the effeetiveness of regular eounselling proviced by physicians and

Alcoholics Anonymous (Table 4). Although 53% of GPs considered Alcoholics

Anonymous ta be effective, ùnly 19% of them recommended it because of the

difficulties associated with recmrmending practices not eovered by the SSN.

Forty-seven percent of physicians said they do not use available techniques

considered effective b cause the SSN does not reimburse patients for such treatment.

Forty-one percent of GPs feel they have insufficient professional training in counselling.

Health education and mass media advertising were considered important factors which

ean fac:ilitate the physicians' in",;l ve!1tion against alcohol abuse, but 85% of GPs

believed specialized treatment centers to be particularly useful (Table 5). In

46

(

(

addition, most physicians (81%) regarded a tightening of controls on drinkina and

driving as a more effective measure than increasing the price of alcohol and restricting

sales.

Accidents in the home among the elderly

Only half of the G Ps surveyed believed advice to elderly patients to he useful in

preventing accidents at home, while 10% feU they had insufficient knowledge to form

an opinion on the tapie. This finding was supported by the fact that ooly 4'71 of the

GPs offered such advice, and 27% of those who did, did so with difficulty. Most

physicians (96%) were aware of the difficulty of modifying the living conditions of

their eIderIy patients, and 57% maintained that their patients failed to follow anyadvice

that was not strietly medieal (Table 6).

Plu vaccination for the eiderly

Seventy-seven percent of GPs believed flu vaccination to be effective for people

over 65 years of age, ooly 18% of GPs directly vaccinate them. Physicians frequently

refer patients to vaccination centers within the SSN.

Contraception

Most GPs (92%) considered it useful to provide information on contraceptives

and sexual education, but ooly 34% of them took the initiative to provide them. Many

GPs (82%) referred patients to specialized clioies (consultori) where advice and

assistance js provided for sueh matters as contraception, pregnancy and the prevention

of cancers specifie to wornen. Sorne patients were referred to specialists who

practice in other public rnultispecialized services or have hospital appointments.

Other Preventive Measl!.es

Most physicie.l1S maintained that the measures listed in Table 7 were extremely

effective, with the exception of vitamin A for the prevention of lung cancer.

At the tirn ~ of the survey, two legislative bills were tabled making the wearing

of safety helmets by motorcyclists, and seat belts by car drivers compulsory. The bill

on safety helmets was subsequently enacted into law. However, 58% of GPs did not

47

,1 consider il their responsibility to recommend the use of safety helmets and seat belts.

Secondary prevention

Luna cancer Although 57% of GPs believed chest X-rays to be effective in the early detection

of lung cancer, only 30% ordered them and 19% prescribed chest X-rays only for

patients who smoke at least 20 cigarettes per day and are 45 years of age or older.

Gynecoloaica1 cancers

Prevention of gynecologica! cancers is shared by G Ps with others in the National

Health System. Of the GPs surveyed, 18% maintained that such preventive activity i8

the duty of gynecologists, while 11 % believed it should be the responsibility of the

"consultorio". The working relations between GPs, cHoic physicians, and specialists

are often rather difficult, and 45% of GPs reported that they did not get enough

....ooperation from such colleagues.

Cancer of the cervix

Virtually all physicians (99%) consider the PAP test effective, but we uncovered

differences in the frequency with which it is performed relative to the age of the

patient (Table 8). Most physicians performed PAP tests frequently on women over 35

years of age, but oo1y 16% of thpm gave women under 35 the test.

Breast cancer

The physicians interviewed considered the mammogram to be more of a diagnostic

technique than an early detection measure for asymptomatic women. Oo1y 10% used

mammography as a screening procedure in the age group at risk (50-59 years of age).

A physical examination of the breast, in the absence of breast related symptoms, was

carried out by ooly 21% of physicians.

Physicians seemed to regard breast self examination (8SE) as a more important

secondary preventive measure, and 95% believed regular BSE to be a 'Iseful early

detection technique. Of the 87% of physicians who recommended it to their patients,

66% recommended that it begin at age 20. There was, however, some doubt about how

48

, ,

c

well the technique was taught to patients since only 25% of GP's make any follow-up

effort to ensure it is being performed properly.

Rather than teaching their patients BSE, 21% of GPs gave them literature on the

subject or referred them to a gynecologist or to a "consultorio".

Hypertension

It was common practice for GPs to take the patient's blood pressure during

routine examinations, but 5% of physicians stated that they only did so when certain

symptoms were present. Seventy-one percent of GPs took the patient's blood pressure

on the first visit only, 23% took it du ring every clinical encounter, and 6% invited

patients to return for periodic monitoring.

Twenty-eight percent of GPs began drug treatment of high blood pressure in

asymptomatic patients over 40 years of age when the diastolic reading was between 90

and 95,64% percent began treatment when the diastolic reading was between 95 and 100, and 7% when it exceeded 100.

DISCUSSION

The raIe of the primary care physician in providing preventive services has been

emphasized in North America in the pa st decade. Two recent reviews assessed the

penetration of preventive activities into the clinical practice of primary care physicians

in the U.S.A.37 and Canada38• Bath concluded that, even though progress has been

achieved in some areas where there are weIl accepted guidelines, such as smoking

counselling and early detection of cervical cancer, there is considerable room for

improvement in the implementation of the sets of guidelines promulgated by the

Canadian Task Force on the Periodic Health Examination3.24-27 and by the U.S.

Preventive Services Task Force2s-

31•

The health care reforms du ring the late 1970s in Italy have triggered a profound

rethinking, not only of the Italian health care system but, of the respective roles of

general practitioners and specialists in primary care. The high response rate of GPs,

their level of interest during interviews, and the strong beliefs they expressed about the

effectiveness of preventive activities can be viewed as signs of their growing interest

49

, ' , ~r

in playing a more active role in promoting their patients' health. Indeed, a similar

survey of physicians' attitudes towards the prevention of gynecological tumours

conducted in Italy by Mossetti et al. 38, about ten years ago, had a 13% response rate, and

demonstrated a lack of knowledge and poor utilization of early diagnostic techniques.

Our findings indicate a need for additional incentives for physicians in carrying

out their new role. The physicians we interviewed confirmed their beHef in the

efficacy of the various preventive activities they were asked to judge and they tended to

overestimate the effectiveness of early detection of cancer and other diseases. The

most effective measures were, in fact, entrusted to consulting specialists23• With

regard to primary prevention, the practices considered most effective by GPs were

either not yet targets for counselling during clinical encounters (e.g. the use of crash

helmets and seat belts), or seen as being the responsibility of the consultant

gynecologist (e.g. counselling about contraceptive methods).

Interventions for such problems as smoking or drug and alcohol abuse were

delivered with only moderate confidence in their effectiveness. Attitudes regarding

smoking cessation are illustrative. Although the majority of physicians are firmly

persuaded that smoking cessation is very important in promoting individual health, only

60% of physicians comply with published guidelines, counselling all smokerst

regardless of the number of cigarettes they claimed to smoke daily. Consistent with

other studies32-n , smoking habits of physicians influence their counselling behaviours.

Another factor that influenced GPs' decisions to prescribe particular preventive

maneuvers was the coverage of medical interventions for those enrolled in the SSN.

Sorne interventions, such as psychotherapy, are partially reimbursed by the SSN and

GPs may be reluctant to prescribe procedures that result in an expense for the patient,

their effectiveness notwithstanding. Indeed the cost of procedures was often claimed by

GPs as a limiting factor in recommending them.

In general, interest in preventive practices appears to be oriented toward early

detection mea~ures as primary preventive activities are ooly beginning to receive

attention by primary care physicians in Italy, and the rates of usage of screening

techniques are, in general, higher tban those for adoption of primary preventive

interventions. Although the Reform of the National Health Service in 1978 clearly

emphasized the role of GPs in prevention, no follow-through action has been

50

(

· (

undertaken. The duties of GPs are still being viewed in the traditional perspective of

diagnosis and treatment. Preventive measures involving "medical" too18 are considered

more appropriate than counselling on the use of seat belts and crash helmets or on how

elderly patients may avoid domestic accidents.

In North America, practice guidelines have been provided by the Canadian Task

Force on the Periodic Health Examination, the U.S. Preventive Services Task Force,

and other recommending bodies such as the American Cancer Society and the Consensus

Development Conferences of the National Institutes of Health. In Europe. practice

guidelines have been formulated mainly by the International Union Against Cancer of the

World Health Organization. Although a reformulation of practice recommendations

May not he necessary, an Italian organization could be set up to summarize the state of

the evidence supporting preventive interventions and to ensure its adequate diffusion to

practising clinicians.

Appropriate incentives for preventive practices should be considered in order to

accelerate physicians' involvement in the emerging worldwide reorientation towards

disease prevention and health promotion.

51

1.

REFERENCES Frame PS, Carlson SJ. A critical review of periodic health screening using

specifie screening criteria. Part 1. Selected diseases of r~spiratory,

cardiovascular, and central nervous systems. J Fam Pract 1975;2:29-36. 2. Breslow L, Samers AR. The lifetime health-monitoring program: a practical

approach to preventive medicine. N Engl J Med 1977;296:601-608. 3. Canadian Task Force on the Periodic Health Examination. The periodic health

examination. Can Med Assoc J 1979;121:1194-1254. 4. Roemer MI. The value of medical care for health promotion. Commentary. Am

J Publk Health 1984:74:243-248. 5. Frei E, Frechette AL. The future of cancer control. N Engl J Med

1978;298:567.

6. Basson EC. The role of the doctor in public education. Health Education,

Theory and Practice in Cancer Control, UIeC Technical Report Series, vol. 10,

1974.

7. Smith A, Alvarez CA (eds). Cancer control. Advances in medical oncology,

research and education. England: Pergamon Press, 1979. 8. Romm F J, Fletcher SW t Hulka BS. Periodic health examination: comparison of

recommendations and internists' performance. Sa Med Journal 1981;74:265-271. 9. Radecki SE, Mendenhall RC. Patient counselling by primary care physicians:

results of a nationwide survey. Patient Education and Counselling 1986;8:165-177.

10. Gemson DH, Elinson J. Prevention in primary care: variability in physician

practice patterns in New York City. Am J Prev Med 1986:2:226-234. 11. Lurie N, Manning WG, Peterson e, Goldberg GA, Phelps CA, Lillard L.

Preventive care: do we practice what we preach? Am J Public Health

1987;77:801-804. 12. Wu B, Cook EF, Weisberg M, Goldman L. Screening procedures in the

asymptomatic adulte Comparison of physicians' recommendations, patients'

desires, published guidelines and actual practice. JAMA 1985;254:1480-1484.

13. McPhee SJ, Richard RJ, 50lkowitz SN. Performance of cancer screening in a

university general internai medicine practice. J Gen Int Med 1986;1:275-281.

52

~ ~, '!~."4j , l' • .. 'l r t,t·· ' ..

14. Val ente CM, Sobal J, Muncie HL, Levine DM, Antlitz M. Health promotion:

, physicians' beliefs, attitudes and practices. Am J Prev Med 1986;2:82-88.

(

15. Orleans CT, George LK, Haupt JL, Brodie KH. Health promotion in primary

care: a survey of US family practitioners. Prev Med 1985;14:636-647.

16. Battista RN. Adult cancer prevention in primary care: patterns of practice in

Qu6bec. Am J Public Health 1983;73(9):1036-1039.

17. Battista RN, Palmer CS, Marchand BM, Spitzer WO. Patterns of preventive

practice in New Brunswick. Can Med Assoc J 1985;132:1013-1015.

18. Battista RN, Spitzer WO. Adult cancer prevention in primary care: contrasts

among primary care practice settings in Qu'bec. Am J Public Health

1983;73(9):1040-1041 19. Elford W. Patterns of preventive practice of Southern Alberta Family

Physicians. Department of Family Medicine, University of Calgary, 1987.

20. Ho A, Herbert C, Farrall J. Periodic health screening: what members of the

Department of Family Practice at the Vancouver General Hospital are doing.

University of British Columbia, Department of Family Medicine, 1986.

21. Borgiel A, Williams j, Anderson G, Bass M, Spasoff R, Dunn E, Lamont C.

22.

23.

24.

25.

26.

27.

28.

Assessing the quality of care in family physicians' practices. Cao Fam Phis

1985;31:853-862. Audunnson G. Preventive infrastructure in family medicine; Master's thesis.

Department of Family Medicine, University of Western Ontario.

Piperno A. Renieri A. Rapporto sul Medico di Base. Salute e Territorio

1980;11:2-9. Canadian Task Force on the Periodic Health Examination. The periodic health

examination: 2. 1984 update. Can Med Assoc j 1984;130:1278-1292.

Canadian Task Force on the Periodic Health Examination. The periodic health

examination: 2. 1985 update. Can Med Assoc J 1986;134:724-729.

Canadian Task Force on the Periodic Health Examination. The periodic health

examination: 2. 1987 update. Can Med Assoc J 1988;138:618-626.

Canadian Task Force on the Periodic Health Examination. The periodic health

examination: 2. 1989 update. Can Med Assoc J 1989;141:209-216.

U.S. Preventive Services Task Force. Recommendations for breast cancer

S3

1

,".

screening. JAMA 1987;257(16):2196.

29. U.S. Preventive Service Task Force. Recommendations for prevention of

sexually transmitted diseases. JAMA 1987; 258(6):814.

30. U.S. Preventive Services Task Force. Recommendations for automobile

occupant protection counselling. JAMA 1988;259(1 ):76.

31. V.S. Preventive Services Task Force. Recommendations for smoking cessation

counselling. JAMA 1988;259(19):2882.

32. Battista RN, Williams JI, McFarlane L. Determinants of preventive practices in

fee-far-service primary carel Am J of Prev Med (Submitted for Publication).

33. Cummings KM, Giovino G, Sciandra R, Koenisgsberg M, Emont SL. Physician

advice to quit smoking. Who gets it and who doesn't? Am J Prev Med 1987;3:69-

75.

34. Maheux B, Pineault R, Beland F. Factors influencing physicians' orientation

toward prevention. Am J Prey Med 1987;3:12-18.

35. Francheschi S, Serraino D, Talamini R, Candiani E. Personal Habits and

attitudes towards smoking in a sample of physicians from north-east of Italy.

Letter to the Editors. Int J Epidemiol 1986;15(4):584-585.

36. Anderson P, Cremona A, Wallace P. What are the safe levels of alcohol

consumption? Brit Med J 1984;289:1657-1658.

37. Lewis CE. Oisease prevention and health promotion practices of primary care

physicians in the United States. In Battista RN, Lawrence RS, eds. Implementing

Preventive Services. Am J Prev Med 1988;4(4)s:9-16.

38. Bass MJ, Elford RW. Preventive practice patterns of Canadian primary care

physicians. In Battista RN, Lawrence RS, eds. Implementing Preventive

Services. Am J Prev Med 1988;4(4 )s:17-23.

39. Mossetti C, Sismondi GP, Panero M. Il compartamento dei medico nell'azione

preventive antitumorale, dati relativi ad un questionario inviato ai medici della

Provincïa di Torino. Minerva Gynaecologica 19n:29:107.

54

(

TABLE 1 - Number of patients allowed, and proportions ot physicians, by. and sex, for an GPs, those in sample and those interviewed.

Number of patients Age Sex "all GPs % sample " interviewed allowed

<=500 <40 M 21.7 21.8 22.8 <=500 =>40 M 15.2 15.1 14.9

501-1499 <40 M 3.0 3.1 2.5 501-1499 =>40 M 3.9 3.5 3.3

=>1500 <40 M 14.1 13.8 14.3 =>1500 =>40 M 26.2 26.7 25.5 any all F 15.9 16.0 16.7

(N=l158) (N=225) (N=209)

55

, ~ "

TABLE 2 - Perceived effectiveness of smoking cessation intenentions -Physicians' response C%)

Actual Use Perceived Effectiveness

Type of intervention Yes Effective Not Don't Effective know

Interventions that GPs ean perform by themselves

Regular counselling 98.1 71.8 27.8 0.4

One-time counselling 90.0 34.5 65.1 0.4

Nicotine gum 26.3 20.6 47.4 32.0

* "Nicoprivetl 28.2 15.8 63.6 20.6

Interventions that G Ps can prescribe and are only partially reimbursed by the SSN to the patients

Individual psychotherapy 26.3 56.0 25.4 18.6

Psychotherapy in clinics 8.6 42.6 29.2 28.2

Group therapy 7.7 41.2 29.7 29.1

Acupuncture 43.1 39.7 45.5 14.8

Hypnosis 19.1 37.8 31.1 31.1

Auriculotherapy 34.4 31.6 42.1 26.3

Specialized clinies 2.9 23.4 40.7 35.9

Mass media advertising Not 73.5 25.0 1.5 Applicable

Audiovisuals/Print 25.4 65.6 33.0 1.5

* Smoking cessation medieation used in Italy , 56

(

T ABLB 3 - Daily alcohol intake considered safe

Alcohol intake per day

o drinks/ day 1-2 drinks/day 3-4 drinks/day 5-6 drinks/day more than 6/ day

Physicians in agreement (%)

1.4 47.4 43.1 6.2 1.9

TABLE 4 - Perceived use and effectiveness of alcohol abuse treatment

Physicians' response (%)

Treatment Actual Use Perceived Effectiveness

Yes Effective Not Oon't know Effective

Interventions that GPs can perform by themselves

Repeated 97.1 58.8 41.2 0.0 counselling

Pharnnacotherapy 53.1 36.9 56.0 7.1 One-time coun,elling 82.8 30.7 68.5 0.8

Interventions that GPs can prescribe and are only partially reimbursed by the SSN ta the patients

Psychotherapy 61.2 76.6 20.5 2.9 Alcoholics Anonymous 18.7 53.1 19.6 27.3

Acupuncture 12.9 14.3 48.4 37.3

57

, ,r,

TABLE 5 - Factors perceived as facllitating the prevention of alcoholism

Physicians' response (%)

Useful Not useful Don't know

Specialized centers 84.7 12.9 2.4

Monitoring level of alcohol in drivers 81.4 17.7 0.9

Mass media campaign 78.0 22.0 0.0

Healtb Education 63.1 36.3 0.6

Taxation 25.4 73.7 0.9

Restrictions on sales 18.2 81.3 0.5

TABLE 6 - Problems encountered by 56 physicians who counsel the elderly on accidents at home

Problem

Impossible to modify living condition

Patient does not follow advice that is not strictly medical

Physician's limited time

Inadequate professional training

Patient's limited time

Physicians' response (%) (N=56)

58

YES NO

96.4

57.1

35.7

28.6

14.3

3.6

42.9

64.3

71.4

85.7

(

c

~ '( • 1

TABLE7- Perceived effectiveness of other primary preventive measures

Physicians' response (%) Preventive measure

Effective hot effective

Crash helmet for motorcyclists 100

Seat belts in cars 94.8 4.7

Weight control 94.7 4.8

Physical exercise 91.4 8.6

Controlled use of drugs 89.4 10.6

Oral hygiene 88.3 11.2

Vitamin A for the prevention of lung cancer 18.2 50.7

TABLE 8 - Use of PAP tests

Physicians' response (%)

Frequency of PAP test prescription Never more than 1 one per every 2 every 3

per year year years years Age of women

<35 16.3 4.4

35-70 1.5 11.8

30.5

69.5

27.1

11.3

59

11.3

2.0

Don't know

0.5

0.5

0.5

31.1

every 5 no years answer

7.0

0.5

3.4

3.4

.. \i'\

APPENDIX A

\1 Table A. 1 ~ of §e~~!nnded practices fraI the Reports of the C&nadian Tuk Force on 'Ille Perlodlc Health Exuinatlon • ,

Qual1tyof Classification ot Condition lfaneuver evidence Recouendation

Lung cancer Short counaelling and follow-up. Nicotine gu. only as an adjunct leasure 1 A

Early detection: chest I.-\'ays not recOlUnded sputUiO cytology not reco .. ended

Alcohol Abuse Case-rlndlng and counselling B

Accidents at Encouraging Cannot hOle IIIOng safety in the hOle be the elderly assessed C

Flu vaccination for the elderly IHunization A

Kotor vehicle Encouraging the Accidents use or seat belts III C

Cervical Early detection: Cancer Papan1colaou Slear 11-2 A

Breast Early detect10n: cancer Annual lfauography and

Physical EXlllnatlon (for wOlen 58-59 yrs) A

Breast self exaalnatlon (for wOlen >48 yrs) III C

Hypertension Early detecUon: Blood Pressure "easureaent A

Ull\/anted Counselllng on pregnancy sexual actlvlty and

contraceptive lethods Il B

t 60

c

------~~----------~,~,,~L .... ,;,~ ... ,~,i, ........ I".W.ni.J~1I'I

Table A.2 Summary of the grades of quality of evidence and classification of recommendations25

•

Quality of evidence

1: Evidence obtained from at least one properly randomized controlled trial. 11-1: Evidence obtained from well-designed controlled trials without

randomization. 11-2: Evidence obtained from well-designed cohort or case-control analytic

studies, preferably from more than one c~nter or research ,roup. 11-3: Evidence obtained from comparison be1.ween times or places with or

WithOl ~ the intervention. Dramatic results in uncontrolled experiments (such as the results of treatment with penicillin in the 19408) could also be included in the category.

III: Opinions of respected authorities, based on clinical experience, descriptive studies m' reports of expert committees.

Classification of Recommendations.

A:

B:

C:

D:

E:

There is good evidence to support the recommendation that the condition be specifically considered in a periodic health examination. There is fair evidence to support the recommendation that the condition be specifically considered in a periodic health examination There is poor evidence regarding the inclusion of the condition in a periodic health examination, but recomm.!ndations may be made on other grounds. There is fair evidence to support the recommendation that the condition be excluded from consideration in a periodic health examination. There is good evidence to support the recommendation that the condition be excluded from consideration in a periodic health examination.

61

1

DETERMINANTS OF PRIMARY PREVENTIVE PRACTICES OF

GENERAL PRACTITIONERS IN TORINO, IT ALY.

62

PRESENT A TION

Guided by the results of the study reported in paper 1, we selected an array of

primary and secondary preventive techniques according to their availability and adoption

in practice. We also focused on sorne traditional Medical procedures for comparison

with other studies, although such alternative approaches as acupuncture for smoking

cessation or Alcoholics Anonymous were also available and used in Torino.

The results of the previous analysis indicated that physicians tend to

overestimate the effectiveness of severai techniques, and entrust the most effective to

consulting specialists or other services. When patterns of adoption were examined, no

homogenous behaviours emerged and cornpliance to published guidelines V8ried among

physicians.

In paper 2, we explore the determinants of a set of primary preventive practices

of General Practitioners in Torino, ItaIy. Scales were constructed to measure

practices, leveis of knowledge and attitudes of GPs with respect to primary preventive

practices. An overall scale did not have an acceptable levei of internaI consistt:ncy,

signifying tlu:.t physicians' preventive behaviours vary across interventions.

Accordingly, we analyzed the determinants of each primary preventive practice.

Paper 2 was written by the author of this thesis, supervised by Drs Renaldo N.

Battista, Nereo Segnan, J. Ivan Williams and Dr Samy Suissa, and in collaboration with

Dr. Antonio Ponti.

63

o

1

DBTBRMlNANTS OF PRIMARY PREVENTIVE PRACTICBS OF

GBNERAL PRACTITIONBRS IN TORINO. IT ALY

Key words:

Running head: Primary Preventive Practices in Torino

Primary prevention, general practice, patterns of practice.

Stefano Rosso, M.D.*,** Renaldo N. Battista, M.D., Sc.D.**

Nereo Segnan, M.D., M.Sc.* J. Ivan Williams Ph.D.**

Samy Suissa Ph.D.*· Antonio Ponti, M.D., M.P.H.*

* From the Area di Epidemiologia, Unita' Sanitaria Locale 1, Torino, Italy

** From the Department of Epidemiology and Biostatistics, McGill University and the Division of Clinical Epidemiology, Montreal General Hospital, Montreal, Canada. Dr. Battista is a Research Scholar of the National Health Research and Development Program, Ottawa, Canada. Dr. Suis sa is a Research Scholar of the Fonds de la recherche en sant' du Qu'bec.

Address Reprint requests to: Dr. Stefano Rosso Area di Epidemiologia, Unita' Sanitaria Locale Torino l, Via San Francesco da Paola 31, Torino, ltaly 10123 Tel.:(l1) - 835386

(11) - 832004

64

ABSTRACT We conducted a studyof general practitioners in Torino, Italy, to determine

their patterns of preventive practice. A set of primary and secondary preventive

interventions and their determinants were examined. Seales were constructed to

encompass praetice behaviors, knowledge, beliefs, and barriers. Organizational

aspects of health care in Italy, and physicians' lifestyle were considered in the

analysis.

In this article we explore the determinants of primary preventive interventions,

including anti-smoking and alcohol abuse counselling, counselling for prevention of

accidents at home among the elderly, flu vaccination for the elderly, and counselling on

contraceptive use.

The explanatory factors were grouped in cognitive, socio-demographic, and

organizational. Different patterns emerged for each maneuver. Cognitive factors

played an important role, but their importance varied for each intervention. Smoking

behavior of physicians was found to be the major predietor of anti-smoking

counselling.

The importance of better understanding determinants of practice behaviors is

emphasized for implementing strategies to enhanee the diffusion of effective

preventive techniques.

Key words: cancer prevention, primary prevention, general practice, patterns of

practice.

65

t

INTRODUCTION

The evo1ution of health care and monetary constraints in recent yean have

underscored the raie of prevention in primary care. A new èpproach wap proposed in

the 1ate seventies by Breslow and Sorners 1 , the Institute of Medicine- and the Canadian

Task Force on ~e Periodic Health Examination:!. Scientific evidence for the

prevention of several important health problems was reviewed. The loal was the

diffusion of recomrnended practices during patient visits for periodic or epiaodic caret

The proeess of implementation is neithel' complete nor uniform"-18• Sorne

practices, such as the prescription of Papanicolaou test for early detection of cervical

cancer, have received wide acceptance into Medical practice whereas others such as

counselling on accidents at home among the elderly have yet to be widely adopted.

We need a better understanding of the factors influencing integration of

preventive activities into medical practice. As most of the studies on diffusion of

preventive activities in primary care were conducted in countries with a fee-for­

service or mixed fee-for-service 1 salary system-a- 51, we decided to explore practice

behaviors in a capitation system.

The Italian National Health Service (Servizio Sanitario Nazionale -SSN-),

founded in 1978, is based on Local Health Authorities whose administrators are elected

by the municipal government. Primary care, public health and hospitals are under their

jurisdiction. General Practice is done mainly by general practitioners, but it can also

include internists and surgeons devoting part of their time to primary caret General

practitioners are paid on a capitation basis for an allowed number of patients that

varies according to their professional commitments.

The object of our survey was ta study the attitudes and behaviors of primary

care physicians in Torino, Italy, with respect to primary preventive practices based on

recommendations from the Canadian Task Force on the Periodic Health

Examination3•20

-a :! and the U.S. Preventive Services Task Forcea4

-27

•

METHOns

A systematic sample of 225 general practitioners was drawn from the files of

66

;"

1

the Local Health Authority of Torino. The sample was stratified by qe, sex and

practice size, as measured by the maximum number of patients allowed under the

capitation system. Sixteen physicians refused to be interviewed (7.1").

Information was collected on items encompassing reported patterns of

preventive practice, perceived effectiveness of interventions, knowledge of the

diseases associated with smoking and alcohol abuse, and perceived barriers to the

implementation of specific preventive interventions in their medical practice. Also we

documented several practice features such as size of practice, group or solo activity,

type of training of physicians, and their personal health habits such as smoking.

The data were coUected through face-to-face interviews by three trained

interviewers and results were based on physicians' reports.

In the analysis of the data we created scales for anti-smoking and alcohol abuse

eounselling, knowledge, and barriers. Factor analysis28-28 was used to reduce items

to scale scores for counselling behaviors and barriers. Oo1y the items with factor

loadings of 0.4 on the principal factor were retained. Cronbach's alpha2ti1-

30 was used

to assess the internaI consistencyof each scale previously delineated through factor

analysis. The correlation matrices of each scale's items are presented in Appendix A

(Tables A.1-A.2). The total and partial scores for each scale were standardized using

Z-score transformation « score - mean ) / scale's standard deviation ).

Outcome variables.

The anti-smoking and alcohol abuse counselling seales were constructed by

eombining different items, including the type of clinical encounter during which

counselling was done (first visit, periodic check-up, visit for symptoms unrelated to

the risk factor), frequency of given counselling (always, often, seldom or never) and

the patients targeted by the intervention (a11 patients, high risk group only or

symptomatic patients).

The internaI consistency coefficient for the anti-smoking counselling items was

0.64. Alcohol abuse counselling items had an internaI consistency coefficient of 0.67.

Factor analysis showed a major scale factor for both scales, scores were normally

distributed, and the scales were left as continuous variables.

The questions on counselling for accidents in the elderly at home and giving of

67

J'f ,~ ~:- ,~ ~ 1 T q. v ... ' l • L ~ , '

a

contraception advice had four response categories (always, often, seldom or never

performed), and they were subsequently dichotomized for analysis.

Physicians were asked if they carried out flu vaccination for the elderly. A

score of 1 was assigned if the answer was positive and zero if patients were referred

to other services.

Determinants.

Knowledge of diseases caused by smoking and alcohol consumption was assessed

with two distinct seales. Physicians were requested to rate the evidence pertaining to

the associations between smoking and alcohol abuse with diseases on a four point scale

(strong, fair, poor, no evidence).

Physicians' self-confidence in the effectiveness of their interventions refers to

the doctors' beHefs that these interventions will reach the desired goals. Physicians

were asked to grade their confidence in the effectiveness of interventions on a four

level scale (very effective, rather effective, somewhat effective and never effective).

A "don't know" category was also included. For aIl practices, except counselling for

accident at home in the elderly, the frequencyof "don't know" was less than 5%. A

"don't know" response was recoded as a lack of perceived effectiveness (never

effective). Perceived effectiveness scores for anti-smoking and alcohol abuse

counselling were normally distributed. Perceived effectiveness scores for counselling

for prevention of accidents at home among the elderly, influenza vaccination, and

counselling on contraceptive use were bimodally distributed. Consequently we

dichotomized them.

GPs were also asked what problems they had encountered in implementing

smoking cessation and alcohol abuse interventions. Barrier scales were cons:tructed

including the following items: lack of knowledge, time constraints, time cost for the

patient, lack of monetary incentives, ove raIl cost of the procedure, accessibility, and

patients' compliance. The barrier scale for anti-smoking counselling had a borderline

internaI consistency coefficient of 0.60. It was normally distributed and was used in

the analysis as a eontinuous variable. The barrier seale for alcohol abuse counselling

had alow alpha and a skewed distribution. The variable was dichotomized into alow

score (physicians who had c1aimed none or one barrier) and high score (physicians who

68

had claimed 2 or more barriers).

The possibility of "collaborating" with other colleagues was thought to he

important in improving preventive practices7,31. Measurement of the level of

"collaboration with other colleagues" is based on two questions that elicit different

degrees of interaction with peers. The first question asks if there are other

physicians practising in the same office, and the second question focuses on the level of

collaboration with colleagues. Scores are: 0 (neither collaborate nor sbare office

facilities); 1 (share office facilities); 2 (attend occasional professional meetings); 3

(attend periodic professional meetings); 4 (manage common patients occasionally); 5 (sbare medical records and manage common patients). The scale showed a bimodal

distribution and for this reason was dichotomized in "solo" (scores 0 to 1) (64.1") and

"group" practice (scores 2 to 5) (35.~). Group practice is defined as physicians who

have periodic working meetings with other colleagues for discussing common

management of their patients or clinical cases.

We classified practitioners according to their main activity: full-time

practitioners (59.8%); internists devoting part of their time to primary care (25.8%): and surgeons devoting part of their time to primary care (14.4%).

Gender and number of years since graduation were also incorporated in the

analyses.

The distributions of variables included in the analysis are presented in Appendix

B (Tables B1-B5).

Analysis

For the continuous outcome variables (anti-smoking and anti-alcohol abuse

counselling), we used multiple linear regression analysis3a- n • A stepwise selection

procedure was applied in order to select the best fitting model using several variables

including knowledge, beliefs, barriers, daily intake of alcohol considered damaging and

number of years since graduation. A multiple-partial F test32 was used for

comparison of models when adding categorical variables (gender, categoryof

practitioners, collaboration with other colleagues, and smoking behavior). We

reassessed the significance of the first set of variables after inclusion of significant

categorical variables and analyzing residuals.

For the dichotomous outcome variables (flu vaccination for the eiderly,

69

, ,

•

t

<"

counselling for accidents at home among the elderly and counselling on contraceptive

use), multiple logistic regression analysis was used with a stepwise selection

procedurcl4-

3!1.

First order interactior .. terms were also considered in both analyses. Higher order

interaction terms were excluded because of difficulty in interpreting the models.

RESULTS

Different patterns of determinants emerged for each preventive practice. A

summary of the important predictors is given in Table 1, where determinants are

classified as cognitive, socio-demographic, and organizationaI. We presented summary

statistics for each model and measures of association such as partial correlation

coefficients for multiple linear regression models and adjusted odds ratios for logistic

models. Multiple regression models cou Id only explain between 7 to 10% of the

variance in practice behaviors, and logis tic models showed a limited goodness of fit.

The principal findings are discussed below for each intervention.

Anti-smoking counselling.

Our GPs claimed they gave repeated counselling in a high proportion (98%) of

their patients, but only 60% of them counselled aIl their patient smokers in accord an ce

to recommendations3•27

• The principal detenninants of anti-smoking counselling were

perceived effectiveness of counselling, smoking habits of physician, and category of

practitioners with partial correlation coefficients ranging from 0.13 to 0.23.

Physicians who are non-smokers have the highest adjusted score. Although

important differences exist in the adjusted mean scores between smokers and non­

smokers (13% of the scale's overall range) and between ex-smokers and non-smokers

(7% of the scale's overall range) only the first comparison is significant (Table 2).

Intemists devoting part of their time to primary care had a higher counselling

score than full-time OPs or surgeons with part-time commit ment to primary care

(Table 2).

Younger physicians appeared to counsel their patients more frequently than their

70

) i, '. ;# .

oider colleagues, although number of years since graduation had borderline

significance. Most of the lowest scores were from a minority of oIder physicians.

When these outliers were removed from the analysis, number of years since graduatbn

was no longer a significant predictor of practice.

Perceived effectiveness of anti-smoking counselling was also an important

determinant, contributing about 15% of the variance explained by the model.

Alcohol abuse counselling.

Counselling for preventing alcohol abuse was reported by 97% of GPs, although

the intervention was considered less effective tban anti-smoking counselling. Levelof

knowledge, and number of years since graduation were important determinants of this

practice. Younger physicians with a better training (higher knowledge score)

counselled their patients more on alcohol-abuse. The poor fit of the model (R-square

of 0.08) however, underscores the need for a better theoretical model that would

include other determinants, and more precise measurements.

Counselling for accidents at home among the elderly.

About half of the physicians (47%) reported they counselled elderly patients on

prevention of accidents at home. GPs can refer their patients to social services

directly supported by the local community, and 36% of them reported to have referred

their elderly patients because of the presence of environmental hazards at home which

could result in faIls and injuries.

Factors associated with this type of counselling were, the perceived

effectiveness of counselling (50.7% of GPs perceive counselling as very or rather

effective), and a good working relationship with social services which offer support

and help to the elderly. Only 17.7% of interviewed physicians had a good working

relationship with social services and referred their patients to them.

Flu vaccination.

Eighteen percent of physicians directly administered flu vaccine to the elderly.

The remaining physicians frequently referred patients to vaccination centres within the

SSN.

71

~ .... ~ , ,,'

In the logistic regression, perceived effectiveness of the flu vaccination among

patients over 6S years of age was only marginally related to practice. Physicians who

perceived flu vaccination as very or rather effective (78.0%) were three times more

likely to carry it out.

Counselling on contraceptive use.

Although the majority (92%) of GPs considered contraception effective in

preventing unwanted pregnancies, ooly 34% of them actually counsel their patients.

Many of them (82%) refer their patients to specialized services.

Pemale physicians in group practice were the mostly likely to provide such

advice.

DISCUSSION

Patterns of preventive practices result from the interaction of several factors,

and various classifications of determinants have been proposed. Green et al.38

classified the factors into three categories, predisposing, enabling, and reinforcing

factors. The three sets are not mutually independent and are difficult to put in

ope rational terms. We preferred to classify them in cognitive, socio-demographic, and

organizational factors as proposed by Battista et a1.37-

38• Nevertheless, as noted in

other studies9• 39-41 ,determinants work differently for each preventive practice and a

more efficient theoretical framework is needed.

Smoking counselling has been studied by several authors8• 37-43 a.nd similar

patterns of determinants have been recognized. Other studies have documented that

internists seem to be more oriented towards counselling 13-14. 31 .44-45.

Younger physicians offer both anti-smoking and alcohol abuse counselling more

often than their oIder colleagues~ thus reflecting a change in the training received in

more recent years.

Recommendations for the inclusion of counselling on accidents in the home

72

among the elderly have only recently been considered by the US Preventive Services

Task Forcelt ... Even though the prevention of home accidents is recognized by our

physicians to be an important public health issue, this intervention is DOt yet part of

their usual medical practice.

Perceived effectiveness of flu vaccination for the elderly was the oo1y

significant predictor of its use, whereas other studies have also found that younger and

board-certified physicians were more likely to meet these immunization guidelineslt7•

Gender and group practice were found to be the key factors associated with

contraception counselling.

The analysis of the se data is the first attempt to investigate the determinants of

physicians' primary preventive practices in Italy and to compare them with studies in

other countries.

Our study showed that in general, prevention is carried out by physicians at a

comparable level with similar determinants. Local organizational features, such as

availability of other primary care services, are also important factors modulating the

level of preventive care offered by physicians.

Any attempt at improving physicians' performance in preventive care should take

these factors into account, and consider physicians' involvement in prevention in the

broader context of public health efforts.

73

1.

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approach to preventive medicine. N Engl J Med 19n;296:601-608.

2. Institute of Medicine. Preventive Services for the Well Population. Report of the

Institute of Medicine, National Academy of Science, Healthy People

(appendices), 1-22. Washington, US Department of Health, Education and

Welfare 1978. 3. Canadian Task Force on the Periodic Health Examination. The periodic health

examination. Can Med Assoc J 1979;121 :1194-1254.

4. Battista RN. Adult cancer prevention in primary care: patterns of practice in

Qu'bec. Am J Public Health 1983;73(9):1036-1039.

5. Battista RN, Palmer CS, Marchand BM, Spitzer WO. Patterns of preventive

practice in New Brunswick. Can Med Assoc J 1985;132:1013-1015.

6. Catford JC, Nutbeam D. Prevention in practice: what Wessex General

Practitioners are doing. Br Med J 1984;288:832-834.

7. Gemson OH, Elinson J. P~evention in primary care: variability in physician

practice patterns in New York City. Am J Prev Med 1986;2:226-234.

8. Goldstein B, Fischer PM, Richards jW, Goldst'!in A, Shank je. Smoking

counseling practices of recentIy trained Family l">hysicians. J Fam Pract

1987;24( 2) :195-197.

9. Lurie N, Manning WG, Peterson C, Goldberg G/. t Phelps CA, Lillard L.

Preventive Care: do we practice what we prea(;h? Am J Public Health 1987;

10. Orleans CT, George LK, Houpt JL, Brodie KH.Health promotion in primary

care: a survey of U.S. Family Practitioner:i. Preventive Medicine 1985;14:636-

647. 11. Rigotti NA, Calkins DR, Gordon NP, Cleary PD.Do Physicians advise petients

about health practiccs, and does it make a difference? Clinical Research

11985;33:73-85. 12. Romm F J, Fletcher SW, Hulka BS. Periodic health examination: comparison of

recommendations and internists performance. So Med journal 1981;74:265-271.

13. Val ente CM, Sobal J, Muncie HL, Levine DM, Antlitz M. Health promotion:

physicians' beliefs, attitudes and practices. Am J Prev Med 1986;2:82-88.

74

'e

14. Wechsler H, Levine S, Idelson RK, Rohman M, Taylor JO. The physician's role

in health promotion: a survey of Primary Care Practitioners. N Bill J Med

1983;308 ( 2) :fJI-1 00. 15. Wells m, Lewis CE, Leake B, Ware JB Jr. Do physician preach what they

prar.ticû JAMA 1984;252:2846-2848.

16. Blford W. Patterns of preventive practice of Southern Alberta Family

Physicians. Department of Family Medicine, Univ~rsity of Calgary, 1987.

17. Ho A, Herbert C, Farrall J. Periodic health scrr,t,;;ng: what members of the

Department of Family Practice at the Vancouver General Hospital are doing.

University of British Columbia, Department of Family Medicine, 1986.

18. Borgiel At Williams J, Anderson G, Bass M, Spasoff R, Dunn E, Lamont C.

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24.

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27.

28.

Assessing the quality of care in family physicians' practices. Can Fam Phys

1985;31 :853-862.

Audunnson G. Preventive infrastructure in family medicine; Master's thesis.

Department of Family Medicine, University of Western Ontario.

CSlladian Task Force on the Periodic Health Examination. The periodic health

examination: 2. 1984 update. Calll Med Assoc J 1984;130:1278-1292.

Canadian Task Force on the Periodic Health Examination. The periodic health

examination: 2. 1985 update. C8IIl Med Assoc J 1986;134:724-729.

Canadian Task Force on the Periodic Health Examination. The periodic health

examination: 2. 1987 update. Can Med Assoc J 1988;138:618-626.

Canadian Task Force on the Periodic Health Examination. The periodic health

examination: 2. 1989 update. Can Med Assoc J 1988;141:209-216.

U.S. Pr~ventive Services Task Force. Recommendations for breast cancer

screening. JAMA 1987;257(16):2196.

U.S. Preventive Service Task Force. Recommendations for prevention of

sexually transmitted diseases. JAMA 1987; 258(6):814.

U.S. Preventive Services Task Force. Recommendations for automobile

occupant protection counselling. JAMA 1988;259(1):76.

U.S. Preventive Services Task Force. Recommendations for smoking cessation

counselling. JAMA 1988;259(9):2882.

Zeller RA, Carmines EG. Measurement in the Social Sciences: The Link

75

between Theory and Data. Cambridge University Press, London 1980. - 29. SPSS Ine. Statistical Package for the Social Sciences. User's Guide 2nd ed.

McGraw-Hill, New York 1986.

30. Nunnally JC. Psychometrie Theory. 2nd ed. McGraw-Hill, New York 1978.

31. Radecki SE, Mendenhall RC. Patient counselling by primary care physicians:

results of a nationwide survey. Patient Education and Counselling 1986;8:165-

rn. 32. Kleinbaum DG, Kupper LL, Muller JŒ. Applied Regression Analysis and Other

Multivariable Methods. 2nd ed. PWS-KENT Publishing Company, Boston MA

1987. 33. Statistical Analysis System. Raleigh, NC: SAS institute INc., 1979.

34. Bishop YMM, Fienberg SE, Holland PW. Discrete multivariate analysis: Theory

and practice. MIT Press, Cambridge, Mass 1975.

35. BMDP Statistical Software. Departments of Biomathematics University of

California, Los Angeles. University of California Press, 1981.

Rf 36. Green LW, Eriksen MP, Schor EL. Preventive Practices by Physicians: \

Behaviourial Determinants and Potential Interventions. In Battista RN, Lawrence

RS, eds. Implementing Preventive Services. Am J Prey Med 1988;4(4)s:101-

107.

37. Battista RN, Williams IJ, MacFarlane LA. Determinants of primary medical

practice in adult cancer prevention. Med Care 1986;24(3):216-224.

38. Battista RN, Williams JI, McFarlane L. Determinants of preventive practices in

fee-for-service primary care. Am J Prev Med (Submitted for Publication).

39. Cummings KM, Giovino G, Sciandra R, Koenisgsberg M, Emont SL. Physician

advice to quit smoking. Who gets it and who doesn't? Am J Prev Med 1987:3:69-

75.

40. Maheux B, Pineault R Beland f. Factors influencing physicians' orientation

toward prevention. Am J Prey Med 1987;3:12-18.

41. Lewis CE, Wells KB, Ware J. A model for predicting the Cot.mse1l~ Practices

of Physicians. J Gen Intern Med 1986;1:14-1<).

42. Attarian L, Fleming M, Barron P, Strecher V. A CompArison of health promotion

practices of general practitioners and reside.ne)' trained famHy physicians. J , 76

Comm Health 1987;12(1):31-39.

43. Wells KB, Ware JE, Lewis CE. Physicians' attitudes in counsellinl patients

about smoking. Med Care 1984;22(4):360-365.

44. McAlister A, Mullen PD, Nixon SA, Dickson C, Gottlieb N, McCuan R, Green L.

Health promotion among primary care physicians in Texas. Texas Medicine

1985;81 :55-58.

45. Wells KB, Lewis CE, Leake B, Schleiter MK, Brook RH. The practices of

general and subspeciality internists in counseling about smoking and exercise.

Am J Public Health 1986:76(8):1009-1013.

46. Hindmarsh], Estes EH, Scatartige C. Falls in the elderly: etiology and

intervention. Unpublished draft for the US Preventive Services Task Force ju1y

1987 meeting.

47. American College of Physicians, Committee on immunization. Guide for adult

immunization 1985. Philadelphia: American College of Physicians 1985.

48. Pineault R. The effect of prepaid group practice on physicians' utilization

behaviour. Med Care 1976;14:121.

49. Contandriopoulos AP. Stimulants iconomiques et utilisation des services

midicaux. Act Eeon 1980;56:264.

50. Rice T. The impact of changing Medicare reimbursement rates on physicians'

induced demand. Med Care 1983;21 :803.

51. Manning WG, Leikowitz A, Goldberg GA. A controlled trial of the effect of a

prepaid group practice on use of services. N Engl J Med 1984;310:1505.

77

•

TAIlLE 1

P.·Ual correlation coefficients (r) and adJusted odds ratios (or) for use of pri .. y preventive interventions (Logistic regres.ion 95_ Confidence intervals of odds ratios in parenthesis)

Prift8r~ 2[eventlve interventions Predietor variables

Alcohol Counselling for Anti-SIIIOking abuse accidents at home Flu Contraception counselling counse1l1ng among the elderly Vaccination counsell1ng

Perceived (or) 27.1 (or) '.1 effeetiveness (r) 1.14. (2.2,81.8) (1.9,111.')

Knawledge (r) Il.19**

Vers slnee graduation (r)-I.l'· (r)-II.2I··

SIoking behavior of physiciens (reference category -non SIIIOkers- ) (r)-1.2'··

Gender of (or) Il.' physicien (1.1,1.6) (reference category -female-)

C8tegory of Practitloners (reference category Gps full-Unie ) (r) Il.18.

Good vs poor (reference category) working relation with (or) 6.11 sociel services (2.4,15.9)

Group vs solo (referenee cetegory) (or) 1.8 practice (1.1,'.')

SUmmary statistlcs for IIIOdels

R-square Il.''''' Il.118''' AdJusted R-square .11.111 Il.117

P- value for Goodness of fit Chi-square 8.98 8.93 1.111

'p<8.B5 "p<8.B1 "·p<8 . .,B\

78

(

TABlE 2

Adjusted MeanS of entl-SIOklng counselling score for physicien SIOklng behavlor end category of practtt1oners.

AdJusted Man Physiciens SIOklng

habits

SIIokers Ex-SIIOkers Non-SIIOkers (reference category)

-8.18 .. 8.81 8."

Category of Practltloners

* ..

Internists Surgeons GPs full-Ume (reference category)

8.26 * 8.18

-8.14

p < 8.81 P < Il.11111

(comparlson with the reference category) (comparlson with the reference category)

79

'f"" " , ft '<.--~-.f,·--

APPOOIX A

o Correlation Matrices of Scale ft.

TABLE Il.1

Antl-SMoklng Counselling Items

2 , 4

CcMJnselllng durlng lst visU 1.1111

2 CcMJnsel11ng during ~al check-ups Il.'11 1.1111

, Counselllng durlng vls1ts for problems not related to s.oklng Il.'4 8.54 1.811

4 Targeted population (ail SIOkers. heavy s.okers. smokers with l~tOlllS) 8.119 8.22 Il.32 1.1111

Correlation ~, fI.'1I17 Correlation standard error Il. 1484

Antl-IIlcohol Abuse Counselling Items

2 , 4 5

Counselling durlng lst vlslt 1.1111

2 Counselling during general check-ups Il.411 1.111

, Counselling durlng vls1ts for problems not related to alcohol abuse ".," Il.56 1.1111

4 Targeted population for one-Ume counselling (ail drlnkers. heBvy drlnkers. drinkers wl th symptoms) Il.17 Il.16 Il.25 1.1I1l

Targeted population for repeBted counselling Il.27 Il.14 Il.22 Il.49 Lell

Correlation mean Il.29611 Correlation standard error Il.14'5

80

i. ; • 1 li J

TAIlLE A.2

Antl-SMoklng Counselllng Barriers

2 , 4 5 6 7

1 Lack of training 1.11.

2 Physicl .. 's tille constralnts Il.24 1.1111

, Patient's tille constralnts Il.1' Il.'7 1.1111

4 Lack of IIOnetary lncenUves Il.15 Il.27 Il.11 , .11

5 Accessibil1ty 1.17 Il.17 •• 14 1.19 1.1111

6 Costs for patients Il.2' Il.21 Il.2' Il.14 1.117 LIli

7 Avallab1Uty of te.:hnique 1J.28 1J.19 1J.15 Il.87 8.16 Il.'9 1.811

Correlation Mean Il.1928 Correlation standard error Il.118486

c 81

1

, ; .

Standardized scores

1.' - 1.2 1.1- 1.1 Il.9 - 1.8 Il.7 - 1.6 Il.~ - 1.4 Il.' - '.2 Il.1 - 1.1

Il.11 - -11.1 -11.2 - -II.' -11.4 - -11.5 -1!.6 - -11.7 -11.8 - -11.9 -1.11 - -1.1 -1.2 - -1.' -1.4 - -1.5 -1.6 - -1. 7 -1.8 - -1.9 -2.11 - -2.1 -2.2 - -2.' -2.4 - -2.5

Standardized scores

1.9- 1.5 1.4 - 1.11 Il.9 - Il.5 Il.4 - Il.' Il.11 - -11.4

-II.~ - -11.9 -1.11 - -1.4 -1.~ - -1.9 -2.11 - -2.4 -2.~ - -2.9

APPENlIX 8

DISTRIBUTHW CE VARIABLES INl.t.ŒD IN ANAlVSIS

TABLE B.l

Distribution of standlrdized Anti-SMoklng Counselling Scores

Frequencv

42 Il

14 17 Il

21 18 7

14 22 2 1~ 9 2

12 6 , 2 2 1

Distribution of standardized Alcohol Abuse Counselling Score'

Frequency

18 17 41 24 29 49 19 11 7 1

82

(

Rank of knowledge scores (Highest to lowest)

1 2 , 4 5 6 7 8 9 l'

Rank of 1Cnow1edge Scores (Hlghest to lowest)

1 2 , 4 5 6 7 8 ,

TAIlLE B.Z

Distribution of SIIoIcing Knawledge Scores

Frequency

4 29

" ., '8 15 11 14 8 8

Distribution of Alcohol Abuse Knowledge Scores

Frequency

8 64 '2 ., 22 24 12 , 1

83

o

~~ c-~ t'"""'~~ - - ~ v Of' "

Rank of IIrrlers scores (Hlghest to l~st)

1 2 , 4 5 6 7 8

TABlE B.'

Diltribution of Anti-SIoklng Counselling Barriers

Frequency

TABLE 8.4

Perceived Effectiveness of Anti-Smoking and Alcohol Abuse Counselling

Very Effective Rather Effective SeldOil Effective Hever Effective

Don't know

Vears

< 5 5 - 7 8 - 18

11 - 1; 16 - 28 21 - 25

26 - " " - '5 '6 - 48 41 +

Frequency Antl Smoking Counselllng Alcohol Abuse Counselling

67

" 48 11

TABLE B.5

Vears Since Graduation

Frequency

2 44 46

" " 15

" 2' 15 7

84

19 58 59 48

15

(

DETERMINANTS OF CANCER EARLY DETECTION PRACTICBS

OF GENERAL PRACTITIONERS IN TORINO, ITALY.

85

il : ,-," , ,

o PRESENT A TION OF THE ARTICLE

In paper 2, the determinants of primary preventive interventions were examined

and classified as cognitive, sociodemographic, and organizational. Different patterns

of determinants emerged for each intervention.

In paper 3, we explore the determinants of early detection practices for lung,

cervical, and breast cancer. Scales were constructed to measure practices,

knowledge, beliefs, and barriers and the determinants were analyzed separately for

each early detection technique.

Paper 3 was written by the author of this thesis, under the supervision of Drs.

Renaldo N. Battista, Nereo Segnan, J. Ivan Williams, and Samy Suissa, and in

collaboration with Dr. Antonio Ponti.

86

c

Key wards:

DETERMINANTS OF CANCER EARLY DETECTION

PRACTICBS OF GENERAL PRACTITIONERS

IN TORINO, IT ALY

Running head: Cancer Prevention Practices in Torino

Cancer prevention, general practice, patterns of practice.

Stefano Rosso, M.D.*,** Renaldo N. Battista, M.D., Sc.D.**

Nereo Segnan, M.D., M.Sc.* J. Ivan Williams Ph.D.**

Samy Suissa Ph.D. ** Antonio Ponti, M.D., M.P.H.*

* From the Area dl Epidemiologia, UnHa' Sanitaria Locale 1, Torino, Italy

i !,

** From the Department of Epidemiology and Biostatistics, McGill University and the Division of Clinical Epidemiology, Montreal General Hospital, Montreal, Canada. Dr. Battista is a Research Scholar of the National Health Research and Development Program, Ottawa, Canada. Dr. Suissa is a Research Scholar of the Fonds de la recherche en sant6 du Qu6bec.

Address Reprint requests to: Dr. Stefano Rosso Area di Epidemiologia Unita' Sanitaria Locale Torino If Via S. Francesco da Paola 31, Torino, Italy 10123 Tel.:(l1) - 835386

( 11) - 832004

87

ABSTRACT

We surveyed general practitioners in Torino, Italy, to ascertain their patterns of

primaryand secondary preventive practices and their determinants. Scales were

constructed encompassing practice behaviors, knowledge, beHefs and barriers.

Organizational aspects of health care in Italy, and physicians' lifestyle were also

considered in the analysis.

In this article we focus on early detection of lung (chest x-rays and sputum

cytology), breast (mammography, physical examination, and teaching of breast self­

examination), and cervical (Papanicolaou smear) cancers.

The explanatory factors were grouped as cognitive, socio-demographic, and

organizational. Different patterns emerged for each maneuver. Cognitive factors

(perceived effectiveness and knowledge) are important predictors of use of early

detection techniques. The availability of other primary care services is an important

factor in the early detection of gynecological cancers. Given the importance of

cognitive determinants, continuing education programs are warranted in changing

patterns of early detection practices.

Key words: Cancer prevention, early detection, general practice, patterns of

practice.

88

INTRODUCTION

A planned approach for the use of early detection techniques was proposed in the

late seventies by the Canadian Task Force on the Periodic Health Examination as weIl

as others1-

3• It is based on age- and sex-specific health protection packages. In

Europe, practice guidelines have been formulated mainly by the International Union

Against Cancer4•

The Italian National Health Service (Servizio Sanitario Nazionale -SSN-),

founded in 1978, is based on Local Health Authorities whose administrators are elected

by the municipal government. Primary care, public health and hospitals are under their

jurisdiction.

General Practice is done mainly by general practitioners, but sorne internists and

surgeons devote part of their time to primary care. General practitioners are paid on a

per capita basis for an allowed number of patients based on their professionsl

commitments. GPs provide free and accessible primary care and act as "gatekeepers"

within the SSN. However, patients May go directly to vaccination centers and

"consultori" or clinics specialized in family planning, gynecological disorders and

sexual counselling.

The diffusion of preventive practices has been studied in countries that have

fee-far-service or mixed fee-for-service 1 salary systems. We explored patterns of

primaryand secondary preventi'.re practice in a group of italian primary care physicians

reimbursed on a capitation basis.

In this article we present the analysis of the determinants of early detection of

lung, breast and cervical cancers.

MBTHODS

We interviewed 225 general practitioners practising in Torino, Italy. They

were systematically selected after stratification by age, sex and maximum number of

patients allowed. Sixte en physicians (7.1%) refused to be interviewed.

Information was coUected on reported patterns of preventive practice, perceived

effectiveness of interventions, knowledge of the risk factors associated with the three

89

r r

f.

i' <

(

c

cancers under study and perceived barders to the implementation of specifie preventive

interventions in their medical practiee. Also, specifie features of physicians' practice

setting, their specialty, and their health behaviors were documented.

The data were collected through face-to-face interviews by three trained

interviewers and results were based on physicians' reports.

We used factor analysis5-

6 to reduce items to seale scores for deteetion

practices, and Cronbach's alpha to assess the internai consistency of each scales - 7•

Outcome variables.

There was no internaI consistency between the items on che st x-rays and sputum

cytology and on mammography, physical examin3.tion performed by physicians and

teaching of breast self-examination. Consequently we analyzed the determinants

separately for each intervention.

Most of the outcome variables, except the teaching of breast self-examination,

had bimodal distributions and they were subsequently dichotomized.

Patterns for the teaching of breast self-examination were delineated through

two questions on the targeted patients and the follow-up strategy of thcse patients.

Items were eombined in a seale with six levels.

We analyzed prescription of mammography, as a dichotomous variable, assigning

a score of one to physicians who prescribed mammography as an early detection

technique (annually for women 50 to 59 years of age, women with low parity, and

women with family history of breast cancer) (31.5%), or a score of zero if physicians

prescribed mammography in already symptomatic women (68.5%).

Twenty one percent of GPs performed breast examination in a11 asymptomatic

women during visits not for gynecological disorders. In the analysis this group of

physicians was given a score of one.

The scale for prescription of Papanicolaou test for early detection of cervical

cancer was based on questions pertaining to th\~ age groups screened, the periodicity of

Pap test prescription, and follow-up of patients. These items had an interna!

~onsistency coefficient (alpha) of 0.74 (see correlation matrix in Appendix A) and

factor analysis fitted the items into a single dimension. As the resulting seale had a

bimodal distribution, it was subsequently dichotomized for analysis, with 66.S% of the

90

,J ,l , ,

1 GPs in the high score group.

Adoption of chest x-rays and sputum cytology for lung cancer early detection

were dichotom;zed for analysis.

Determinants.

Knowledge of risk factors for breast and cervical cancer was assessed with

separate scales. Physicians indicated on a four level scale their knowledge of the

existing evidence about risk factors for breast and cervical cancer (strong, fair, poor,

no evidence).

Physicians' confidence in the effectiveness of an intervention is referred to as

"perceived effectiveness" or "self-efficacy belief". Physicians were asked ta grade

their beliefs on the effectiveness of interventions on a four level scale (very effective,

rather effective, somewhat effective and never effective). A "don't know" category

was also included. For aIl the interventions there were very few "don't know" answers

(below 1%). They were recorded as lack of perceived effectiveness (never

~ffective). This variable was continuous in the lung and breast cancer detection

models, while it was dichotomized in the ce:vical cancer detection model (it was

skewed towards positive values) (89.0% of Gl's).

Information on practice organization allowed us to differentiate between GPs

who have a solo (64.1%) or group practice) (35.9%). We also asked physicians about

their perceived role in preventing gynecological cancer and their professional

relationship with gynecologists and "consultori".

We c1assified practitioners according to their specialty: full-time practitioners

(59.8%); internists devoting part of their time ta primary care (25.8%); and surgeons

with sorne primary care practice (14.4%).

The distributions of variables inc1uded in the analysis are presented in Appendix

B (Tables BI-B3).

Analysis

We used multiple linear regression ta examine the continuous outcome variable

"teaching of breast self-examination", and the best-fitting model was identified through

a stepwise selection procedures- e • For the dichotomous ontcome variables (chest x-

91

c

,C

rays, sputum cytology, mammography, breast examination, and pap-test), logistic

regression was used with a stepwise selection procedure 10-11.

First order interaction terms were also considered in both analyses. Higher

order interaction terms were excluded bec.ause of difficulty in interpreting the models.

RESULTS

Different patterns of determinants emerged for each preventive practice. In

Table 1 we present a summary of the results with meaS'Jres of association, such as

partial correlation coefficients for multiple linear regression models, and odds ratios

for logistic models. Summary statistics for each model are also presented.

The multiple regression model could only explain alx..lt 7% of the variance in

practice behavior , while the logistic models showed a limited goodness of fit.

Lung Cancer.

There are no effective screening techniques available for the early detection of

lung cancer; nevertheless 30.6% of GPs in our sample used che st x-ray Emd 12% sputum

cytology for this purpose.

Perceived effecti"eness of early detectior. was the most important predictor of

the use of che st x-ray. Male physicians were more likely to prescribe radiograms for

early detection of lung cancer than their female colleaguet ev en after adjusting for

speciality and years since graduation.

None of the studied variables could explain the use of sputum cytology.

Breast Cancer.

Only 10% of our physicians used mammography as a screening procedure in

asymptomatic women 50 to 59 years of age as recommended.

The use of mammography seems to be influenced mostly by the degree of

perceived effectiveness of the procedure. Alsot younger GPs order mammogram more

often than their older colleagues. Full time G Ps and surgeons devoting part of their

92

, 1

t

time as general practitioners prescribe mammograms as an early detection technique

more often than their internist colleagues.

Physicians in our study were less likely (21%) to carry out breast examination

than physicians in other studies 13,14,16,19, where rates of adoption ranged from 77%

to 99%. A possible explanation could be their preference to send patients to

gynecologists or to "consultori". Female physicians are more likely to carry out breast

examination in asymptomatie patients than male. Aiso a better knowledge of breast

cancer risk factors is associated with greater integration of the procedure into the

usual medicai practice.

Most GPs in our sample (87%) teach BSE to their patients, but only 25% of them

follow patients to ensure it is being performed properly. About 21% of the physicians

refer patients to a gynecologist or a "consultorio".

Belief in the effeetiveness of the procedure is the most important determinant

of this maneuver, with a partial correlation coefficient of 0.23. Physicians who teach

BSE and follow their patients (high score) are more likely to c1aim an active role for

General Practitioners in preventing gynecological cancers (69.0% of GPs).

Cervical Cancer.

The Papanicolaou smear is a weIl accepted practice, but GPs in our sample tend

to prescribe it more for women after age 35 than for younger women21• Determinants

of early detection of cervical cancer were found to be the qge of physicians, and

perceived effectiveness of the Pap test.

DISCUSSION

Since the introduction of the concept of integration of preventive activities in

primary care, determinants of this integration have been assessed. No single

explanatory model has emerged, rather the patterns of determinants seem to be

condition and maneuver specifie. The results of our study eonfirm this finding.

We c1assified determinants as cognitive, socio-demographic and organizational

as proposed elsewhere22-

23• In general, cognitive factors (perceived effectiveness

and knowledge) played the most important role in determining patterns of early

93

(

(

detection practice (Table 1), in agreement with other studies 12 • 1 &. 2,. •

A similar pattern of determinants (mainly cognitive and organizational factors)

was also found in our analysis of primary preventive practices2Q, underscoring the role

of continuing education programs in modifying practice patterns.

However, a note of caution must be introduced as the causallink between

education and beHefs is not yet weIl understood. Other factors such as positive

feedback from patients and peers can encourage the process of implementation of new

techniques:!5.

Demographic factors such as seniority in the profession and gender of

physicians play an important, Etlbeit lesser, role in shaping practice behaviors. F emale

physicians seem to be more sensitized to the problem of breast cancer than their male

colleagues. As suggested in the literature, a better doctor-patient relationship for

women physicians could explain their higher involvement in early detection of

gynecological cf.ncers26-

28•

The higher use of chest x-ray by male GPs, as found in our study, was not

confirmed in other studies22• 23.

Recently graduateci GPs are more likely to pre scribe mammography and Pap

test. A greater emphasis on these techniques in medical schools in recent years could

explain these findings, also reported in other studies 12.15.22-24.

Beyond these cognitive and demographic determinants, organizational factors

influence practice behaviours. Type of activity or specialization and perceived role of

physicians in prevention of gynecological cancers appear to be important predictors of

use of mammography and teaching of BSE. Surveys showed that gynecologists are

more apt to follow preventIve guidelines about mammography than other

specialists 17.34. In our sample, surgeons including gynecologists and obstetricians do

mammogram for early detection of breast cancer more often than full-time GPs and

internists.

Sorne authors23 have found other organizationaIfreatures to be important

determinants of preventive practices such as greater accessibility of the practice and

practice volume. The introduction of monetary incentives in fee-for-service settings

has also been proposed for improving physicians performances22-

23• 30-33. In a

capitation system such as in Italy, cognitive factors seem to carry a lot of weight in

94

-

• shaping practice patterns.

,

In this context, a strateg'f for improving physicians' preventive practices should

include reorientation of continuing education programs towards preventive m,!dicine, the

introduction of appropriate inr,entives, and a better coordination of GPs' actïvities with

other primary care services.

95

(:

(

REFERENCES

1. Frame PS, Carlson SJ. A critieall'eview of periodic health sereening using

specifie screening criteria. Part 1. Seleeted diseases of respiratory,

cardiovascular, and central nervous systems" J Fam Pract 1975;2:29-36.

2. Breslow L, Somen; AR. The lifetime health-monitoring program: a praetieal

approaeh to preventive medicine. N Engl ] Med 1977;296:601-608.

3. Canadian Task Force on the Periodic Health Examination. The periodie health

examination. Can Med Assoc J 1979:121:1193-1254.

4. Basson EC. The role of the doctor in public education. Health Education,

Theory and Practh:e in Cancer Control, UIeC Teehnical Report Series, vol. 10,

1974. 5. Zeller RA, Carmines EG. Measurement in the Sociai Sciellc~s: The Link

between Theory and Data. Cambridge University Press, London 1980.

6. SPSS Ine. Statistical Package for the Social Sciences. User's Guide 2nd ed.

McGraw" Hill, New York 1986.

7. Nunnally JC. Psychometrie Theory. 2nd ed. MeGraw-Hill, New York 1978.

8. Kleinbaum DG, Kupper LL, Muller KE. Applied Regression Analysis and Other

Multivariable Methods. 2nd ed. PWS-KENT PubUshing Company, Boston MA

1987. 9. Siatistieal Analysis System. Raleigh, Ne: SAS institute INc., 1979.

10. Bishop YMM, Fienberg SE, Rolland PW. Discrete multivariate analysis: Theory

and praetiee. MIT Pre~s, Cambridge, Mass 1975.

11.

12.

13.

14.

15.

BMDP Statistical Software. Departments of Biomathematics University of

California, Los Angeles. University of California Press, 1981.

Basset LW, Bunnel DH, Cerny JA, Gold RH. Screening m~mmography: Referral

practiees of Los Angeles physicians. A]R 1986;147:689-692.

Battista RN. Adult cancer prevention in primary care: patterns of practiee in

Qu'bec. Am J Public Health 1983;73(9):1036-1039.

Battista RN, Palmer CS, Marchand BM, Spitzer WO. Patterns of preventive

practice in New Brunswick. Can Med Assoc] 1985;132:1013-1015.

Cummings KM, Giovino G, Sciandra R, Koenisgsberg M, Emont SL. Physieian

96

advice to QUit smoking. Who gets it and who doesn't? Am J Prey Med 1987;3:69-

1 75.

t

16. Gemson DH, Elinson J. Prevention in primary care: variability in physilCÏan

practice patterns in New York City. Am J Prev Med 1986;2:226-234.

17. American Cancer Society. Survey of physicians' attitudes and practices in early

cancer detection. CA. 1985;35(4): 197-213.

18. Rosen MA, Logsdon DN, Demak MM. Prevention and health promotion in primary

care: Baseline results on physicians from the IN SURE Project on Lifecycle

Preventive Health Services. Prev Med 1984;13:535-548.

19. Canadian Task Force on the Periodic Healtl. ~xamination. The periodic health

examination: 2. 1984 update. Can Med Assac J 1984;130:1278-1292.

20. American Cancer Society. Guidelines for the cancer-related checkup:

recommendations and rational. CA 1980;30:193-240.

21 Segnan N, Battista RN, Rosso S, Ponti A, Senore C, Aimar D. Preventive

practices of general practitioners in Torino, Italy (Personal Communication)

22. Battista RN, Williams U, MacFarlane LA. Determinants of primary medical

practice in adult cancer prevention. Med Care 1986;24(3):216-224.

23. Battista RN, Williams JI. McFarlane L. Determinants of preventive practices in

fee-for-service primary care. Am J Prev Med (Submitted for Publication).

24. Woo B, Woo B, Cook EF. Weisberg M, Goldman L. Screening procedures in the

asymptomatic adult: comparison of physicians' recommendations, patients'

desires, published guidelines, and actual practice. JAMA 1985;254(11):1480-1484.

25. Green LW, Eriksen MP, Schor EL. Preventive practices by physicians:

26.

27.

28.

Behaviourial determinants and potential interventions. In Battista RN, Lawrence

RS, eds. Implementing Preventive Services. Am J Prev Med 1988;4(4)s:101-

107.

Gray J. The effect of the doctor's sex on the doctor-patient relationship, J R

Coll Gen Pract 1982;32:167.

Hopkins EJ. A study of patients' choice of doctor in an urban practice. J R Coll

Gen Pract 1%7;14:282.

Preston-Whyte ME, Fraser RC, Beckett JL. Effect of a principal's gender on

consultation patterns. J R Coll Gen Pract 1933;33:654.

97

(

'19. Rosgo S, Battista RN, Segnan N, Williams JI, Suissa S .. Dete11llinants of

primary preventive praetiee of general practitioners in Torino, Italy. (Personal

Communica tio!\).

30. Pineault R. The Effeet of prepaid group practice on physicians' utilization

behaviour. Med Care 1976;14:121.

31. Contandriopoulos AP. Stimulants iconomiques et utilisation des ser'lkes

midicaux. Act Eeon 1980;56:2.64.

32. Rice T. The impact of changing Medicare reimbursement rates on physicians'

indueed d'~:;land. Med Care 1983;21:803.

33. Manning ~~I G, Leikowitz A, Goldgerg GA. A Controlled trial of the effect of a

prepaid group practiee on use of the services. N Engl J Med 1984;310:1505.

34. Albanes Dt Weinberg GB, Boss L, Taylor PRo A survey of physician's

breast cancer early detection practices. Prev Med 1988;17:643-652.

98

o

t

TABLE 1

Prilal correlation coefficient.s (r) end adJusted oads ratios (or) for lise of orly dltecUon techniques (Logistlc r~gression 95_ Confidence int.ervals of odds rat:Js ln parenthesls)

Predictor variables

Perceived effectiveness

Knowledge

Vears since graduation

Sender of physicien (reference category

MIe - )

SUrgeons

GPs full-tlme

Internists (reference category)

Chest X-ray

(/Ir) 1.6 (1.2.2.1 )

(or) Il .• (8.2,1.11)

Role of GPs 1n Preventlng gynecologlcal cancers

Summary statlstics for models

R-square AdJusted R-square

p- value for GIlodness of fit Chi-square Il.1l4

·p<8.fl5 "p<lI.el '''p<8.881

(Oi') 2.11 (1.5.~.1I)

(or) Il.95 (8.95.11.98)

(or) 2.6 (8.9.7.2)

(or) 2.4 (1.1.5.5)

1.1'

fl.89

Earlv detectlon technlgue~

Breast examlnatlon

(or) 1.2 (1.11.1.4)

(or) 2.7 (1.2.5.9)

Il .• '

Teaching of BSE

(r) Il.15'

Il.118''' 8.117

Pep telt

(or) '.2 (1.'.8.4)

(or) Il.95 (11.96.11.97)

Il.11'

APPENlIX A

CMRELATlIIi MTRIX IF SCALE ITE/'IS

TABLE A.1

Cerviral Cancer DetectIon Scores

2 4

Pep test prescription 1.""

2 Follow-up of patients Il.51 1.118 , Repeated advice for earj" detection Il.61 Il.44 U.

4 Targeted population ( '5 yrs J'.52 Il.22 Il.'6 1.1111

5 Targeted popula~lon ~ '5 yrs 8.65 8.43 Il.62 Il.54 1.118

Corrplation llletln 8.4900 Correlat1on standard error ".1~19

(

100

Standardlzed scores

1.4 - 2.2 11.7 - ", lU - 8.6

-11.6 - lU -1.' - -8.7 -1.~ - -1.4

Rank of Knowledge scores (Highest to lowest)

l 2 , 4 5 6 7 8 9

HI 11

Rank of Knowledge scores (Highest to lowest)

1 2 , 4 5 6 7 8 9

-------------------------------------------~------...

APPOOIX 8 Distribution of Vcrlables Included in Analysis

TABLE B.1

Distribution of standardized Breast Cancer Detection Scores (Teachlng of Bre8st Self-Examlnatlon)

Frequency

19 19 27 91 26 27

TABLE 8.2 Distribution of Breast Cancer Knowle1ge scc"es

Frequency

, 8 7 9

25 37 29 59 26 11 5

Distribution of Cervical cancer Knowledge scores

Frequency

101

12 41 '4 5' 29 24 6 5 5

(

(

Value

POOl' Good

Very Effective Rather Effective Seldom Effective Hever Effective

Don't know

Very Effective Rather Effective Seldom Effective Never Effective

Don't know

Very Effective Rather Effective SeldOlft Effective Never Effective

Don't know

~; , ,!

TABLE B.'

Working Relationshlp with Gynecologlsts and ·Consultorl- for Prevention of Gynecologiesl Cancers

Frequency

9J lUI

Percelved Effectiveness of Mamnography

Frequency

142 24 15 26

2

Percelved Effectiveness of Breast Self-EXamlnatlon

Frequency

179 28 2 8

8

Perceived Effectiveness of Chest X-Ray

Frequency

102

,§.. i

.. .... -,.

CONCLUSION

Interest in prevention has grown, in recent years, not only among health

professionals but also among lay communities.

Environmental pollution and hazards, and the need for better health habits and strategies

for more efficient primary care services pose formidable challenges. Meeting their

increasing complexity, successfully, requires nrw and integrated approaches to

prevention.

Part of the challenge for improving health rests in physicians' practices, as

documented by the increasing portion of time allocated to preventive activities in family

medicine, general internaI medicine and other primary care practices.

There is now an evident and growing need for scientific methods for evaluating

the evidence of ef:ectiveness, and for sound policies for implementing effective

interventions in the most approp.iate and efficient way. Among the approaches put

forward, du ring recent decades, are those of the Canadian Task Force on Periodic

Health Examination, the U.S Preventive Services Task Force, and the National

Institutes of Health Consensus Conferences.

Different strategies have been proposed for diffusing and implementing

interventions, and it has been suggested that the capitation system is more successful in

inducing physicians to adopt preventive strategies. The more stable and dfdfined

population of patients in the capitation, vis-a-vis the fee-for-service system

makes it easier for physicians to have positive feed-back from their preventive

activities.

Our study documents preventive practices and their determinants in a sample of

general practitioners in Torino, Italy, where a capitation system was introduced with

the National Health Service, in 1978. During the debate on The Health Reform, and

since its adoption, the role of general practitioners and primary care physicians has

been widely discussed.

Although specifie bills created other preventive services in occupational hazards,

family planning, psychiatrie care, and drug addiction, The Health Reform also included

them in primary care without guidelines for their integration into GPs preventive

practices.

103

Although still general in nature, proposaIs about the implementation ~f preventive

strategies by GPs have subsequently appeared in such official reports and laws as the

General Practitioners' Contract in 1985 (Convenzione per la Medicina Generale) and

the Reports of the Piedmont Region on Organization of Health and Social Services

(Piano Socio-Sanitario della Regione Piemonte - anni 1983, 1986).

The organization described in our study is in effect throughout Italy and,

although sorne local differences may exist, the general findings of our study portray the

characteristics and behaviours of G Ps in most italian settings.

Our study indicates that the Italian capitation system is not clearly superior, if

physicians' attitudes are not taken into account, because estimates of the proportion of

physicians c1aiming to adopt practices are analogous to those found in other studies. On

the other hand, the SSN was created only recently and comparisons with data gathered

before its institution would be required to determine whether improvements have been

achieved. A comparison of our results with those of a similar survey conducted before

the institution of the SSN (Mossetti, 19n), showed an improved interest in prevention

and a better knowledge of preventive techniques, but the methods employed and the

selection bias in this earlier survey make its findings questionable.

Factors influencing preventive practice cannot be limited to type of

reimbursement. A complex pattern of determinants emerges from several studies

(Battista, 1986; Lurie, 1987; Maheux, 1987), and various classifications of determinants

and models have been proposed. The findings from these studies indicate that there are

separate patterns of determinants for each condition and intervention, but the precision

of the proposed models is quite poor and explain, at most, 20% of the variance.

In general, the main problems affecting the results of these studies are the

inadequacy of the measurement tools and the conceptualization of models. Nevertheless,

some factors appear consistently although with different weights.

Cognitive indicators, such as knowledge and perceived effectiveness, appear as

factors in both primary and secondary preventive interventions, in our study. Reviews

of other studies reveal a wealth of approaches in current use for improving physicians'

knowledge and attitudes towards prevention, but many are inadequately tested.

Recommendations, from these reviews, suggest the incorporation of elements from

different types of educationa} interventions (Haynes, 1984; Lomas, 1987).

104

• ....

In Italy, there is no official organization that provides specifie recommendations

in preventive strategies. Although a complete reformulation of practice

recommendations may not be necessary, assessing priorities, summarizing the state of

existing evidence, and supporting preventive interventions and their adequate diffusion

to practising c1i~icians, should be the initial tasks undertaken when responsibility for

them is assumed by sorne existing or yet-to-be-created organization.

Another issue that needs to be addressed is the integration of general practice

into other primary carl'. services, ·as illustrated by our findings on the way GPs oiten

refer their patients to other services and consultant specialists. The role of GPs as

gatekeepers for preventive interventions requires reconsideratio~ on the basis of an

understanding of whether it is more effective and efficient to keep sorne interventions

in general practice or to assign them to specialists with spedfic training.

Although prevention has evolved diff ~rently in various countries, the role of

physicians has become preeminent despite differing organizational solutions. Our study

is one of several that demonstrate the need for better integration of preventive

interventions in primary care, including the orientation of medical schools toward

prevention and the reformulation of continuing education programs .

105

c

(

t

1.

2.

REFERENCES

Battista RN, Williams n, MacFarlane LA. Determinants of primary medical

practice in ad1'lt cancer prevention. Med Care 1986;24(3):216-224.

Haynes RB, Davis OK, McKlbbon KA, Tugwell P. A critical appraisal of the

efficacy of continuing medical education. JAMA 1984;251:61-64.

3. Lomas J, Haynes RB. A taxonomy and critical review of tested strategies for the

application of clinical practice recommendations: from "official" to "individual"

clinical policy. In: Battista RN, Lawrence RS, eds. Implementing Preventive

Services. Am J Prev Med 1988;4(4)(suppl):77-94.

4. Lurie N, Manning WG, Peterson C, Goldberg GA, Phelps CA, Lillard L.

Preventive care: do we practice what we preach? Am J Public Health 1987;

5. Maheux B, Pineault R, Beland F. Factors influencing physicians' orientation

toward prevention. Am J Prev Med 1987;3:12-18.

6. Mossetti C, Sismondi GP, Panero M. TI comportamento deI medico nell'azione

preventiva antitumnrale, dati relatjvi ad un questionario inviato ai medici della

Provincia di Torino. Minerva Gynaecologica 1977;29:107.

106

o

APPENDIX

t 107

r, ~ •

: ~~ '.

.. il':,

LETTER dF PRESENTATION SENT TO PHYSICIANS. '

c ~.\ f NIZIO SANITARIO NAZIONALE Hb! jlONE PIEMONTE

SIIIa

Societ6 Italiana di Medicina Generale Sezione di Torino

(

U.B.L. TORINO 1-23

Alea di F.pidemiologia Alea dl Educazione Sanitaria

l' . 1 ~

( , J\)~" l '-..1

Tonno ••

Al Dr.

Egregio Collega,

col patrocinio dell'Ordine dei Medici della Provincia di Torino è

in corso un'indagine rispetto al ruolo che 11 medlco di Medicina Genera le svolge nel campo della prevenzione primaria e secondaria, ed agli ostacoli che eventualmente incontra.

Dall'elenco dei Medici dl Medicina Generale convenzionati con il SerVIZlO Sanitario Nazionale operanti a Torino è stato estratto a caso un campione di 225 colleghi, tale che sia assicurata all'indagine dal punto di vista statistico adeguata potenza e precIsione.

Il tuo no~e è compreso tra quello dei colleghl chiamati a parteci­pare aH' indagine, e non pua essere sosti bn to a pena dl ridurre la va­lidltà dej risultatl. Ci permettiamo qUlndi dl chledere la tua gentile, personale collaborazione per una intervlsta della durata di circa 1 ora.

Il nostrO collaboratore che avrà )'incarico dl inter~istarti si met terà ln contat~o telefonicamente con te nel proSSlml giornj per stabill­re ]'appuntam~nto.

Grazle u cordlaJi salutl

Dr. NJ~}t~ Respnnsah1]e dell'Area di Epidemiologia

'1

..1 '- -'~./ ~/VL---

Dr. Glùf'C':,pe Ventngl la

Respons~r,le RegIonale della Società ItaJ18w. j' :.'edlclna Generale

qi . , !f

f" .. :!'

.'

1

~.

.- ~ c ,-

;, : " .~ , , ..

.. r'~

-:.

- "

o SURVEY QUESTIONNAIRE,

INDAGlNE SULLA PREVENZIONE IN IlEDICINA GENERALE

condotta da:

- Area di Educazione Sanitaria. USL'Torino 1-23

- Area di Epide.iologia, USL Torino 1-23

- Societl ltali~ di Medicina Generale, Sezione di Torino

con il patrocinio dell' Ordine dei ledici della provincia di Torino

QUe4ta .i.n.d.a~e ha f..i.n.i.. de4 C/lil.ti.. vi... 5i.. fJ/LflgantJ i.. CoLl.~ di.

/l.i..potti:.OA.e a.ttIl.aVeMO i.. qUe4UonOA.i.. i.n.f-OIlJna]A.oni.. il p.i.ù po.1.1i..bue

ac~ate .1ulie ~o~o opLnLoni.. e ~a ~~o con~eta p~ati..ca œnbu~ato­

l1.i..~e.

1 ï utte ~e domande .1,(, 11.i..f-e.JliAcono ~a p~ati..ca i.n. conven~i..on e

con U Se/l.vi..~o SanJ...tOA.-t.O Na~on~e.

Le mf-olllTlap_on-t. Il.e~«ate nu qUe4ti..onall.i..o .1MannO cOMuiell.ai~

conf-ui.enJA-aAA.. e non veIl.Il.anno .ut ~cun. modo -1.Me nute m f,olllTla nu­

mi..naUva.

Aprile 198h

:. , .

' ..

-:J. )

--,

-~ ..

:C

Questionari0 Medico

A- INTRODUZIONE

Nell'ultimo g~orno di ambulatorio:

1. Quanti pazienti ha visto

< 10

III 11-20

I~I 21-40

I~I 41-60

I~I

1-'_'-'

non risp.

'~I

2. Tra i I18schi adul ti che ha visto, quanti S0l10, a sua conoscenza i tu.atori di sigaretta

Numero dl rnaschi adulti (non ricorda=88 / non risponde=99)

Numero di fumatori

3. Delle _ pers one che ha dichiarato di aver visto quante aono state

-prime visite ,

-visite di controll0 generale

-visite per problemi specifici

-visite per sole certificar,ioni

-incontrl pel' solo rinnovo di prescrizioni (vedendo il paziente)

4. Ha avuto bisogno dt consultare 0 agiornare la cartella .. indi viduale dei suOi pazienti

SEMPRE III

SPESSO I~I

RARAMENTE 121

MAI I~I

NON RISP. 12\

5. Quali di quest! clati a soUto riportare

anamnesi del fumo III valori pressori

6. Riceve su appuntamento

SI III NO I~I

anamnesi dell'alcool Igi

nessuno IQ/

7. Qualcuno l'aiuta nell'organizzazione della sua attivltà ambulatoriale

SI Il/ NO I~I--.. (passare alla dom.9)

8. Chi tra questi e quando è presente in ambulatorio sempre spesso raramente mai non risponde

-famiJiare I!I I~I I~I I~I 12/ -lnfermlere Il:1 I~I I~I I~I 12/ ~., ~ 1 t r l 111 ") 1 1,1 1 • 1

.1

1-' -'_, J

,-,-' , 1_1-' 1

'-'-'10 I_I_/'t

1-' -' II(

'_'-"6 I_'-"i

1_11'

.2

9. Ha un associ ato

0 SI III NO I~I 1 -' If,

10. Nel suo a.bulatorio praticano altri .edici

SI Il.! NO 121-. (passare alla Sez.FUMO) 1-' 11

11. Si tratta di: medi c i genori ci III specialisti I~I entrambi I~I 1-' t\

12. Esiste uno sf;8IIbio di opinioni/esperienze

" SI III NO I~I 1 -' l.'/ Se sl: si no

,* -gestione in comune di una parte di assisti ti III 121 1_1 ~o >-.lot

~

'It ~ . ~ . -incontri periodici per la discussione dei ,u i. 1

problemi incontrati III I~I i -' sr t.

-scambio di opinioni occasionale III 121 J 1 -' JI

-al tro (speci f. ) ............................ III 121 1_1 CJ

PRESENTARI TABEI.I.! 1 e 2

.. B- FUIIO

1. Quali di queste I18.lattie lei ritiene steno causste da! ru.o di sigaretta

sl prob.si ;:.

veros.no no non sO 1 r" Ca polmone .111 Igi I~I I~I I~I 1 -'fil ~ ..

- Coronaropatie III Igl I~I I~I I~I 1 Ilç " 1 <'

AteroBclerosi I!I Igi I.~I 1.11 I~I 1 1 ~f, --Bronchite cronica III Igi I~I I~I I~I 117

1

III Igi Ca vescica I~I I~I I~I 1 39.

Ca l-aringe III I~I I~I 141 I~I ln

Ca bocca I!I 121 I~I I~I I~I 1 tu

Ca pancreas III I~I I~I I~I I~I l't' Ca colon III I~I I~I I~I I~I l,

Ca collo utero III I~I I~I I~I I~I 1 l '1\

r, Tromboangioite .. oblitt:!rante III I~I I~I I~I I~I

"

-'-.

..

(

2. In occasione di quali visite si inforas sulle abi tudini (ü fUIIO dei suoi assistiti

sempre spesBo raramente mai non rie.

-prime visite Il.1 Igl I~I I~I I~I

-in vislte generali I!I Igl I~I I~I I~I

-in vlsi te pel' problemi legati al fumo I!I Igi I~I I~I I~I

-in visite per problemi partieolal'i non asso-ti al fumo Il.1 Igi I~I I~I I~I

-altro (specifjcare ) I!I Igi I~I 111 I~I ....................... 3.Quali tecniche specifiche per far cessare l'abitudine al ru.o lei

conosce · ........................................... . · ........................................... . · ........................................... .

Presentare Tabella 3

4. Se non adotta 0 suageriace tecniche che ritiene utili. quali SODO i proble.i che glielo i~iBConO

-inadeguata formazione

-insufficienza di tempo deI medico

-insufficienza di tempo deI paziente

-assenza di incentivi

-carenza di spazilmezzi nell'ambulatorio

-terapie non mutuabili

-non di sp10nibilità della tecniea

-searso interesse e/o rispondenza presso gli assistiti

-altro (speLif.) ...••••.•.••••••.•••

CITATO SUGGERITO

III 111 111

111 111 111

111

5. Se eonsiglia ai suoi assistiti di smettere di fumare. questo avviene con: -tuttI i SUOI assistiti fumatori Il.1

-solo con i fortl fumatori I~I (specificare ..•..•••.. )

,.

6. Ritiene che smettere di fumare possa comportare eCCetti indesiderati

iii

.3

1 _.14<,

1_141

IJ <'1

,_, '-S

1_1 t"

I_I_I~, ~

1_1-' s~

'_1-' ss " " "

~ .. :~.'

'.

,-' ~t ,1

1-' '1

1_1 ~~ ,1

1-' Sl/

1 Ibo

1 161 -l 'l

16 ;

1 ~I,

(1

,

"

................................... 7. C'è qualche condizione di età e/o salute per la quale gli eCCetti

citati sconslgliano un suo intervento

slili no~~1

~ Se si, specificare

................................... B. Ri tiene che il rischio di _.alarsi di tuIIOre deI polllOne sI

modificht negli ex-cu.abOri

si,semprelll

non so Isl T

81,80]0 per pIccoli 0 recenti fumato~l

no I~I_ (passare aU a dom.10) t

9. Dopo quanti ann! ri Uene che il rischio di tuIIOre al polllOne di un

ex fuma tore eguagll quello di una persona che non ha llI8i fullato

10. Che cosa di quanto indicato potrebbe Cacili tare la sua opera di prevenzione dei danni da ru.o

l'

molto ~~ poco inutile non so utile utile utile

-opuscoli di educazione sanitaria da distribuire

-campagne mass media

-aumento del prezzo delle

III III

sigarette III 1

-leglslazjone più restrittival!1

-altro (specificare)

I~I

Igi

I~I

i~1

I~I

I~I

I~I

I~I

Il. Se dovesse utilizzare, in appoggio ai suoi consigli,materiale illu­strativo da distribuire ai suoi assistiti,preferirebbe che questo ma teriale avesse una impostazione tendent~ prevalentemente a: -

-spaventare 0 Intlmorlre IJ fumatore SUI dannl da fumol!i

-presentare lInon fumatore come una persona socj~lmente 'in' o posltiva I~I non sol~1

. -'

1_1 Tt;

1 1 ln

1 1 1'71

1_1_ls,

1 l 'l" _.'_ a .. ,

1_1 g.;

1_-'\1(,

1 _ Ill?

1 1 ~

· .r ... ;

. " . !,Jo .' · ' . --, · '. ,---.,: ..

-.'

1. ~_

c

12. Ri ti ene che la diagnosi precoce deI tuIIore pol.anare truite Rx

torac0 ai suoi assistiti fumatori sia:

eff1cacel.!1 abbastanza efficacelgl poco efficacel~1

inefficacel~1 non sol~1

13. Prescrive un Rx torace ai suoi assistiti tu.atori asintOMatici per la diagnosi precoce deI tumore polmonare e con quale periodismo

PERIODISMO si •

6mes. lanno 2aa altro,specificare

-a tutti I fumatori UJ Igi I~I I~I · ......... -a tutti I fumatori con più di 45 annl 111 12 1

_1 I.~I I~I · ......... -a chi fuma più di 20 sigarette ad ogni età 111 Igi I~I I~I · .............

-a chi fuma più di 20 sigarette e con più di 45 anni 111 Igi I~I I~I · .........

-altro (specificare) 111 Igi I.~I I~I · .......... . ......... " .....................

rio. mal 111

14. Prescrive un esame citologico dell'escreato ai suoi aasistiti fUma­tori per la diagnosi precoce del tuIIOre pollllOll8re e con quale pe-riodismo PERIODlSMO

51,

-a tutti i fumatori

-a tutti i fumatori con più dl 45 anni

-a chi fuma più di 20 sigarette ad Qgni età

-a ChI fuma plÙ di 20

sigarette e con p~ù dl 45 anni

-altro (specificare)

no, mal III

6mesi

111

111

111

III

, 1 "0 2aa

. I~I . . Igi 121

Igi 121

I~I

altro,specific.

I~I .. ............

I~I · ................

111 .................

1 ~ 1 ••••••••••

1 ~ 1 ................ ..

15. Ritiene che l'assuozione di vitamina A e/o Beta carotene sia effi­cace per prevenire i tumori deI polmone

effIcace Il.1 abbastanza efflcace I~I poco efficace I~I

1 .1

• S

1 1 <iz

1 1,1'S

1 J 7,*

IJ~~

1 1 fC,

1_191

IJ ~"

1111

l,.,."

1 1,01

1 i.)

(

>.

(

3. Qu8le livello giornalieco di consuma di alcool rltlene che sarebbe raccomandabile non superare per un adulto sano con nor.ale attività fisica, secondo la sua opinione

-0 ml di alcool asscluto III -25 ml di alcool assoluto (1 bicchiere di vino a pasto) Igl

-50 ml di alcool assoluto (2 bicchieri di vino 8 pasto) I~I

-75 ml di alcool assoluto (3 bicchieri di vino a pasto) 111 -100 ml di alcool assoluto (1 litro di vino al giorno) I~I

-altro (specificare) ..•.•••••••....•••••••••••••••.••• 161

-non so I~I

4. Quali _alattie. a suo parere causate dall"abuso di bevande alcoliche. rl1eva plù f"requenteMnte tra i 8uoi pazientl (elencare le prime tre)

· ........................................... , .............................................. · ........................................... .

5. Quali tecniche specifiche lel con08ce per far ce8S&re 11 consUllO di alcool

• ••••••• 0 ••••••••••••••••••••••••

· ............................... . · ............................... .

Presentare tabella 4

6. Che cosa di quanta indicato potrebbe facili tare la aua opera nel C8llpo della prevenzione dell' alcolisllO

-opuscoli di educaz.sanitaria da distribuire

-indicazione di centri specif. pp.r prevenzlone e cura

-campagne mass-media

-restrizione vendita

- tassaz l one

-controllo alcolemia de! guidatore

-altro (specif.)

III

III III

III

I.?I

Igl

,~,

181

.7

IJ It~

I-'-'In ,_,-' 119

1 1 IIJI

'-'-'ru I_I-'"s

'_'-',n

1 .I,\~

1 111.0

1 1""

'. "

,-,.

7. Se non adotta tecniche che ritiene utili, oppure se le adotta .eno frequente.ente di quanto potrebbe,quali sono i aotivi che glielo illpediscono

-inadeguata farmazione

-insufficienza di tempo deI medico

-insufficlenza di t~mpo del paziente

-assenza di incentivi

-earenza di spazi/mezzi nell'ambulatorio

-terapie non mutuabili

-altro(specificare) .••••••••••••.•••••• ..................................... ,

D- IPIRTENSIONI

CITATO

III

111

III

III

III

I.!: 1

Iii

SUGGERITO

1. NeU' ul tiao giorno di a.bulatorio a quanti paienti ha .isurato la presaione (se 0, passare alla dom.3)

2. A quanti su richiesta deI paz lente

3. Control la la pressione indipendente.8nte da .alattie legate aU' ipertenoione slili nol~1 ~ (passare alla dam.S)

4. Se sl, a quali assisti ti e con quale perlodisllO

-a tutti

-solo ad aleuni gruppi di assiste

· ............... . · ............... . · ............... .

solo lD visita

IQI

IQI

IQI IQI

invito a tornare agni 3ms 6ms la aitro

III

Il.1

I.!.I

III

I.~I I~I I~I

Igi I~I I~I

I~I I~I I~I

I~I I~I I~I

quando vengano in ambulatorio

151

5. Nell'ultiao giorno di a-bulatorio quanti assistiti in trattamento faraacologico per ipertensione ha visto

6. Incontra difficoltà nel pratic~e il follow-up dei pazienti ipertesi sil.!.1 nolgl

Se sl, quali

.H

1-' Ill~ l'Ill' '-'14 , 'J ,tl~

'-"119 'J 's­,-"s,

'-'-'IH I_'-'IH

Il'''

1 lin

C

'.

' .

. " . . t,.)~

.117 ~7~ ._.

(

7. Consiglia ai suoi pazienti ipertesi in trattamento far-acologico:

SEMPRE SPESSO RARAMENTE MAI

-automisurazione da parte deI paziente a domicilio III Igi I~I 111

-automisurazione con apparec- III Igi I~I 111 chi automatici in farmacla

B.Nel suo ambulatorio chi misura più frequente.ente la pressione arteriosa

un infermlerelll lei stessolgl solo lei 131

9. Registra i valori riscontrati

sempre I.!I solo se al di fuori della nor~a 1 g 1

solo se riscontro variazioni significativel~1 mail~1

. 10. A partire da quali valori lI8X e/o ain di pre.Bione arterioaa

diastolica e/o sistolica ritiene utile ini.iare un tratta.ento f8I'118cologico in un adulto aaschio con pin di 40 anni

MAX MIN 1_1_1_1 1_1_1_1

E- TUIIORI FEIDIINILI

1. Ritiene che l'orienta.ento delle donne rispetto alla prevenzione dei tuaori deI collo dell'utero e della ~lla debba essere svolto prevalente.ente da:

medico di base I.!I ginecologo 1 g 1

consultorio I~I altro(specif.)I!I •••••••••••••••••••••

UTERO

2. Quali considera fattori di rischio di K collo utero SI PROB.SI VEROS.NO NO NON SO

- C'ontraccetti vi in usa I.! 1 Igl I~I I~I I~I

-numero partners sessuali I.! 1 Igi I~I I~I I~I

-numero fi g] i I.! 1 Igl I~I I~I I~I

-precocità rapporti sessuali I.! 1 I~I 131 111 I~I

-igiene intlma 111 Igi I~I 111 I~I

-cl asse soclal e I.! 1 Igi I~I I~I I~I

-malattle veneree I.! 1 Igi I~I 111 I~I

-herpes genitale ! 1:. 1 Igl I~' I~I I~'

.9

1 _I,,,~

1-' It~

'_'_IJI1I#

IJJJm

1-' I?~ ,. l'~l'

1_1,,,,

l ,~~ I,Q

1 : ~I,

l'~,'

'. -. ..; ~-' t~' :-: ;'. r

.... •

; .

, ,~~ - ~--~~'~~~~-.--------------.... -----IWOŒLLA

10. Quali dei se~enti elementi considera fattori di riBchio per il K della .aDMDella

SI PROB. SI VEROS. NO NO NON SO

-dieta

-familiari tà

-obesità

-contraccettivi orali in uso

-nu1l1 pari tà

-prima gravldanza dopo j 30 anni

-menarca precoce

-menopausa tardiva

-radiazioni

-fumo

I.~ 1

I!I I!I

I!I I!I

III I!I

I.~I

I!I I!I

I~I

I~I

Igi Igi Igi

Il. Pratica l'esaae obiettivo della ...-ella

I~I

I~I

i~1

I~I

I~I

I~I

I~I

I~I

I~I

I~I

-solo sulla base dei sintomi dichiarati dall'assistita I!I (passere alla dom.13)

-anche indipendentementa dalla denuncia di sintomi p come pratica a sé Igl

-mai (passare alla dom.13) I~I

12. La fa per quali assistite almano 1 intervallo oeeasio­vOlta/an più lungo nalmente

-tut te le assistite con più di 18 aa

-solo al'euni gruppi di età (speci fi ~. ) .............................

-solo nelle donne a rischio

111

III

1.11

I~I

I~I

I~I

13. Considera la .ammografia eseguita periodicamente una tecnica che riduce la probabili tà di IIIOrire per K della mammella in tutte le donne per alcune claBsi di età

SI 111

PROB. SI

121 VEROS.NO NO

I~I I~I 1 1 (pas sare alla

NON SO

181 !

dom.15)

.11

lJ Iqs

IJ i'lV

1_1100

IJ/.#, 1_ll.ot

I-'z-J 1:..11.01,

1-' lA

1-' z.c;

1_1~7

1 l" v

1 17,,,

1 Jl"

.

.'

- -'-

(

3. Considera il Pap-test una tecnica che riduce il rischio di .orire per tuaore deI collo dell'utero

SI

III PROB.SI

Igl VEROS.NO

I~I NO

I~I NON SO

I!! 1

4. Lo consiglia aIle sue pazienti

SI, a tutte le donne sesualmente attive I!I a tutte le donne in dcterminate classi di età 12\

alle donne ad alto ~ischlO 13\

solo a chi chiede consiglio 111 solo aIle donne sintomatiche

NO (passare alla sez.MAMMELLA)

perché ............. ' ............................... . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . .. . . . . . . . .

5. A. quante sue 88sistite ha consigliato il Pap-test nelle ultiae due setti.ane

6. Ritiene soddisf'acente il sua rapporto con 10 specialista e/o la struttura deI consultorio

SI III NO Igi Se no, perché .•••..••••••..•••••.•.••.••••••••.•••••••••.••••••

7. Richiede che le donne cui consiglia il Pap-test ritornino con il risultato dell'esame

SI Il ~ NO 121

8. Ripete regolarmente l'invito a sottoporsi all'esame

SI III 1 No 12\

9. Con quaie periodicità 10 consiglia

< 1 volta 1 volta agni 2aa ogni 3aa agni 5aa

l'anno l'anno a più

(35 ANNI I.~I Igi I~I I~I 121 35-70 ANNI III Igl I~I I~\ 15' _1

.10

IJ,l~

. "

'.

.. . , . : ~

0" .... :,

". "

14. Da che età a che età consiglierebbe l'esame .••..•.••.........

15. Prescrive la mammograCia aIle Bue pazienti

SI I!I NO 1 g 1 __ (passare alla dom.1 7 )

16. La prescrive :

-a tut te le assistite nell'ambito delle età citate III

-solo aIle donne a rischio Igl -solo in presenza di sintomi

Con quale periodismQ (in anni) (se tutte / donne a rischio)

17. Considera l'autipalp~zione esegulta periOdicamente una tecnica che riduce la possiblll tà di ~rire per Je della .ammella per alcune classi di età

SI PROB.SI VEROS.NO NO NON SO Igl I~I 141 lai r r (passare alln dom.19)

III

18. Da che età a che età la consiglierebbe •.•••••••.•••••••••••••.•

19. Prescrive l'autopalpazione alle Bue pazienti

SI I!I NO 1 g 1-+ (passare alla dom. 24)

20. La prescrive:

-a tutte le assistite nelJ'ambito delle età cltate III -solo aIle donne a rischio

Con quale periodismo (in settimane)

21. Nel caso lei insegni l'autoesame deI seno rlc~iama la sua 8Ssistita per verificare la correttezza della tecnica

SEMPRE SPESSO RARAMENTE MA!

I~I

NON INSEGNA

IQI l (passare alla dom.23)

l " • r

,_,_ 1 1

111( .. lb

1 1. 10

. . .

"

c

22. Come ha appreso la tecnica di insegnamento dell'autopalpazione

· ............................................................ . · ............................................................ . · ............................................................. .

(passare alla dom.24)

23. Se non insegna l'autopalpazione cosa cQnsiglia prevalenteaente

-utilizza opuscoli che illustrano I!I la tecnica

-invia al consultorio

-invia al ginecologo

-altro (specificare)

· ........................... .

121

I~I

I.~I

24. Che cosa,di quanto indicato, potrebbe facilitare la sua opera nel campo della prever~iœle dei tu.ori fe.minili

MOLTO ABBASThNZA POCO INUTILE NON

-opuscoli di educa­zione sanitaria da distribuire

-indicazione di en­ti che praticano l'esame e norme di accesso

-campagne mass­media

-altro (specif.) ............. ,. ... ................

UTILE UTILE UTILE SO

I!I

I~I I~I

I~/ /4/ I~I

I!I I~/ I~I

.1'3

o

~ .. "

, .-~.

F- ADOLESCENTI

INCIDENTI

1. Ritiene efficace l'uso di caschi per i motociclisti nella prevenzi~ ne dei danni da incidenti stradali

MOLTO EFFIC. III

ABBAST.EFFIC. Igi

POCO EFFIC.

I~I

INEFFIC.

I~I L

(passare

NON so lai r

a dom.3)

2. Si accerta dell'uso deI casco da parte dei suoi pazienti IIIOtociclisti

SEMPRE III

SPESSO Igi

RARAMENTE MAI

I~I I~I

3. Rltlene efficace l'uso delle cint~ di sicurezza per aIl automobi­listi nella prevenzlone dei danni da incidenti atradali

MOLTO EFFICCACE III

ABBAST.EFFIC. POCO EFFIC. INEFFIC. NON 50 Igl I~I 141 lai

T 1" (passare a dom.S) 4. SI accerta dell'U8o delle cinture di

pazienti autoaobilistl slcurezza da parte dei suoi

SEMPRE III

SPESSO Igi

RARAMENTE I~I

MAI I~I

5. Lei pensa che rlentri tra i suoi cOlipiti quello raccOll8lldare l'uso di caschi e cinture di sicurezza

SI III NO 121 NON 50 lai ~ - l -

(passare alla Sez.5essualità)

6. Cosa potrebbe influlre negativamente sull'ascolto delle sue raccOliandazioni

-non seguono le mie indicazioni su argomenti non sanitari

-per i costi che comporta 1'ac­quisto di un casco

-altro (specificare)

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

citato suggeri to

I!I Igi

I!I

• l 11

1 Il~'

1_12140

1 l 'I,l

1 1 •

. . .

'.

.~ , .. " ,

, "

-1. 1

1

c

SESSUALITA'

1. Ritiene utile una sua attività di inforaazione sulla contraccezione al fine di prevenire gravidanze indesiderate

MOLTO UTILE

Il:1 ABBAST • UTILE

Igl POCO UTILE

12.1 NON UTILE

141 NON 50 lai r r (passare alla 5ez.ANZIANI

2. Fornisce questa indicazione di sua iniziativa

5EMPRE III ~

(passare

SPE5S0 RARAMENTE

121 I~I r alla dom.4)

3. La foroisce su richiesta

SI III NO Igl

MAI

I~I

4. Invia al consultorio/spec1a11sta

SI I!I NO Igi

5. Incontra ostacoli nel fornira queste 1nf'ol'll8Zioni SI Il:1 NO Igl Se sl, quaIi: -inadeguata formazione

-difficoltà ad affrontare l'argomento con le pazienti per resistenze cultural! e ps!cologiche

-altro (specif.) ••••••••••••••••••••••••• ......... -............................. .

G- ANZIANI

VACClNO ANTIINFLUBNZALE

I!I

1. Ri tiene' che la vaccinazione antinfluenzale nelle persone > 65 énrii sia efficace nella prevenzione delle cOMplicanze polmonari

SI

III PROB.5I . I~I

VERSO.NO

I~I

2. La esegue direttamente SI III NO I~I

NO NON 50 141 lai T r

(passare alla Sez.successiva)

3. Consiglia il ricorso a tale vaccinazione negli anziani (>65 aa) SEMPRE SPESSO RARAMENTE MAI III I~I 131 141 - T

(n"::JiL C"..,. ..... C'lI .... 1',.,. C" __ ........ -..-.. ...... ___ .! _,

,

• 1 ~

1._1 Zl"

1 1 tl.S

1 I.!

,

0

, .

.:

4.I~pazienti seguono la sua indicazione

SEMPRE SPESSO RARAMENTE MAI III I~I I.~I I~I

5. Quali problemi si presentano ai suoi pazienti nel rispondere a questa sua indicazi~ne

cltato suggeri to

-costo deI vaCCIno

-accesslbJ]ltà servlzio vaccInale

-altro (sppclflcarp)

.................................... ~ .............................. , ... .

INCIDENTI

6.A suo parere le indicazioni del medico di base possono avere una utilità nel prevenire incident1 degli anziani in a.bito domestico

MOLTO UTILE

III ABBAST • UTILE

Igl POCO UTILE

I~I INUTILE NON SO

141 I~I (passare alla Sez.success.

7. Lei di solito dA indicazioni in questo senso

SEMPRE III

SPESSO Igl

RARAMENTE I~I

8. Incontra problemi nel Cornirle

SI III NO Igi

9. Se sl, quali

-formazione inadeguata 1

-tempo deI medico

-tempo del paziente

-il paziente non segue conslgli non sanitari

-impOSSIbllltà dl modificare la sltuazlone dl vita

-a)tro (specjfirare)

..... , ....................... .

MAI I~I-.(passare alla Sez.successiva)

citato suggerito

Il.1 Igi

I!I Igi

I!I Igl

I!I Igi

I!I Igi

Il.1

10. Le è capitato di segnalere ai Servizi Sociali }'esistenza di casi a particolare rischio dl Incidentj domestjci

,F

, 1

in

: '!~

l',

'"

,',

.'

" "

(

AUTONOMIA FUNZIONALE

Il. Ritiene che l'adozione dei seguenti pres1d1 preventivi possa limitare il rischio di diminuzione dell'autonomia ~unzionale nell'anziano

MOLTO

UTILE ABBAST. POCO INUTILE NON UTILE UTILE SO

-cOrretta allmentazione

-contrO]~0 a]meno annuale de]Ja preSSlone ln anzlanl non Ipertesl

-cura unghle/calll per fav~ rire una corretta deambula zione

-cura dentale

Il,1 I~I

I~I

I~l

I~I

12. Fornisce di solito in~ormazioni sui Servizi Socio-Sanitari cui l'anziano puô ricorrere

18' -'

SPESSO RARAMENTE MAI SOLO SU· RICH.

-comunità alloggio

-assistenza domiciliare

-servlzi promossi dal C~ mune (corsi ginnastica, vacanze, Iniziative cul turaJi)

-serVIZ1 promOSSl da altri entl (speclflcare)

......... , .................. .

III

III

III

III

I~I

13. Incontra di~ficoltà nel fornire queste in~ormazioni

SI III 1 NO 1 ,g 1

Se si, quali cltato

. -non è ~lO complto

-non ho abbastanza tempo

-non conosco i servizi

-altro (speclficare)

... , ..... , ............. .

I~I

suggeri to

.] -

•••

1 1 ,_ l/l.

1 'Ig

1 1

'-1"

'l,

1)'

''\ ; ' .. ,. f.

o H- FARMACI

1. Ha incontrato nella sua attività il problema di abuso di autoprescrizione di farmaci

SEMPRE III

SPESSO Igl

RARAMENTE I~I

MAI I~I

2. Esiste nella sua attività il prrblema dell'errata interpretazione delle sue indicazioni circa il dosaggio e le modalità di assunzione dei farmaci

SEMPRE III

SPESSO Igl

RARAMENTE

I~I MAI

I~I

3. Control la la corretta assuozione dei tarmaci che prescrive

SEMPRE I!I

SPESSO Igi

RARAMENTE I~I

MAI I~I

4. Si informa sui tarmaci assuoti contemporaneamente a quelli da lei prescritti

SEMPRE III

SPESSO Igl

RARAMENTE MAI

I~I I~I

5. Ritiene che le sue raccomandazioni e controlli possano avere un ruolo di prevenzione nell'abuso di farmac!

MOLTO UTILE III

ABBAST.UTILE Igi

POCO UTILE

I~I INUTILE

I~I NON 50 I!;! 1

,Ji

. ~81

, 1

_ 12S"

, I~)

(

1 ,.

--,

c

1- ABlTUDINI PERSONALI

1. Lei {'uma

slgarette (speCl ficare numero f! anni

(speclflcare numero e anni

pIpa (specificare annl dl fumo)

di fumo)

di fumo)

III

I..?I

1.21

I~I

121

ex fuma tore (spPclflcarp numero p anni dalla cessazione)

mai fumato

2. Lei {'uma in ambula~;orio

anche davant! al paZlentl

solo fuori dalla sa] a in CUl vIsi to

solo se non vi sono pazlenti

mai

3. Nella sua sala d'attesa ~ permesso tumare

SI III NO Igl

4. Sulla sua automobile sono montate le cinture di sicurezza

SI III NO 121

5. Quando le usa

mal 11:.1 solo in città Igl solo fuori città I~I

sempre 141

1 1 1 1 1 1 1 1 tg!. l~ 1«,)

In mol te delle domande formulatel~ Je ahblamo chiesto di quantificare le

risposte, anche se non disponeva dl datl oggettivi.

Per Questa ragione le sue stlme non .",ClrantlO completamente esatte.

Da un punto di vlsta scientlflCo vaJldare Je risposte di indagini svol-

te, come questa, tramlte questlonarlo, dà una misura della affidabilità

dell'indaglne, attraverso una venfIea su dati oggettlvi.

Un metodo lndiretto dl valldazlone C'onslste nel chledere alla persona

intervistata qual è la sua stlma dell'errore che pua essere stato intro-

dette.

Lei precedentem~nte mi ha detto di aver visto nell'ultimo giorno di am-.. bulatorio assistiti: quaI è il numero minimo e il numero massimo

dl persane che è sicuro di aver visto?

non mena di

non più di

ANALOGAMENTE: Lei mi ha cetto di aver misurato, nell'ultimo giorno di

ambulatorio, la pressione a assistiti: QuaI è il numero minlma e

il numero massimo di assistiti cui è sicuro di averla misurata?

non meno dl

non più di

I._I-'!o~

1 i 1 ~ol

,

.~ .

.--,-~--------------------~~~------~--....

In una seconda fase di questo studlO ci proponiamo di valutare l' effic!,

c: cia dei consigli del medico genera)e nel facilitare la cessazione della

abitudine al fumo tra i proprl asslstiti.

Questo progetto è concepito facendo riferimento ad altri analoghi con­

dotti nei paesi anglosassoni e verrà definito nei dettagli in relazione

al contrlbuto de] colleghi che co]laboreranno ad esso.

Sarebbe interessato a partecipare ad un intervento di educazione 8anit!,

ria sul fuma in cui le verrebbe richiesto di seguire nel tempo (orient!,

tivamente 4-5 volte in un anno) un gruppo di suoi assistiti fumatori

SI I!I NO Igl

Se SI

Posso farla contattare nei prossimi mesi dai responsabili della studio

(SIMG e Area di Epidemiologia) per fornirle magaiori informazionl sulla

ricerca e concordare la sua eventuale partecipazione?

SI I!I NO Igi

• ?1

1_'W9

·c

'''. r

-,-" ,

" "." ...

t

NOTE PER L'INTERVISTATORE

Rilevare se nella stanza in cui il medico effettua le visite vi siano

portacenere sulla scd vania pulito IQI11

portacenere sulla scrivania sporco IQI,g1

sigarette/accendino IQI~I

odore di fumo I!IQI

Rilevare se nella sua sala d'attesa esiste il divieto di fumare

SI III NO Igl

In generale rilevare se nella sala d'aspetto esiste materiale divu]-

gativo di educazione sanitar1a (manifesti, depliants) e su quali ar­

gomenti

SI (specificare)

NO

I!I

===========================================================~=========

Data dell'intervista 1_1_1 1_1_1 1_1_1

Durata dell'intervista

Codice intervistatore ......................... ------------------------. Note sull'intervista · .......................................... .

.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . · .................................... , .. , .. . · ............................................ .

.....

1. ! _1 ~II

'-' ~\.$

l ,

(

. ~

~

-:

.[

TABELLA 1 INTERVENTI PREVENTIVI

Con riferillnto I9li iftttr\l!llti/colPOrt.t!llti 'uUa i""'caU:

Quanto 11 rlt1.nl UTILI

nel proluovere 11 silute

di un adulto

Quanto li ri ti.1II PREPARATO

ptr dlrl indiclzioni/conti-

gli/prllcrizioni in IIrito

Quinto SUCCESSO rititnt di

pot", aVlrl Ml dltlrlinar.

un cilbillinto dll11 Ibitu·

dini dli ,uoi Il,i,titi

Riti.nt SUD cDIPito

INTERVEMIRE lU quelti pro

blt.i Inchl prltlO un paZllntl

lino chi non 911.10 richieda

"plIe! tuente

ELIHIHAZIOHE COHTROLLO

FUHO PESO

REGOLARE

ESERCIZIO FISICO

!1!2!3!~!8! !1!2!31~!8! !1!2!3!.!8!

!1!2!3!4!8! !1!2!3!4!8! !1!2!3!.!8!

! 1 !2!3!4!8! !1 !2!3!4!8! !1!2!3!4!8!

SI NO SI NO SI NO

IGlENE ORALE

!1!2!3!4!8 1

,

!1!2!3!t!8!

!1!2!3!4!8!

SI NO

N.B. 1: ~LTO utlle/prep~rato/succe,so 2: M8ASTAHZA IJhle !Ct. 3, POCO uhl, ~r.':,

4 NOH IJt11e ICC. 8, NON 50

2.

---. -.

-,

:' -:,: ~

r~ .. ' ~ -J

,.~ '~ ;,i

' '!' ~

.. ," ~.'.wo!J

~ -.. , .. " J ~ J. 4 - ~~irJ-.'-l"'l'51l "Ir ",!*t ldl .. ~,,;I''''''V''''1'~ II_~ .. ~._ .. .. ~ ~" ' ... , . l : _,' 1 ,_~..J • '. ,~. t .. ~ , ~ ~

TABELLA 2 ALTRI INTERVENTI

l.au.to a"8dI sia effic.ce """'N i ... i dl: .tltr ..... :

ItOlTO MMSTANZA POCO

EFFICACE EfFICACE EfFICACE

-sordit~ InMllfti,~ clinico !1! !2! !J!

-c;rif dentall .... d1Ua bocca,illCOl'aggiare

l'igi.nt oral. quatidiana !1! !2! !J!

-cintra della bocCI .... 411111 bocct ~1! !2! !J!

-~riadontit. .... dlilallacct !1! !2! !J!

-glaIJCOI. toRO ocullr. !1! !2! !J! .. -Cintra dtlll ptll. i.,.ziOM !1! !2! !3!

-canero della YelC1Ca citologia urinaria !1! !2! !J!

-canero ~l colon-rttto Hlllaccuit !1! !2! !3'

-canero della prost.t; ispezion. r.ttal, !1! !2! !J!

fosfatlli litrichl !1! !Z! !3!

-canero deI pollOnt Rx InnUlI. !1! !2! !J! ..

-altro (~~,r.lflr.are)

---------------

---------------

Ci

INEfFICACE HON

SO

!~I !8!

!4~ !8'

!4! 'B!

!4! 11P

!4! 'B' !~, !8'

!4! !S'

!4! '8'

!4! !B!

!4! '8!

!4! 'S'

l

TABEllA 3 FUHO

C Quanto • eDftYinto IuIll di l'"~ hl Idottlt. I1111D URI l, 4Ulli clli 1. hl Idottltf/con~1911ltt

-tlf ~.!rYlno '101b iMipel\de,,~ell ,~f dl !pUa chi o If 111oth/.:nr'i\g!11

ptftl. oggi dtlll loro utllit' (posliblli plÙ l'l'post,) .

SEhPRE fOf<TI IN F~ESEN:~ vi S' .. j Su

FU"ATÎJR! MALIlT"I~ R" .-,.,.. ... P'" .. t. J 1 ~

-FI~.a:otlrlPil (nlcoprlvl) Il'2'3'4'8' SI ! 11 (doe succ) NO '2 1 (Ilt)

·l~/or'lzlonl '111 IIdil '1!2!3!4!8! (Mn li IPPlica)

-PIJbb llCl shcl/'ud1ovi Il vi Il!2!3!4!8' SI ! l! (dol IUCe) 110 !2! 'aIt' t

• -Inv!to/rICCOIlndlzlOftf dt1

, ' . -,

IICleo uni tlntUi !1!2!3!~!8! SI ! l' (dol tuce) MO !21 (lit' , ,

Il

:

-Invltl/riCCOI,ndIZ10ftl dl! . HdlCO 1'1pttuti !1!2!3!~!1' SI !1! (dol _el 110 !2! (lit),

,'J: -, ,~

c

-Go .. , 1111 nlcotinl !1!2!3!4!1! SI !l! (dol MC' MO !2! 'Ilt) .:::: .. -., ... -Plicot,ripil in cilnici !1!Z!3!4!1! SI !1! 'dol _e' MO !2! (lit)

;;. il

.. ..1

-Pll~ot,rlPll di gruppo !1!2'3!4!1' SI !l' (dol _e' MO !Z~ 'lit) ~ .~

·Pll~ot,rlPll indiYldulle ! 1 !2!3!4!8! SI Il! tdDI suce) MO :2! (11t) .~

'1

-Ipncli !1!2!3!4!1! SI !a! (411 suce) MO !Z! 'ait' .~ ~

-~opunturl !1!2!3!~!'! SI !1! (dol suce' MO !Z! (ait', '''; , •

-Rlcovlrro 10 clinlcht

IpWihzZltt !1!2!3!4!8' SI 'l' (dol suce) NO !2' (Ilt, 1

-AU~lcolctlr.pll '1'2'3'4!8' SI '1! (dot luccl NO !2! (Ilt)

-Hlt-e :sper.:heue) .

... -...... _----_ ... _-- '1'2'3'1t'8' SI 'li (dol syec) NO 12 1 (alt)

--------------- ___ w .... __ •• ___

-N,a, 1 MLTO uh 1. 2 A6SASTANZA IJh le 3 POCO 'Jhl, 4 INllTILE 8, NON 50

1/;. 1:'~-;~:ït~·~r·-r~A~d/:I':tt7/:,·{y.~,.",·'\~''''-!:'~t \1~ _"'.::. ï."~~

!J TABELLA 4 ALCOOL Cl

e. rU"t.t. all. tIeIidw sotta ildieah:

.'8uRto t eowilto I)_li di 1111 hl _ttatt 0 CllMiglim o 51 l, .. _tt.t. QI. MDtt., 1 -dMt 'iel'Vana I.na ... volt. i ... i ..... teeaat. ... i. 4UIli easi 10 fa / ha fatto

.. 110 dit ,.... .... UI 1.0 uti1iü ~i~ili pi~ ritpDltl) .

5BfI[ FGITI III PlESt-:NlA Dl SU &"R1 .... IMT.I .. niE (dl alcool) RIatIESn CASt RIeta

-Pucottripii !112IJ I 4!8! 51 ! 1! <doit. succ.) HO !21 (ilt)

-Invito/raccoaaftdlzlonl

dtl Mdico UftI bntta 1112IJ!4 18! SI !1! <".succ.) NO !2! (ilt)

-IftYltl/racCDllft6azloni

dll 1141CO ripttutl '112'3!418! SI !1! (daI.succ.) 110 !2! (ait)

~lcaoli,tl IftOnili !1 12!J!4 I BI 51 !1! (",succ.) NO !2! (lit)

-f Il'IIICOUripia !112!3!4!8! 51 !t! (".suce.) NO !2! (ait)

-Agopuftturi '1!2!314!81 SI Il! (a. suee. ) NO !2! (lIt)

-Altre (speciflcare)

i '11:'314181 SI 111 (dol. suce.) NO '2 1 (alt) : ----------------- ~

-----------------. -----------------

~

(4 E 1101 ta 'Jtlle 2 abbi5tanza utIle 3- pGCo utile ft IfllJhle 8- non 50

-.1 • ..... 2· : ... :-K .. -:r....C_.!...cJ.., .. '.I.'1:.!i .... t~J~.§.~"'''".,. 4& J •.. :\) n~., , .. ,.