Didactic Sequences as an Educational Product to Facilitate Teaching-Learning Processes in Lato Sensu Graduate Courses in the Area of Health Management in Primary Care

Teaching strategies can be considered as techniques that are constructed to be used with the objective of promoting teaching and learning in the classroom, so that the teacher is considered a mentor, as he is the one who selects, analyzes, studies, organizes, builds and proposes the most classic tools to facilitate the learning process [1]. This study is an experience report related to the construction of an educational product that consists of the elaboration of pedagogical strategies, characterized by five didactic sequences in the perspective of collaborating with teaching-learning processes in lato sensu graduate courses. The themes that are part of the didactic sequences were built based on the results obtained in scientific research carried out during the development of the strict sensu postgraduate course in Teaching in Health and Technology, which involved: the work of coordinators who work in the field of health management in Primary Care, situations that challenge the management of Primary Care and the potentialities of work in the management of Primary Care. The didactic sequences have fun teaching strategies that provide meaningful learning for a future qualified professional performance. These sequences involve the use of active methodologies and the use of digital tools. The educational product developed seeks to promote benefits that can collaborate with the improvement of Primary Care Management and teaching-learning processes in the training of health professionals. Therefore, the pedagogical strategies, as well as its entire construction process, were developed through the collaboration of professors of the Health and Society discipline at the State University of Health Sciences of Alagoas (UNCISAL), seeking to make it qualify for effective construction of knowledge and that promote its wide use in the academic environment.

Identifying High-Risk Medication Prescriptions to Prevent Potentially Severe Adverse Drug Events in Primary-Care Patients with Chronic Multimorbidities:The Polychrome Study

Background:The association between multimorbidities and polypharmacy among elderly individuals is well documented,and polypharmacy has been shown to increase the risk of adverse drug events(ADEs).However,little information is available about the risks associated with the lifelong use of medications to treat chronic multimorbidities.Objective:To determine the prevalence and nature of high-risk prescriptions among primary-care patients with chronic multimorbidities.Methods:We studied a weighted stratified random sample of 105 prescriptions for different patients with chronic multimorbidities taken from the Polychrome database established using information from the French primary-care record database(Observatoire de la Médecine Générale).A medication review was conducted to identify contra-indications and potential drug-drug interactions for each prescription.Results:Contra-indications were identified for 60(57.1%)prescriptions,potential drug-drug interactions for 70(66.7%),absolute contra-indications for 9(8.6%),and inadvisable drug combinations for 11(10.5%).In all,19(18.1%)different patients were at risk for major ADEs.Cardiovascular and nervous-system drugs contributed 66.2% of contra-indications and 69.3% of potential drug-drug interactions.Conclusions:This exploratory study confirms the high prevalence and potential seriousness of prescriptions at risk for ADEs in a population of primary-care patients with chronic multimorbidities.The high prevalence of interactions involving the cardiovascular and nervous systems indicates that efforts to improve prescription practices should target these two categories of conditions and drugs in patients with chronic multimorbidities.

The situation of primary care institutions under the background of new medical reform in China

[目的] 分析新医改背景下我国基层医疗卫生机构的发展现状,探讨存在的问题,为进-步完善基层 卫生事业改革发展提供参考.[方法]利用2008 - 2 0 1 2年中国卫生统计年鉴数据,对基层医疗卫生机构基础设 施、人才配置和卫生服务利用状况进行分析.[结果] 2008 - 2 0 1 2年我国基层医疗卫生机构总数量年平均增速 为 1.55%,其中西部地区的机构数量最少、但年平均增速最快,中部地区的数量比西部多比东部少;在三大基 层医疗卫生机构当中,社区卫生服务中心（ 站）、乡镇卫生院和村卫生室机构数量年平均增长率分别为8 . 4 4 %、 -1.3%和 1.6%; 三大基层机构卫生技术人员数量年平均增长率分别为2 0 . 2 5 %、3% 和 5 . 0 2 % ; 三大基层机构 诊疗人次数年平均增长率分别为2 3 . 6 8 %、3. 96% 和 8. 92 %.截至2 0 1 2年 ,社区卫生服务中心卫生技术人员的 学历以大专为主（占40. 9%）,职称以师级/助理为主 （占32. 8%）; 乡镇卫生院卫生技术人员的学历以中专为 主 （占51. 3%）,职称以士级为主（占40. 2%）.[结论]新医改后我国基层医疗卫生机构发展迅速,但资源分 布仍不均衡;基层卫生技术人员数量不断增加,但学历职称层次仍偏低;基层医疗卫生机构卫生服务利用增 加 ,但患者就医仍缺乏有效引导.

Primary Health Care-基础医疗卫生服务应该在中国新医改中得到正确理解和全面实施

英文"primary health care"(PHC)-基础(基本)医疗卫生服务这个概念在中国被错误地理解和翻译成"初级卫生保健"已经有半个多世纪。而专科医疗则被认为是"先进的高级医疗服务"。这种对PHC的错误理解渗透到中国政府和医疗卫生各个部门,在国家的医疗卫生服务宗旨和宏观发展战略决策中造成广泛的影响,如政府的卫生政策制定,医疗服务保障制度建立,医疗卫生基础设施布局,以及医疗卫生服务专业人才队伍的培养等。本文全面阐述了PHC的概念在中国是如何被错误地理解并被翻译成中文"初级卫生保健"的,并从多个角度分析为什么这样理解和翻译是不合理的和错误的:"primary"和"health care"英文单词的基本含义,关于综合性PHC的概念,全球PHC的正反历史经验和上述错误理解对中国医疗卫生服务的发展以及对整个社会造成了部分伤害。中国正在进行的以基础医疗卫生服务为中心的新医改已经取得了很大的前期进展,但是也面临着一系列困难和挑战,包括对基础医疗卫生服务这个概念还存在广泛而根深蒂固的错误理解。我们希望医疗卫生领域的学者、医疗卫生专业人员和政府部门的官员能够充分理解和接受PHC-基础医疗卫生服务这个正确概念,消除"初级卫生保健"错误观念在发展中国基础医疗卫生服务事业中的各种影响,促进新医改的健康发展,使广大人民群众能真正享受到新医改的好处。

Rectal cancer: An evidence-based update for primary care providers

Rectal adenocarcinoma is an important cause of cancer-related deaths worldwide, and key anatomic differences between the rectum and the colon have significant implications for management of rectal cancer. Many advances have been made in the diagnosis and management of rectal cancer. These include clinical staging with imaging studies such as endorectal ultrasound and pelvic magnetic resonance imaging, operative approaches such as transanal endoscopic microsurgery and laparoscopic and robotic assisted proctectomy, as well as refined neoadjuvant and adjuvant therapies. For stage Ⅱ and Ⅲ rectal cancers, combined chemoradiotherapy offers the lowest rates of local and distant relapse, and is delivered neoadjuvantly to improve tolerability and optimize surgical outcomes, particularly when sphincter-sparing surgery is an endpoint. The goal in rectal cancer treatment is to optimize diseasefree and overall survival while minimizing the risk of local recurrence and toxicity from both radiation and systemic therapy. Optimal patient outcomes depend on multidisciplinary involvement for tailored therapy. The successful management of rectal cancer requires a multidisciplinary approach, with the involvement of enterostomal nurses, gastroenterologists, medical and radiation oncologists, radiologists, pathologists and surgeons. The identification of patients who are candidates for combined modality treatment is particularly useful to optimize outcomes. This article provides an overview of the diagnosis, staging and multimodal therapy of patients with rectal cancer for primary care providers.

Colorectal cancer,screening and primary care: A mini literature review

Colorectal cancer(CRC) is a common health problem,representing the third most commonly diagnosed cancer worldwide and causing a significant burden in terms of morbidity and mortality,with annual deaths estimated at 700000. The western way of life,that is being rapidly adopted in many regions of the world,is a well discussed risk factor for CRC and could be targeted in terms of primary prevention. Furthermore,the relatively slow development of this cancer permits drastic reduction of incidence and mortality through secondary prevention. These facts underlie primary care physicians(PCPs) being assigned a key role in health strategies that enhance prevention and prompt diagnosis. Herein,we review the main topics of CRC in the current literature,in order to better understand its pathogenesis,risk and protective factors,as well as screening techniques. Furthermore,we discuss preventive and screening policies to combat CRC and the crucial role served by PCPs in their successful implementation. Relevant articles were identified through electronic searches of MEDLINE and through manual searches of reference lists.

Diabetes self-care in primary health facilities in India-challenges and the way forward

India has approximately 73 million people living with diabetes and another 37 million with prediabetes while nearly 47% of the diabetes cases are undiagnosed. The high burden of poor glycemic control and early onset of complications with associated economic costs indicates a high prevalence of poor self-management practices. It is well-established that achieving patient-centered primary care consistent with a chronic care model ensures optimum diabetes self-management support and improves long-term clinical and health outcomes in diabetes patients. The public sector primary care system in India provides services free of cost to beneficiaries but lacks patient-centered care that undermines diabetes selfmanagement education and support. Furthermore, factors like poor patient knowledge of diabetes, suboptimal medication adherence, persistent clinical inertia, lack of data for monitoring and evaluation through clinical audit worsens the standards of diabetes care in primary care settings of India. There is a need for government initiatives to be directed towards the provision of comprehensive outpatient care that is inclusive of uninterrupted supply of drugs, provision of essential laboratory investigators, training and availability of qualified diabetes educators and availability of specialist support when required. Furthermore, the integration of depression screening and smoking cessation services at the primary care level is warranted.

Diabetes empowerment scores among type 2 diabetes mellitus patients and its correlated factors: A cross-sectional study in a primary care setting in Malaysia

BACKGROUND There are limited studies on diabetes empowerment among type 2 diabetes patients,particularly in the primary care setting.AIM To assess the diabetes empowerment scores and its correlated factors among type 2 diabetes patients in a primary care clinic in Malaysia.METHODS This is a cross sectional study involving 322 patients with type 2 diabetes mellitus(DM)followed up in a primary care clinic.Systematic sampling method was used for patient recruitment.The Diabetes Empowerment Scale(DES)questionnaire was used to measure patient empowerment.It consists of three domains:(1)Managing the psychosocial aspect of diabetes(9 items);(2)Assessing dissatisfaction and readiness to change(9 items);and(3)Setting and achieving diabetes goal(10 items).A score was considered high if it ranged from 100 to 140.Data analysis was performed using SPSS version 25 and multiple linear regressions was used to identify the predictors of total diabetes empowerment scores.RESULTS The median age of the study population was 55 years old.56%were male and the mean duration of diabetes was 4 years.The total median score of the DES was 110[interquartile range(IQR)=10].The median scores of the three subscales were 40 with(IQR=4)for"Managing the psychosocial aspect of diabetes";36 with(IQR=3)for"Assessing dissatisfaction and readiness to change";and 34 with(IQR=5)for"Setting and achieving diabetes goal".According to multiple linear regressions,factors that had significant correlation with higher empowerment scores among type 2 diabetes patients included an above secondary education level(P<0.001),diabetes education exposure(P=0.003),lack of ischemic heart disease(P=0.017),and lower glycated hemoglobin(HbA1c)levels(P<0.001).CONCLUSION Diabetes empowerment scores were high among type 2 diabetes patients in this study population.Predictors for high empowerment scores included above secondary education level,diabetes education exposure,lack of ischemic heart disease status and lower HbA1c.

Knee osteoarthritis:Therapeutic alternatives in primary care

AIM To discusses pharmacological and non-pharmacological therapeutic alternatives for managing knee osteoarthritis in primary care by primary health care nurse practitioners.METHODS A case example is presented, the evidence-based guideline recommendations of the Osteoarthritis Research Society International and the American Academy of Orthopaedic Surgeons are reviewed, and a plan of care is developed.RESULTS Osteoarthritis is the most common form of arthritis seen in primary care, and it is a major public health issue because the aging population and widespread obesity have drastically increased incidence. Osteoarthritis is clinically associated with escalating chronic pain, physical disability, and decreased quality of life. Early diagnosis of mild osteoarthritis in relatively young patients presents an opportunity for primary health care providers to manage pain, increase quality of life, and decrease risk of disability. CONCLUSION Primary health care providers can implement these recommendations in their own practices to provide care to patients with knee osteoarthritis based on current best evidence.

Understanding and Promoting Clinical Reasoning in Chronic and Multimorbid Conditions: A Call for GPs and Healthcare Professionals

Multimorbidity, defined as 2 or more chronic diseases, is of increasing importance for health professionals. Many factors are at play when it comes to multimorbidity, but we still know very little about how clinicians actually weigh up the different factors—medical, social, and psychological—to reach a particular course of action. Further research is therefore required to explore the ways in which clinical reasoning processes are involved in the follow up of patients suffering from multimorbidities, to highlight their potential risks of errors. A better understanding of these clinical processes will also enrich supervision of trainees and collaboration between healthcare professionals involved in primary care.

Clinical Audit on the Provision of Diabetes Care in the Primary Care Setting by United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA)

OBJECTIVE: United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) provides primary health care services including care for diabetes and hypertension, with limited resources under difficult circumstances in Gaza, West Bank, Jordan, Lebanon and Syria. A total of 114,911 people with diabetes were registered with UNRWA health centres in 2011. The aim of this cross-sectional observational study was to assess the quality of diabetes care in the UNRWA primary health care centres. METHOD: The study population consisted of 1600 people with diabetes attending the 32 largest UNRWA health centres and treated there for at least one year. Between April and Sept. 2012 data from medical records, including results of clinical examinations and laboratory tests performed during the last one year, current management including self-care education and evidence of diabetes complications were collected and recorded in a previously validated data collection form (DCF). Patients were interviewed and clinically examined on the day of the audit and blood collected for HbA1c testing which was done at a central lab using High-performance liquid chromatography (HPLC) method (HLC&reg-723G8 Tosoh Corporation, Japan). Data was transferred from paper records into a computer and analysed with Epi-info 2000. RESULTS: Type 1 diabetes was present in 4.3% and type 2 diabetes in 95.7%. Co-morbid hypertension was present in 68.5%;90.3% were either obese (64.0%) or overweight (26.3%). Clinical management of diabetes was largely in line with UNRWA’s technical instructions (TI) for diabetes. Records for 2 hour postprandial glucose (2 h PPG), serum cholesterol, serum creatinine, and urine protein analysis were available in 94.7%, 96.4%, 91.4% and 87.5%, cases, respectively. Records of annual fundoscopic eye examination were available in 47.3% cases but foot examinations were less well documented. Most patients (95.6%) were on anti-diabetic drugs—68.2% oral anti diabetic drugs (OAD) only, 14.4% combination of OAD and insulin, and 12.9% insulin only. While 44.8% patients had 2 h PPG ≤ 180 mg/dl, only 28.2% had HbA1c ≤ 7%;55.5% and 28.2% had BP ≤ 140/90 and ≤130/80 mm of Hg respectively. Serum cholesterol ≥ 200 mg/dl, serum creatinine ≥ 1.2 mg/dl and macro albuminuria were noted in 39.8%, 6.4% and 10.3% cases respectively. Peripheral neuropathy (52.6%), foot infections (17%), diabetic retinopathy (11%) and myocardial infarction (9.6%) were the most common long term complications. One or more episodes of hypoglycaemia were reported by 25% cases in total and in 48% of those using insulin. 17.7% and 22.6% cases received no or ≥4 self-care education sessions respectively. CONCLUSION: The study confirmed that UNRWA doctors and nurses follow TI for diabetes and hypertension fairly well. Financial constraints and the consequent effects on UNRWA TI and policies related to diabetes care were important constraints. Key challenges identified were: reliance on 2 h PPG to measure control;non-availability of routine HbA1c testing, self-monitoring of blood glucose (SMBG) and statins within the UNRWA system;and high levels of obesity in the community. Addressing these will further strengthen UNRWA health system’s efforts of providing services for diabetes and hypertension at the primary care level. Given that most developing countries either have no or only rudimentary services for diabetes and hypertension at the primary care level, UNRWA’s efforts can serve as an inspiration to others.

Primary care and mental health: Where do we go from here?

Primary care has been dubbed the“de facto”mental health system of the United States since the 1970s.Since then,various forms of mental health delivery models for primary care have proven effective in improving patient outcomes and satisfaction and reducing costs.Despite increases in collaborative care implementation and reimbursement,prevalence rates of major depression in the United States remain unchanged while anxiety and suicide rates continue to climb.Meanwhile,primary care task forces in countries like the United Kingdom and Canada are recommending against depression screening in primary care altogether,citing lack of trials demonstrating improved outcomes in screened vs unscreened patients when the same treatment is available,high false-positive results,and small treatment effects.In this perspective,a primary care physician and two psychiatrists address the question of why we are not making headway in treating common mental health conditions in primary care.In addition,we propose systemic changes to improve the dissemination of mental health treatment in primary care.

Individualized Treatment and Palliative Care for A90-Year-Old Patient with Primary Gastric Diffuse Large-B Cell Lymphoma:4 Year Follow-up and Inspiration

A 90-year-old man was diagnosed with primary gastric diffuse large B-cell lymphoma(PGDLBL)by PET/CT examination,gastroscopy,biopsy and histopathological analysis at a regular physical check in April,2016.The patient received R-CO chemotherapy(rituximab,cyclophosphamide,and vincristine)and radiotherapy subsequently,with enteral nutritional treatment through 3-cavity nasogastric tube due to development of pyloric obstruction.To satisfy patient's strong desire of eating by himself,we performed surgery of exploratory laparotomy and Roux-en-Y gastric bypass(RGB)to relieve pylorus obstruction.Postoperatively,the patient resumed oral feeding,supplemented by nasogastric tube feeding at 1350-1550 Kcal daily.He is now 94 years old with fairly well nutrition and normal communication.The outcome of 4 year follow-up suggests that nutritional treatment and palliative medicine are important for improving prognosis and life-quality of very elderly patients with end-stage tumors apart from the effective chemotherapy,radiotherapy,and surgery.

Effectiveness of Adherence to Standardized Hypertension Management by Primary Health Care Workers in China:a Cross-sectional Survey 3 Years after the Healthcare Reform

主要护理工人提供的标准化高血压管理是瓷器最近的护理改革努力的重要部分。从代表性的调查调查 5,116 个高血压的病人在 2012 由疾病控制和预防的中国中心进行了，发现那坚持到标准化高血压管理的这研究在高血压相关的知识，健康生活方式行为， antihypertensive 医疗，和血压控制上与积极效果被联系。向主要护理工人提供保证高血压管理的实现和有效性的足够的训练和合理刺激将是必要的。

Evaluation of the Psychological Impact of COVID-19 Pandemic on Chinese Patients with Common Mental Disorders in Primary Care: A Cross-Sectional Study

Purpose: Our study aimed to evaluate the psychological impact of COVID-19 pandemic on Chinese patients with common mental disorders in primary care in Hong Kong. Method: A cross-sectional study was conducted on 102 Chinese patients with common mental disorders and being followed up in two public integrated mental health clinics in Hong Kong from 1st November 2020 to 31st January 2021. Patients would be evaluated about the impact of COVID-19 pandemic on their mood and daily life by using a questionnaire which assessed social distancing effects, financial impact, relationship with family, anxiety and depressive symptoms. The Patient Health Questionnaire-9 (PHQ-9) and General Anxiety Disorder-7 Questionnaire (GAD-7) would also be used to assess patients’ mood symptoms. Factors which were related to COVID-19 pandemic and associated with anxiety or depressive symptoms would be analysed. Results: The mean age of the subjects was 58.0 years and more patients were female (77.5%). There were 84.3% and 72.5% of patients reported their anxiety and depressive symptoms being affected by COVID-19 pandemic respectively. It was found that 17.6% of patients had their income decreased or were unemployed. About one-third (30.4%) of patients indicated that their relationship with their family was worsened while 8.8% was improved. Social distancing was significantly associated with anxiety (p = 0.006) and depressive symptoms (p 0.001) in patients with common mental disorders. Conclusion: There was considerably more psychological impact including an increase in anxiety and depressive symptoms due to COVID-19 pandemic in Chinese patients with existing common mental disorders in primary care. Primary care physicians should raise their awareness of the psychological impact of COVID-19 pandemic on their patients. Our findings shed light on mental health care planning and preventive measures during the COVID-19 pandemic and potential subsequent pandemics.

Rabeprazole test for the diagnosis of gastro-oesophageal reflux disease: Results of a study in a primary care setting

瞄准：为了决定病人的 rabeprazole 测试的诊断价值，由全科医生看。方法：有 GERD 暗示的症状的 83 个病人被全科医生在这个多中心注册，使随机化并且双窗帘学习。所有病人收到了 rabeprazole (20 mg 出价) 或安慰剂一个星期。GERD 的诊断在内视镜检查法或反常食道的 24-h pH 测试在粘膜裂缝的存在上被建立。如果病人们报导至少，“ 7 点 Likert 上的症状的清楚的改进”可伸缩，测试被认为阳性。结果：为 rabeprazole 和安慰剂的测试的敏感分别地是 83% 和 40% 。相应特性，积极、否定的预兆的价值是 45% 和 67% ， 71% 和 71% ，和 62% 和 35% 分别地。操作特征(巨鸟) 分析的接收装置证实最好差别对待截止对应于对“清楚的改进”的描述。结论：禁止者(PPI ) 测试的质子泵的差的特性不支持如此的一条途径在一个主要照顾背景建立 GERD 的诊断。

Contributions of Primary Health Care and Next Step Considerations: A Systematic Review

The essential consideration is the cornerstone of a solid medical care system that provides outstanding health outcomes at a low cost. Medical therapy has evolved over the previous century from concentrating on random etiologies to lifestyle, race, and environmental factors. The aim behind these changes is to serve the public health requirements by delivering frequent and easy services based on the individual, couple, or family. Accurate evaluation of the magnitude by which primary health care contributes to the health care system is essential to the improvement of these contributions and determining next step considerations. The number one factor has been associated with greater access to medical care, better health outcomes, and reduced hospitalization and ER (emergency room) visits. The number one consideration may also help balance the adverse effects of poor financial situations on well-being. Therefore, we need more primary care doctors in the US. Research is also necessary to understand which essential consideration models provide acceptable health results.

A Study Protocol on the Evaluation of Referral Strategies for Inflammatory Arthritis in Primary Care Patients at the Level of Healthcare Organization, Patient Relevant Outcomes and Costs

Background: Considering the importance of getting the right patient at the right location to maintain and optimize quality of life of inflammatory arthritis patients, appropriate referral by general practitioners is essential. This study aims to assess the effect and cost effectiveness of different referral strategies for inflammatory arthritis in primary care patients. Methods: This study follows a cluster randomized controlled trial design. General practitioners from primary care centers in Southwest-The Netherlands are randomly assigned to either one of the two strategic interventions for referring adult patients who are in the opinion of the general practitioner suspected of inflammatory arthritis: 1) Standardized digital referral algorithm based on existing referral models PEST, CaFaSpA and CARE;2) Triage by a rheumatologist in the local primary care center. These interventions will be compared to a control group, e.g. usual care. The primary outcome is the percentage of patients diagnosed with inflammatory arthritis by the rheumatologist. Secondary outcomes are quality of life as a patient reported outcome, work participation and healthcare costs. These data, including demographic and clinical parameters, are prospectively collected at baseline, three, six, and twelve months. Discussion: If this study can demonstrate improvements in appropriate referrals to the rheumatologist, thereby improving cost-effectiveness, there is sufficient supporting evidence to implement one of the referral strategies as a standard of care. Finally, with these optimization strategies a higher quality of care can be achieved, that might be of value for all patients with arthralgia. Trial Registration: NCT03454438, date of registration: March 5, 2018. Retrospectively registered: https://clinicaltrials.gov/ct2/show/NCT03454438?term=NCT03454438&draw=1&rank=1.

Knowledge and practices of primary care physicians on the current referral system of diabetic retinopathy in Islamabad and Rawal-Pindi, Pakistan

AIM: To assess the current knowledge and practices in diabetic eye care and referral system regarding diabetic retinopathy(DR) in health centers of Islamabad and RawalPindi. METHODS: A cross-sectional study was carried out in 4 government and private health centers in RawalpindiIslamabad from May 2018 to Oct. 2018. A total of 38 Primary Care Physicians(general practitioners, family physicians, and internists) were recruited out of which data for 2 were either not returned, or were missing partially. Data were collected through a 27-item consented & validated, multiple-choice questionnaire based on physician characteristics, knowledge and practice of diabetic eye care and challenges faced due current DR referral system. Descriptive analyses for all variables were performed including, mean and standard deviation. Analytical analyses were also conducted to study association between different study variables. RESULTS: Mean scores of knowledge for general practitioners, family physicians, and internists were 41.7%, 42.0% and 46.6% respectively. A lack of knowledge, and suboptimal practices were observed regarding signs, symptoms, screening, testing, evaluation and referral of DR regardless of physicians’ specialty, or years in practice. Lack of expertise regarding direct ophthalmoscopy, interpretation of findings, and referral to an ophthalmologist were noted. Physicians who performed consultation and counselling according to patients’ needs referred more patients to an ophthalmologist than those who restricted their consultationto a fixed amount of time and had more patients per unit time(P=0.01). Physicians who had taken care of less than 5 number of patients with DR marked less incorrect answers with no significantly greater number or correct answers compared to physicians who had taken care of more than 5 number of patients with DR(P=0.044). An association of more than 5 patients with DR taken care of with more need based patient consultation and counselling was also noted(P=0.017). An evaluation of the current referral system for DR revealed major loopholes in the health care infrastructure, proper guidelines, properly functioning equipment, check and balances, and lack of guidance to physicians regarding acquiring and updating knowledge regarding DR. CONCLUSION: Lack of updated and adequate knowledge, practices among primary care physicians, and suboptimal diabetic eye care and referral system have contributed to late presentation of DR. Interventions are needed to improve current diabetic eye care, and knowledge and practices of primary care physicians.

Disease-wide accessibility of the elderly in primary care setting: The relationship between geographic accessibility and utilization of outpatient services in Tokushima prefecture, Japan

In Japan, a rapid pace of aging coupled with the lower birth rates causes the decrease of the population especially in rural area, which leads to the problems with the delivery of healthcare services. We investigated the relationship between the geographical accessibility (time and distance) and the utilization rate of outpatient services in the elderly by major disease groups in Tokushima prefecture, Japan. Distances and driving times to the nearest facilities from residential sites in major disease categories were measured by using geographic information system. Utilization data was obtained from the claim data. In diseases of the musculoskeletal system and connective tissue (M00-M99), diseases of the digestive system (K00-K93), endocrine, nutritional and metabolic diseases (E00-E90), diseases of the eye and adnexa (H00-H59) and diseases of the respiratory system (J00-J99), there were moderate negative correlations (around –0.4 to –0.6) both in distance and time. Distance and time to the nearest facilities were important factors for the utilization of outpatient services of major disease categories in Japanese elderly. Comprehensive approach which include socio- economic factors is needed to mitigate access problems in aging Japanese society.