Contents:
Some questions that primary care epidemiology can answer through studies at different health care levels. Primary care epidemiology is needed to describe: The long-term continuous nature of primary care, often to whole families, highlights both the need for, and opportunities available, to consider the complex genetic, physical, psychological, social and cultural influences on the onset and natural history of common symptoms and illnesses.
Knowledge about the natural history of symptoms can inform the development of effective evidence-based interventions, for instance leaflets about cough that reduce re-consultation rates. Studies have repeatedly shown that most symptoms experienced in the community are managed without seeking health care the so-called symptom iceberg phenomenon. Although sometimes perceived as a phenomenon only related to mild, self-limiting health problems, accumulating evidence shows that large submerged proportions also occur for symptoms of serious disease such as angina, 25 , 26 chronic back pain 27 and asthma.
This work will identify conditions where earlier intervention may be beneficial, as well as identify situations where the medical profession may best leave well alone. Huntingdon's chorea or because of incomplete penetrance of genes e. Currently little is known about the predictive value of different symptoms or clusters of symptoms experienced in the community, particularly for serious disease.
Given the high frequency of many symptoms, and the low incidence of serious disease in the general population, especially among younger people, positive predictive values of individual symptoms are likely to be very low. For example, rectal bleeding is rarely associated with bowel cancer, 32 and headaches with brain tumour.
Without such information, referral guidelines, such as those for suspected cancer 34 are likely to remain inefficient. Although much of the work of primary care epidemiologists necessarily relates to symptoms, some of it needs to consider conditions seen and managed almost exclusively in primary care, such as guttate psoriasis, whose natural history remains poorly understood.
Citing articles via Web of Science 6. Primary care epidemiology is not new, but its scope and potential is wide and increasing, requiring expanded investment of personnel and resources. Epidemiology in Country Practice. Nurses by holding master's degree after passing entrance exam, are eligible to continue their study in PhD in the field of Nursing. An Illustrated History 3rd ed. Neuroscience of Clinical Psychiatry.
Chronic pain is an example of a common, disabling condition whose epidemiology was, until recently, only understood through hospital clinic attendees. Governments throughout the world are striving to provide health care systems which are safe, patient-centred, timely, effective, efficient and equitable. Other countries, for instance France, Germany, India, and the United States of America, provide unrestricted parallel access to primary and secondary care services. Some questions that can be answered by primary care epidemiology will be system-specific, for example, who is using health care services, when and why?
Others will be more generic, for instance, what is the predictive value of usually undifferentiated symptoms first presented to health care professionals whether they be a nurse, community pharmacist, general practitioner or hospital specialist? Primary care systems with registered lists of patients are much more able to look at issues at the community level Table 1 than those without, as the lists provide the necessary denominators populations at risk for study. Whatever the health care system, demand for primary care services is huge.
For example, in the UK there are estimated to be more than million consultations with a general practitioner each year 41 and hundreds of millions more with other members of the primary health care team. With such large numbers, small shifts in demand of only a few percentage points can greatly relieve or strain the system. As well as describing what proportion of people with particular symptoms or clusters of symptoms seek health care, primary care epidemiology provides information about how such usage varies according to the characteristics of individuals and their symptoms, and the availability of different health care services.
Changes in the shape of primary care, and the range of symptoms and illnesses managed by different members of the primary health care team, can influence understanding of: For example, the UK government has recently encouraged more self-management of self-limiting illness 42 and introduced new primary care services such as nurse-led telephone advice lines in and out of hours and walk-in clinics. As a consequence, surveillance systems or studies based solely on general practitioner consultations will give an erroneous picture of the health burden arising from these conditions.
Furthermore, GPs are trained to manage uncertainty in clinical diagnosis. If other members of the primary health care team, with different training in handling uncertainty, manage a larger proportion of patients seen in primary care, demands on GPs and secondary care specialists may change. Primary care epidemiology is needed both for the evaluation of whether primary care services are adequate, appropriate, equitable, effective and efficient, 44 and, where primary care is the gatekeeper to specialist services, to help shape secondary care.
Primary care epidemiology can also inform policy makers about the appropriateness and effectiveness of new medical developments. For example, a study of the epidemiology of upper respiratory tract infections showed that patients with symptoms of the influenza virus are more likely to consult their general practitioner earlier than those with other infections, although usually not before a median of 3 days of symptoms starting. In addition to providing information about the targeting of interventions, primary care epidemiology provides a framework for deciding when to apply them, and how to evaluate them.
The point at which health care is sought during an episode of illness, or exacerbation of symptoms, may influence apparent response to treatment. It has been suggested that patients with chronic pain seek help at times when the pain exceeds its usual severity. On the other hand, if patients seek help when pain severity is increasing, follow-up may indicate a worsening of symptoms in spite, perhaps, of an effective intervention. As well as forming an essential element in the analysis of such studies, knowledge of the epidemiology of symptoms will assist in their planning.
For example, a sampling strategy for randomized controlled trials RCTs will be more efficient with detailed knowledge of sub-groups that should be studied, such as individuals at greatest risk of developing serious pathology, or at the point on any severity gradient or cycle when treatment is most likely to be required. Outcome measures for use in primary care need to reflect the complexity of conditions under investigation, and may not currently exist.
The symptomatic nature of many primary care conditions, requires the development of outcome measures that are patient-centred, and which frequently include social and psychological as well as physical factors. Primary care epidemiology helps with their development by providing information about how much improvement would need to be observed, beyond any natural improvement, for an intervention to be deemed to have produced a clinically significant result.
Such information is important for determining the sample size requirements of RCTs.
Primary care epidemiology faces a number of challenges. These include methodological issues such as the development of valid case identification and outcome measures for use in the community; conflicts between the need for data collection and data protection; problems of sharing information between different primary health care team professionals, and health care sectors; making sense of diagnostic uncertainty; problems of funding, especially for the important context-setting, descriptive work, which may not be perceived as being immediately useful to clinical services; inadequate research capacity; and the need to cross boundaries, with a view to inter-disciplinary working that combines the expertise of generalist and specialist clinicians, epidemiologists, statisticians, and information, laboratory and other scientists.
Primary care epidemiologists also need to rise to the challenges of engaging the public in their work, so that they research with , rather than on the population. In many countries, recent changes in data protection legislation has made epidemiological data collection increasingly difficult if not almost impossible in some places. Epidemiologists need to engage with legislators to find ways of conducting this important work, and with the public to ascertain their views on the use of their personal information for medical research.
Increasing use of information technology within different parts of primary care, and the development of secure, confidential, data encryption systems, allow large quantities of personal data to be handled anonymously. Separate, parallel developments allow reliable linkage of these data with other information derived from research and routine secondary health care. However, the research needs of clinical information needs to be considered prospectively when designing systems, since retrospective attempts to link data are more complex and may not be successful The challenges notwithstanding, there are a large number of opportunities, including increasing recognition that epidemiology is an important area of clinical research within primary care 51 and a growing cadre of researchers undertaking increasing amounts of applied and methodological research.
In many countries another fundamental opportunity is the large proportion of the population registered for primary care services e. This allows the straightforward identification of individuals to approach for participation in research, 52 as proposed for the UK Biobank study. In spite of data protection issues, the quality and quantity of clinical information from primary care in many countries has increased greatly, partly because of the ever decreasing costs of computer systems.
In addition, routine clinical data collected in primary care has sometimes been enhanced by linkages with secondary care clinical datasets. Primary care epidemiology is not new, but its scope and potential is wide and increasing, requiring expanded investment of personnel and resources. Nor is it an isolated discipline, working as it does with other epidemiological, scientific and clinical research. However, primary care epidemiology can make a distinct contribution to our understanding of health, illness and health care utilisation.
In comparison with other medical disciplines, primary care has often been the poor relation in terms of research input and output, 57 even though, in many countries, primary care manages most of the illness presented to health care services. We remain confident that the opportunities for primary care epidemiology are greater than the challenges. With careful development, the full potential of primary care epidemiology to contribute to the delivery of efficient and effective health care services in the community, primary and secondary care environments might be realised.
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