Questions for this month's clinical challenge are based on articles in this issue. The style and scope of questions is in keeping with the multiple choice questions of the RACGP Fellowship exam. The quiz is endorsed by the RACGP Quality Improvement and Continuing Professional Development Program and has been allocated 4 Category 2 points per issue. Answers to this clinical challenge are available immediately following successful completion online at www.gplearning.com.au. Clinical challenge quizzes may be completed at any time throughout the 2011–13 triennium, therefore the previous months answers are not published.
Case 1: Archie and Ben
Archie, aged 76 years, has a history of gastro-oesophageal reflux, but is generally well. He visits your practice regularly and has an up-to-date general practice management plan (GPMP). Today he is booked in for a 75+ health assessment (75+ HA). He has also brought in his 6-year-old grandson, Ben, who has been vomiting. Archie asks if you could see them both as he feels Ben’s condition requires urgent care. You offer Archie an extended consultation, despite being extremely busy.
On assessment, you find that Archie is in good physical and mental health, has good social functioning and has no need for community services. You have conducted all the necessary preventive health screens and reviewed his GPMP to ensure it is up to date. Archie asks about the benefits of attending for another 75+ HA in 12 months.
Which of the following statements regarding health assessments in the elderly is most CORRECT?
- There is sound evidence to support regular health assessments in the elderly.
- Regular health assessments have been shown to result in statistically significant reductions in problems and mortality.
- The 75+ HA has been shown to keep people functioning in the community for longer.
- A large, randomised controlled trial demonstrated no significant difference between the probability of hospital admission or death between those who received a health assessment and those who did not.
- Two systemic literature reviews have shown that the probability of hospital admission or death increases in those patients who are not regularly assessed.
You consider your time management following Archie’s assessment, given his overall good health, regular check ups and up-to-date GPMP.
Conducting a task on the basis of a Medicare Benefits Schedule incentive is an example of which form of time wasting?
- Doctor-generated time wasting
- Role-generated time wasting
- Medicare/government-generated time wasting
- A and B
- A and C.
Archie thanks you for seeing Ben during his consultation, as there were no other appointments available. According to the National Healthcare Agreement report released in 2013, what percentage of patients had to wait more than 24 hours for an urgent GP appointment in 2011–2012?
After seeing Archie and Ben, you reflect on the division of time between acute and preventive medicine in general practice. According to a 2003 study published in the American Journal of Public Health, how many hours per day would be needed for primary care physicians to provide preventive health care as recommended by the US Preventive Services Task Force?
- 1–2 hours
- 3–4 hours
- 5–6 hours
- 7–8 hours
- 9–10 hours.
Case 2: Evelyn
Evelyn, aged 56 years, has a history of mild hypertension and regularly attends for routine screening tests. She is currently undergoing investigation of a thyroid nodule and presents today for a review of her hypertension management.
Regarding a recent Cochrane review examining the treatment of mild hypertension in patients with no history of cardiovascular disease, which of the following statements is most CORRECT?
- Less than 10% of patients ceased anti-hypertensive medications due to adverse effects.
- More than 10% of patients ceased anti-hypertensive medications due to adverse effects.
- Treatment was associated with a reduction in the number of deaths in this population.
- Treatment was associated with an increased number of heart attacks in this population.
- Treatment was associated with a reduction in the number of strokes in this population.
You are aware of current debate surrounding the overdiagnosis of thyroid nodules. Regarding thyroid disease, which of the following statements is INCORRECT?
- About 10% of CT pulmonary angiograms have unexpected findings such as thyroid nodules.
- Autopsy studies have found evidence of papillary thyroid cancer in up to 33% of people.
- The incidence of thyroid cancer in Australia has almost quadrupled in the past 30 years.
- Mortality rates of thyroid cancer in Australia have remained constant over the last 30 years.
- There have been recent calls for less investigation of thyroid lesions of <1 cm diameter.
You consider the research supporting Evelyn’s routine screening tests. According to trials, which one of the following conditions has been associated with net benefits as a result of screening?
- Atrial fibrillation
- Chronic kidney disease
- All of the above
- None of the above.
In considering the various issues surrounding overdiagnosis, which of the following statements is most CORRECT?
- Eight years after the introduction of computerised tomography pulmonary angiography (CTPA) in the US, the number of pulmonary embolism diagnoses tripled.
- Eight years after the introduction of CTPA in the US, the case-fatality rate of pulmonary embolism was halved.
- Lowering the fasting glucose threshold for diagnosis of diabetes increased prevalence of diabetes by 60%.
- Lowering thresholds for disease exposes more patients to treatment with less chance of clinical benefit.
- Studies show current screening methods can differentiate well between indolent and aggressive cancers.
Case 3: Ivan
Ivan, aged 60 years, has a history of type 2 diabetes, asthma, osteoarthritis and depression.
Ivan is confused about his health care, having received conflicting advice from various health care providers. You decide to use the Patient Assessment of Chronic Illness Care (PACIC) measure to assess Ivan’s health care. Which of the following is NOT assessed in the PACIC?
- Collaborative goal setting
- Communication between health care providers
- Provision of follow-up support
- Provision of proactive care
- Provision of problem-solving.
You consider the interaction between diabetes and depression in Ivan. Which of the following statements regarding multi-morbidity is TRUE?
- Patients with diabetes and depression have equivalent glycaemic control to those with diabetes without depression.
- Patients with diabetes and depression are as likely to develop complications as those with diabetes without depression.
- Guidelines for single conditions are highly applicable to patients with multi-morbidity as conditions are often inter-related.
- Patients with multiple conditions are usually included in studies of single conditions to improve external validity of results.
- Treating depression in patients with diabetes has not been found to necessarily improve control of diabetes.
Which one of the following statements regarding multi-morbidity is INCORRECT?
- In 2008, 75% of Australians reported having a long-term medical condition.
- In 2008, 50% of Australians aged over 65 years reported having five or more conditions.
- Multidisciplinary care planning is not associated with improved outcomes in multi-morbidity.
- Patients with multi-morbidity may need around 5–8 hours per day to manage their health.
- The number of conditions may be a greater determinant of patient needs than the presence of specific diseases.
Regarding the chronic care model, which of the following statements is NOT true?
- A recent systematic review found good evidence of effectiveness in multi-morbidity.
- It focuses on health care organisation for provision of management of multi-morbidity.
- It provides a framework for better use of decision support.
- It provides a framework for better use of information systems.
- It provides a framework for how health services should be organised.