The identification of strategies for the prevention, diagnosis, and treatment of cancer is a high priority for the nation. It is estimated that $10 billion is spent each year for hospital and physician services, $25 billion represents lost income, and over two million work-years are lost because of cancer.[1] With 1990 figures from the American Cancer Society (ACS) showing approximately 37,900 new cases in Michigan alone,[2] interventions aimed at early detection and treatment of cancer are actively being sought and implemented. The primary care physician, by virtue of practice location and accessibility to a large percentage of the population, has been identified as an important link in delivering the necessary education and early diagnostic procedures

Much of the literature on prevention of death and disability from cancer, including the ACS report on the cancer-related checkup,[4] assumes that the search for early cancer in asymptomatic individuals will afford the greatest medical benefit in a safe and practical way. Studies in various settings, however, have demonstrated that screening protocols are seldom implemented.[5-9] Patient, physician, test, and health care delivery system factors have all been cited as responsible for the failure to complete cancer screening.

Reports of cancer detection in practice settings are few. A retrospective study of cancer diagnoses from a single family practice over a 10-year period demonstrated that 69 cancers, or approximately one new cancer diagnosis every 2 months, were identified.[12] In the study, the majority of cancers were diagnosed among patients who were participating in cancer screening; however, only 2 of 11 patients with a diagnosis of colon cancer and 2 of 11 women with a diagnosis of breast cancer were asymptomatic. To improve the frequency and effectiveness of cancer screening by primary care physicians, more information is needed on how cancer is currently identified among their patients .

The purpose of the present study was to describe practitioner beliefs about cancer screening, early detection, and actual cancer detection rates (by both screening and case finding) in a population of patients cared for by a group of family practice physicians. It was hypothesized that the majority of cancer cases detected by these physicians would be among patients presenting with symptoms. In addition, it was hypothesized that those reporting a belief in more aggressive screening strategies would detect more asymptomatic cases and more cancers at an early stage of illness.

Methods

Subjects

Physicians who participated in this study were members of the Michigan Research Network (MIRNET), a voluntary network of Michigan practitioners interested in collaborating on primary care research projects. Twenty-nine family physicians and six physician assistants (PAs), representing 10 of the 18 MIRNET practices, participated in the study. These practices included 4 solo physician practices, 2 community-based family practice (FP) teaching faculty practices (7 physicians and 2 PAs), 1 academic FP faculty practice (four physicians), and 3 FP group practices (14 physicians and 4 PAs). Five practices were in rural locations (3 solo, 2 group practices). The 4 PAs in the group physician practices reported cases through the supervising physician rather than independently contributing information; therefore, the total number of practitioners participating in the study was 31.

Measures

A previously validated self-administered questionnaire on cancer screening practices was used with permission from Woo et al.[8] This questionnaire requested information on how often asymptomatic patients of varying ages should receive general (physical or pelvic examination) and specific (breast and/or rectal examination, fecal occult blood, sigmoidoscopy, Papanicolaou [Pap] smear, and mammography) cancer screening. Screening frequencies were reported as never, once in a lifetime, once every 10 years, every 4 to 5 years, every 2 to 3 years, or once annually. Subjects were also asked to rate themselves in general terms regarding the use of screening procedures (more, same, or less than recommended) and to list in rank order the reasons for following this approach. Information was requested on personal and family history of cancer.

A patient information card was used to identify each patient with a new diagnosis of cancer. This card was used to report the patient’s name and identification number, age, sex, diagnosis, screening and diagnostic tests used to identity the cancer, and whether the patient presented with symptoms attributable to the cancer. A test or examination w as considered part of screening if the patient was asymptomatic at the time of testing and the performance of the test was not prompted by the patient. A test or examination was considered diagnostic if the test was performed in response to either patient symptoms or a positive screening test. Cancers considered detectable by routine screening included breast cancer (clinical breast examination and mammography), cervical cancer (Pap smear), colorectal cancer (digital rectal examination, fecal occult blood, and sigmoidoscopy), prostate cancer (digital rectal examination with or without prostate specific antigen [PSA] test), and skin cancer (skin inspection during physical examination). The designation of these cancers as detectable was based on recommendations offered by the ACS.

Medical abortion has been available in the United States for some time but, until recently, was viewed mainly as an experimental procedure or new technology.[1] Publication of the article by Gold, Luks and Anderson[2] shows how medical abortion could enter into the mainstream of family practice and highlights the controversy surrounding this subject.

The accessibility of medical abortion brings family physicians to yet another crossroads. The procedure itself is effective, low-cost, easily learned, noninvasive, well-tolerated and potentially accessible to nearly all patients. Yet medical abortion, with its moral implications, may only complicate the practices of many family physicians.

Family physicians are still divided on their attitudes toward abortion.[3] One survey, taken at a time when only surgical abortion was available, reported that although approximately 50 percent of family physicians supported a woman’s right to choose an abortion, only 3 percent were performing abortions.[4] Perhaps the technical aspects of a surgical abortion were too daunting for most family physicians, or the public nature of the procedure deterred physicians from performing surgical abortions. Equally plausibly, the gap between believing that a woman has the right to choose an abortion and actually performing an abortion presented too great a moral leap for most practitioners to take. Medical abortion eliminates the first two potential obstacles, leaving family physicians to wrestle with the moral implications of the procedure.

Paradoxically, the simplicity and convenience of medical abortion may also be a drawback. A patient can now simply go to her physician for a “routine” visit to discuss her pregnancy options and terminate her pregnancy if she chooses. No special location is required. No special time to schedule a procedure is necessary. Medical abortion thus offers a woman and her physician more control over her decision and moves discourse about the procedure more out of public view. The patient’s support network can easily be excluded if she wishes. The physician will more often be left managing a “family secret” in addition to an undesired pregnancy. Managing such secrets will further complicate primary care practice.[5]

Nevertheless, the distinct advantages of medical abortion over surgical abortion as a primary care procedure will lead most family physicians to consider whether to offer this procedure. Many family physicians who have been daunted by barriers imposed by surgical abortion will make the decision to offer medical abortion to patients, undoubtedly after significant soul searching. Others will decide to not provide medical abortion in their practice. Family physicians will also decide whether to assist patients who are suffering the adverse effects (both physical and psychological) of medical abortion, although most family physicians presumably have already faced this issue with respect to surgical abortion and will extend the medical care provided in their practice into this new realm.

The question of how to interact with colleagues who are making a different choice is important. Family physicians absolutely opposed to abortion view abortion of any type as the taking of human life. How then does a family physician absolutely opposed to abortion interact with a colleague who decides to offer medical abortion?

Because few family physicians have performed abortions, different views toward abortion within the same practice have been manifested by the nature of counsel offered around the issue of abortion and in referral patterns for patients considering abortion. A patient made her choice and, if she chose termination, terminated her pregnancy outside the immediate realm of her family physician’s office. A family physician’s support for abortion was ultimately manifested by events that occurred outside the physician’s office. Family physicians opposed to abortion might continue to practice with colleagues supportive of abortion based on one or several of the following rationales: (1) The colleague is only recommending or facilitating abortion, not performing it. The patient still is able to choose on leaving the office. (2) Patients who would otherwise pursue abortion without first considering alternatives may hear those alternatives, because the practice includes physicians who oppose abortions as well as those who do not. (3) Colleagues may be persuaded to become less supportive of abortion. Now, on the other hand, abortion or the definitive event leading to it can occur routinely in the physician’s office. This is an untenable position for a family physician absolutely opposed to abortion, who may have been able to coexist with different opinions but cannot coexist with different practices. Having a dialogue about taking human life may be upsetting, but being potentially present when human life is being taken is a call for definitive action for some practitioners.

Although the right to conscientious refusal to assist with abortion has been discussed,(6) there has yet been no dialogue among physicians about how to deal with the refusal to “coexist” with abortion. How each physician, either alone or in a group practice, answers this question has profound implications for the practice of family medicine. (Other staff working in outpatient family practices will face similar questions.) Practices may eventually sort into “medical abortion” and “no medical abortion” groups. The introduction of a very private procedure into family practice may paradoxically force physicians to publically declare their support or disdain for it. Thus, while the patient will have less motivation than before to discuss her choice with her family, counselors and friends, physicians may be compelled to enter into a potentially divisive dialogue that might undermine their collegial relationships.

The development of practice policies or clinical guidelines has recently met with great popularity in many countries.(1)(2)(3)(4) National consensus development, modeled after the original National Institutes of Health procedure, can be seen in Canada, Scandinavian countries, France, the United Kingdom, the Netherlands, and elsewhere. A more recent initiative is the clinical guideline development by the Agency for Health Care Policy and Research (AHCPR) in the United States.(5) Guidelines are also developed on a large scale by professional bodies and by regional or local groups of care providers and other organizations.(2) Guideline setting is now considered by most policymakers and professional organizations of care providers to be a priority, and essential for the improvement of the quality and efficiency in health care.

A crucial question in this development is: how effective are all these different approaches for setting guidelines? This paper outlines a method for national guideline development for family practice in the Netherlands and provides a comparison of this method with that of the AHCPR in the United States.(6)(7)(8)(9) In the Netherlands, national guidelines for family practice care have been developed and disseminated in a rigorous, structured manner since 1987.(10)(11)(12) More than 45 of these guidelines covering a wide range of topics have been disseminated among more than 80% of all Dutch family physicians. Using a systematic updating program, which was started in 1991, eight to ten new topics are addressed each year. The guidelines are developed by the Dutch College of General Practitioners (NHG), the scientific organization of family physicians, while the National Association of Family Physicians (LHV, the “union”) is responsible for their implementation. A large majority of the almost 7000 practicing family physicians are members of these professional bodies.

This guideline initiative has been quite successful because it is initiated and “owned” by the family physicians themselves. It is also linked to the specific role of the family physician in the Dutch health care system: being the gatekeeper for specialist care, providing long-term, continuous care to patients, and treating patients for minor as well as chronic problems. In addition, guideline development is being adapted to the morbidity in primary care. Watchful waiting and the prevention of unnecessary or potentially harmful care, therefore, are important basic values for the guidelines. The emphasis in the model for Dutch guideline setting differs considerably from that of the AHCPR (Table), which has focused on expensive procedures, such as cataract surgery.

Table. Differences in Aims and Emphasis Between Guideline-Setting

Procedures of the Agency for Health Care Policy and Research (AHCPR) and the Dutch College of General Practitioners

AHCRP                                Dutch College
* Governmental initiative        * Initiative of professional
organization of family
physicians
* Mainly experts developing      * Experts and practitioners
guidelines                      developing guidelines
* Multidisciplinary, including   * Only family physicians
consumers
* Strong emphasis on evidence-   * Emphasis on mixture of
based, scientifically
justified                       scientific evidence and
guidelines                      feasibility in practice
* Development and
implementation                 * Implementation is part of
are separate processes          developmental process
* Patient/consumer preferences
on                             * Patient preferences not
outcomes taken into account     included
* Small range of topics           * Broad range of topics
* Development carried out by     * Development by and owned
independent scientific
institutions                    by family physicians
(contractors)
* Central aim: elimination of    * Central aim: supporting family
inappropriate, unnecessary,
and                             physicians in daily work and
inefficient care                strengthening family medicine
as an independent specialism

Guideline-Setting Procedures of the Dutch College of General

Practitioners

The 45 guidelines as developed by the Dutch College cover a wide range of problems and conditions seen in family practice, such as type II diabetes, sprained ankle, otitis media, dementia, and sleeping disorders. A guideline incorporates statements on adequate care, sometimes in the form of an algorithm, and supporting background materials. It is structured according to the steps involved in patient contacts (history, examinations, tests, evaluation, patient education, treatment, follow-up, referral), preceded by a clarification of terms and concepts. The aim of guideline development is to provide family physicians with a point of reference for their daily work and to provide a basis for continuing medical education and postgraduate training for family physicians.

Background. Previous analyses of published clinical trials have identified major deficiencies in reporting, design, analysis, and overall quality. The purpose of this study was to determine the strengths and weaknesses of published clinical trials in family practice, and to identify predictors of quality in these trials.

Methods. Randomized controlled clinical trials published in The Journal of Family Practice from 1974 to 1991 were eligible for the study. Two raters independently evaluated the adequacy and appropriateness of reporting, design, and analysis for each clinical trial, using the Chalmers index for assessing clinical trial quality. Multiple linear regression was used to determine the predictors of quality.

The 53 trials included in the study showed deficiencies in reporting, design, and analysis, although fundamental design issues, such as blinding, were a relative strength. On average, the trials scored 35% of the possible points on the scale. Three factors were positively associated with overall quality: year of publication, number of pages of the published report, and the type of intervention. Trials with pharmacologic and nonmedication therapy interventions, such as diet, had higher quality scores than did trials with psychosocial or educational interventions.

Conclusions. The overall quality of these clinical trials was less than optimal but comparable to previously analyzed groups of trials. The improvement in quality over time may be related to improvement in the quality of the trials themselves, or more exacting editorial standards, or a combination of the two.

Clinical trials; randomized controlled trials; meta-analysis; research design; quality of research. (J Fam Pract 1994; 39:225-235) Although many clinical trials are methodologically sound, even a casual review of published clinical trials reveals that many trials have not incorporated fundamental principles of clinical trial research. Analyses of clinical trials published in a wide variety of journals have identified large deficiencies in reporting, design, analysis, and overall quality.

These findings may not be generalizable to clinical trials in the family practice research literature for several reasons. First, to our knowledge, few if any of the previous analyses included trials from the family practice literature. Second, because family practice is a relatively new discipline, few clinical trials have been published in this specialty.Third, given the importance of psychosocial factors in family practice theory, the content of clinical trials in family practice may be different from that of other disciplines.

Several previous analyses of clinical trials also have attempted to identify predictors of overall quality. In a study of breast cancer trials, Liberati and colleagues showed that the quality could be predicted by the year the trial started and biostatistician involvement. In an analysis of clinical trials from a variety of disciplines, Emerson and colleagues showed that quality could be predicted by year of publication and clinical content. However, there are several important factors that may be related to quality that were not considered in either study. The type of intervention (eg, medication vs patient education), research training of the authors (eg, authors with PhD or MPH degrees), affiliation of the authors (university-based vs practice-based), and size of the research team (number of authors) all may be related to quality of the clinical trial. Since adequacy of reporting is one component of the quality of the published report, the number of pages also may be related to quality of the published report.

The purpose of this study was to answer the following three research questions:  What are the strengths and areas for improvement of published clinical trials in the discipline of family practice, as reflected by clinical trials published in The Journal of Family Practice? How do trials published in The Journal of Family Practice compare with those of other disciplines?  What are the predictors of quality?

To answer these questions, we performed a cross-sectional analysis of clinical trials published in The Journal of Family Practice, using a standard instrument, the Chalmers index,to assess trial quality. Although original research in family practice is published in a variety of medical journals, this study is limited to clinical trials in The Journal of Family Practice for two reasons. First, it is the primary journal for original research in the discipline. Faculty who seek or have been nominated for academic promotion(23)(24) are far more likely to publish in The Journal of Family Practice than in any other single journal. As noted in a 1989 review of articles published in family practice, “The Journal of Family Practice remains the principal repository of original work in the field.”(19) Second, if clinical trials from multiple family practice journals had been eligible for inclusion, it would have been impossible to disentangle the effect of year of publication from that of “start-up” difficulties for new journals.

Monday

Charles, a 70-year-old man, came in today for a routine follow-up visit for congestive heart failure (CHF). At age 45, he had an acute myocardial infarction and was treated in the standard manner of that day–rest, analgesia, nitrates, and anticoagulants. He made an uneventful recovery and returned to work. He continued to have moderate angina and was referred to a tertiary care medical center for evaluation. This occurred in the early days of coronary artery angiography and coronary artery bypass grafting (CABG). At that time, the primary indication for CABG was angina not controlled by medical treatment. When Charles was studied, he was found to have significant three-vessel coronary artery disease (CAD) and was not considered a candidate for CABG. His symptoms were fairly well controlled with beta blockers and nitrates, and he was later prescribed statin drugs for hyperlipidemia. Currently, he is active, works full time in his own business, is a happy gardener, and a doting grandfather. This example should remind us, in the current milieu of highly aggressive interventional cardiology, that medical therapy for CHF was, and can still be, an effective treatment in combination with surgical intervention or alone in many patients with CHF.

Tuesday
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RHS was both tricked and helped by his age and experience when asked to see a patient who had been vomiting about every 30 minutes since 5 a.m. this morning. An initial survey of the chart revealed a birth date of 07/23/00, which the long-time occupant of the 20th century perceived as 07/23/1900. Actually, the patient was 18 months old, with a 07/23/2000 birth date. The child vomited again as RHS entered the examination room. She was awake and alert but very still in her mother’s arms. The initial history and physical examination were unremarkable except for a placid, quiet, and unresisting child. The mother commented that her daughter’s behavior was uncharacteristic of previous visits to the physician. Because of his long experience, RHS was wary of the “quiet child.” So prompted, he completed a detailed history and physical examination and found no other abnormalities. This allowed him to diagnose nonspecific gastroenteritis and render positive assurance to the very anxious mother. Oral fluids and antiemetic suppositories, if needed, should result in an uneventful recovery in about 36 hours. Beware the “quiet child!”

Wednesday

Yesterday was PRP’s day off, and AMS was just finishing with a patient she was seeing for the first time, although the patient was well established with PRP and JDF. Ms. James said, “I’m going to tell you what I told them about you up front.” AMS looked inquisitively at Ms. James as she described her conversation with the front-office staff. She had asked to see one of her regular medical professionals. When told that AMS was the only one available, Ms. James said, “I don’t care to see that one. These two know me already. They’ve seen me when I’ve been at my best and at my worst. I’ve no interest in seeing someone who doesn’t understand me and isn’t going to listen to me.” She concluded, saying to AMS, “But you’ve been real nice.” AMS thanked Ms. James and was pleased to have made a good impression. It is important for every patient to feel comfortable with their health care professional and to have the choice of who they see. Of course, that is not always possible. AMS recommended that Ms. James come back tomorrow for a blood pressure recheck (it was markedly higher than usual). “Okay, but…” she paused. “That’s okay,” AMS replied, “PRP will be here tomorrow.”

Thursday

Valerie, an 80-year-old woman, was seen in the office today by RHS for a follow-up of multiple problems, including COPD, pulmonary hypertension, right ventricular hypertrophy with secondary ventricular dysrhythmias, atopic dermatitis, and type 2 diabetes. For RHS, this visit recalled a day some 30 years earlier when Valerie came to the office with a primary symptom of chest pain. The initial electrocardiogram (ECG) showed only minor T-wave changes. In the midst of making disposition decisions, RHS dashed to an urgent house call one block from the office. As he finished the house call, he received a “may-day” call to return to the office, where he found a nurse and an emergency medical technician performing cardiopulmonary resuscitation on Valerie, who was unresponsive. An ECG strip from our recently acquired monitor/defibrillator showed fine ventricular fibrillation. External direct-current shock was administered, and in a brief time normal sinus rhythm was restored. Valerie was responsive and alert. In the hospital, acute myocardial infarction was ruled out, and an uneventful recovery occurred. Postdischarge, she was closely followed on a regular basis. Other medical problems have developed but, as of today, no myocardial infarction has been diagnosed. Following patients over extended life spans is a magnificent learning experience.

Friday

JDF was taking care of some day-to-day tasks when she noted a coworker who seemed not to be feeling well. Heather, who is 29 years of age and in good health except for recent problems with sinus congestion and “sinus headache,” said that she had not “felt quite right” since taking the first dose of prednisone for the sinus problems. She was immediately checked by JDF. Her blood pressure (BP) was 160/110, and fasting glucose was 156. She had not taken any over-the-counter or prescription sympathomimetics, nor did she have a history of risk factors for hypertension or type 2 diabetes. It was decided that she had an adverse reaction to the steroid, and it was discontinued after the initial dose. Over the next several days, Heather’s BP was persistently elevated, and shortness of breath, headache, and chest pain ensued. A combination of beta blocker, calcium channel blocker, and diuretic was required to control her BP. Labs were all unremarkable. Today, ECG, stress cardiolyte, and renal ultrasound are pending. Her blood sugar has normalized, and her headache has resolved. However, she continues on multiple medications for unexplained hypertension. This situation reminds us that sometimes treatment of a straightforward problem with a common medication in an uncomplicated patient may not always be straightforward, common, or uncomplicated.

CALGARY — The declining number of medical students choosing family medicine in favor of other specialities is a cause of concern for health care planning: A study conducted at three medical schools in Calgary, Edmonton mad Vancouver attempts to show some of the influences that affect the students choices. The results of the study were reported in the Canadian Association of Medicine Journal, June 2004.

The study identifies several characteristics of those indicating family medicine as their career preferences at entry to medical school:

* they were concerned about medical lifestyle and to having lived in smaller communities at the time of completing high school;

* they were also less likely to be hospital oriented;

* they were much more likely to demonstrate a societal orientation and to desire a varied scope of practice.
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583 students completed the questionnaire. Only 20% of the respondents identified family medicine as their first career option, mad about half ranked family medicine in their top 3 choices.

The researchers suggest that “if the factors that Influence medical students to choose family medicine can be identified accurately, then it may be possible to use such a model to change medical school admission policies so that the number of students choosing to enter family medicine can be increased.

Family practice in the United States is under threat. Patient demand for direct access to specialists is growing, which reflects the population’s insatiable appetite for high-technology medicine and may also be indicative of a backlash against the gatekeeper model imposed by managed care. The hospitalist movement is further removing family physicians from the inpatient care setting. The number of advanced nurse practitioners and physicians’ assistants claiming to deliver primary medical care of equivalent quality to and lower cost than family physicians is also growing. Patients also have ready access to a broad army of health and medical care information services through the Internet, which may provide the opportunity for them to decide what kind of specialized medical care they need.

Many managed care organizations (MCOs) have instituted demand management programs that give patients direct access to telephone triage centers staffed by nurses 24 hours. MCOs have also instituted chronic disease management programs for managing patients with specific chronic diseases (diabetes, asthma, heart failure) in a more cost-effective manner, often “carving out” that part of their care away from the primary care physician.

There are more and more published studies that purport to show that the outcomes of care for patients with certain chronic diseases are better when provided by specialists compared with generalist physicians.[2] Wagner and colleagues[3] believe that improved outcomes of care by specialists are probably related to better-organized processes of care and not necessarily to superior specialist knowledge or expertise. They note that studies comparing usual generalist care with usual specialist care have found no differences in care outcomes.

Family physicians find that their level of reimbursement is decreasing, while the amount of regulation, paperwork, and office overhead is increasing. They have to see more patients in less time to maintain their incomes. Sometimes feeling like hamsters on a wheel, they are becoming more dissatisfied with their practice. This is not going unnoticed by medical students; the number of US medical school graduates matching in family practice residency programs has declined for 4 years in a row. Family practice as we know and practice it today is in peril.

Clinical Quiz questions are based on selected articles in this issue. Answers appear in this issue.

American Family Physician has been approved by the American Academy of Family Physicians as having educational content acceptable for Prescribed credit hours. Term of approval covers issues published within one year from the beginning distribution date of December 2001. This issue has been approved for up to 2 Prescribed credit hours. Credit may be claimed for one year from the date of this issue.

The American Academy of Family Physicians is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The AAFP designates this educational activity for a maximum of 2 hours in Category 1 credit toward the American Medical Association Physician’s Recognition Award. Each physician should claim only those hours of credit that he or she actually spent in the educational activity.

AAFP Credit

Each copy of AFP contains a Clinical Quiz answer card. AAFP members may use this card to obtain the designated number of Prescribed credit hours for the year in which the card is postmarked.

AMA/PRA Category 1 Credit

AAFP members who satisfy the Academy’s continuing medical education requirements are automatically eligible for the AMA/PRA.

Physicians who are not members of the AAFP are eligible to receive the designated number of credit hours in Category 1 of the AMA/PRA on completion and return of the Clinical Quiz answer card. AFP keeps a record of AMA/PRA Category 1 credit hours for nonmember physicians. This record will be provided on request; however, nonmembers are responsible for reporting their own Category 1 CME credits when applying for the AMA/PRA or other certificates or credentials.

For health care professionals who are not physicians and are AFP subscribers, a record of CME credit is kept by AAFP and will be provided to you on written request. You are responsible for reporting CME hours to your professional organization.

With more than 1000 new guidelines produced annually over the past decade, it is impossible for the practicing family physician to determine which ones should be adapted into their clinical practice. The Ontario Ministry of Health and Long-Term Care and the Ontario Medical Association formed the Guideline Advisory Committee (GAC) in 1997 to assess and disseminate guidelines that would improve the quality and utilization of health care services in the province. Over the past 3 years the GAC has developed a strategy to identify important topics, to rank guidelines published on these topics based on the quality of their development, and to reformat guidelines as necessary to make them user-friendly for implementation in clinical practice. The GAC is currently assessing a number of strategies to enhance the dissemination of selected guidelines to improve the quality of care delivered in the province.

A method of selecting, reviewing, and endorsing clinical practice guidelines has been established in the province of Ontario, Canada. Recommended guideline summaries are posted on a Web site with links to full text for easy access by practicing physicians (www.gacguidelines.ca).

Strategies for the successful implementation and impact evaluation of recommended guidelines are currently in development.

Clinical practice guidelines are statements that are systematically developed to assist physisican and patient decisions about appropriate health care for specific clinical circumstances. (1) Published guidelines have become widely available through Internet technology; it has been estimated that more than 2500 exist. Most are produced by specific interest groups (eg, national societies and pharmaceutical companies), disseminated by publication in a medical journal or traditional mail, and seldom demonstrate any effect on clinical practice. (2) Such a large volume of guidelines creates confusion for clinicians who often do not follow any of them because of the time required to assess their quality.

* OBJECTIVE Our goal was to compare the content of family practice in different countries using databases containing information on reasons for encounter, diagnoses, and interventions that are coded with or can be addressed by the International Classification of Primary Care (ICPC).

* STUDY DESIGN In the Netherlands, Japan, and Poland data were collected identically with an electronic patient record (Transhis). For all face-to-face encounters the reasons for encounter, diagnoses, and interventions were coded according to the ICPC within an episode of care structure; prescriptions were coded with the ICPC drug code. Data were collected for research purposes and cannot be considered representative for family practice in these countries. We derived comparable estimates for the United States using visit data from the National Ambulatory Care Survey (NAMCS), with specific emphasis on the contribution of family physicians. NAMCS data were mapped to the ICPC and the ICPC drag code, and Dutch, Polish, and Japanese data were directly standardized for the 1996 US population. Data on utilization, reasons for encounter, encounters per episode of care, new episodes of care, and prescriptions were compared. We also present World Health Organization and Organisation for Economic Co-operation and Development data on health care delivery, efficiency, expenditure, and health status for each country.

* POPULATION We included the following: from the Netherlands: 10 family physicians, 48.640 patient years, 1995-2000; from Japan: 6 family physicians, 17.082 patient years, 1996-1999; from Poland: 22 family physicians, 11.315 patient years, 1997-1999; and from the United States: NAMCS 1995-97, 30.991 patient years, 91395 visits (26% with a family physician).