Nov - Dez - English

osé

BPS

610

ssoc

ras

2014; 60(6):599-612

increase in the diagnosis of asthma, 14% increase in COPD

and 63% increase in other diseases.

Broekhuizen et al.

assessed patients aged over 50

with persistent cough lasting more than 14 days without

a previous diagnosis of asthma or COPD. After evalua-

ting the lung function tests and discussing the clinical

data in a panel formed by two physicians, it was conclu-

ded that 29% of patients had a diagnosis of COPD, 7%

had asthma and 4% an overlapping condition. It should

be reiterated that these diagnoses were new, that is, the-

re was no previous diagnosis made by assistant general

practitioners (Table 1).

iscussion

This comprehensive literature review found that despite

the methodological heterogeneity of the studies encoun-

tered, the accuracy of acute and chronic respiratory di-

sease diagnoses elaborated by general practitioners in pri-

mary health care is low.

Even those approaching the conditions separately

presented different methodological delineations and as-

pects, which hindered the interpretation and elaboration

of definitive conclusions. As an example, the imprecision

of the asthma diagnosis varied from 54% underdiagno-

sis to 34% overdiagnosis,

32,20

while for COPD there was

81% underdiagnosis up to 86.1% overdiagnosis.

23,34

This

heterogeneity may have occurred, at least in part, becau-

se the studies were not randomized, due to the diversifi-

cation in sampling and definitions of each disease, and

the variables considered in the populations analyzed.

In relation to ARI, the use of auxiliary diagnostic

exams almost always resulted in improved diagnostic ac-

curacy and consequent decrease in the prescription of an-

tibiotics.

12,14

In relation to tuberculosis, the better results from

specialists over those from general practitioners in pri-

mary care seem obvious and natural, but as it is a condi-

tion of interest to national and international public health,

a better performance was expected from general practi-

tioners.

The studies encountered prove the low level of

knowledge about tuberculosis by general practitioners

working in primary care.

18,19

Underdiagnosis and thus under-treatment may pre-

sent a significant impact on the increased morbidity and

mortality of respiratory diseases.

40,41

Similarly, overdiag-

nosis may lead to increased costs and possible collateral

effects related to unnecessary treatment.

The literature reviewed places the general practitioner

as the key player in the context of mistaken diagnosis, whe-

ther through lack or excess. In both cases, the degree of lia-

bility of accidents for the mistakes cannot be determined.

It is also difficult to determine on what proportion it can

be defined as systematic errors relating to difficulties ac-

cessing exams, or cognitive errors by general practitioners

- errors owing to interpretation of signs and symptoms

when the patient presents them. In other words, some au-

thors interrogate if under diagnosis is due to the inappro-

priate interpretation of symptoms by the physician or the

patients’ failure to express their symptoms to the doctor.

42-45

Another point to consider is that the slow and pro-

gressive nature of diseases such as asthma and COPD

seems to lead to a decreased perception of their manifes-

tations. Cough and reduced tolerance to exercise may be

seen as normal phenomena in certain age ranges. As a re-

sult, patients do not seek general practitioners and in an

eventual appointment may fail to report such symptoms

to their physician.

For around 50 years it was thought impossible for

blood pressure to be measure by nurses or nursing tech-

nicians. Nowadays the importance of these professionals

in official blood pressure control programs is recognized.

Thus, a multi-professional strategy in the detection of

high prevalence diseases should be implemented as op-

posed to focusing solely on experts, a common approach

at present.

For example, the incorporation of simple

questions in the routine of health professionals, such

as “Do you smoke? Do you want to stop smoking?”, as

part of a program could significantly increase the diag-

nosis of COPD and the effectiveness of programs for smo-

king cessation.

The common sense that the context of PHC is less com-

plex than those with medium to high complexity seems

incorrect. PHC has the most extensive clinical practice and

is where interventions of high complexity should be un-

dertaken, such as those relating to changes in behavior and

lifestyles in relation to health, including stopping smoking,

adopting healthy eating behaviors and physical activity,

among others. The secondary and tertiary levels of care in-

clude practices with higher technological density, but not

necessarily higher complexity. This distorted view of com-

plexity, whether singular or systematic, leads politicians,

managers, health professionals and the population as a

whole, to overvalue the practices that are carried out at the

secondary and tertiary levels of health care and, consequen-

tly, to a trivialization of PHC.

In the cases of the most prevalent diseases and tho-

se of major interest in the management of public health,

it is expected that PHC physicians should obtain high de-

tection rates, or at least higher levels of sensitivity, consi-

dering the fact that they provide front line medical atten-