Design: A qualitative study employing a participatory design approach, with an inductive analytical thematic approach utilising semi-structured interviews. Empirical data was analysed using the qualitative data analysis software (QDAS) Nvivo.
Setting: General practices in Denmark.
Subjects: Eight interviews were conducted with an average duration of 60?min. The interviewees were GPs from different geographical settings and different organisational structures, varying in age and professional interests.
Main outcome measures: Barriers and facilitators for future use of the HIT application for patients with LBP.
Results: Through the inclusion of healthcare professionals in the design process, this study found that in order for GPs to recommend a HIT application it is essential to target the application towards their patients. Furthermore, GPs required that the HIT application should support patient self-management. Additionally, the content of the HIT application should support the initiated treatment and it should be easy for GPs to recommend the HIT application. Finally, healthcare professionals need to be involved in the design process.
Conclusion: When designing health IT applications for patients with LBP in general practice it is important to include both patients and GPs in the design process. GPs would be more willing to recommend a HIT application that: applies content in line with frequently used recommendations; targets patients; supports patients’ self-management; and supports the patients’ needs.
- KEY POINTS
Online information is currently applied in general practice to some patients with low back pain
Online information cannot replace the GP, but can rather be a bonding tool between the patient and the GP
It is important to address both GP and patient barriers to applying new technology and to consider the literacy level
Participatory methods could play a central role in the future development of online information material
Design: A cross-sectional study.
Setting: Occupational health care in the region of Pori, Finland.
Subjects: 671 municipal employees (89% females) with a mean age of 49 (SD 10) years. Information about the study subjects was gathered from medical records, by physical examination and questionnaires containing information about physical and mental health, health behavior, work-related and sociodemographic factors. The number of sickness absence days was obtained from the records of the city of Pori.
Main outcome measures: The relationship of absenteeism rate with sociodemographic, health- and work-related risk factors.
Results: In the multivariate analysis, the mean number of chronic diseases (IRR 1.24, 95% CI 1.13 to 1.36), work ability (IRR 0.83, 95% CI 0.76 to 0.91), and length of years in education (IRR 0.90, 95% CI 0.85 to 0.95) remained as independent factors associated with absenteeism.
Conclusion: According to our results, chronic diseases, self-perceived work ability and length of years in education are the most important determinants of the rate of sickness absence. This implies that among working-aged people the treatment of chronic medical conditions is also worth prioritizing, not only to prevent complications, but also to avoid sickness absences.
- KEY POINTS
Various sociodemographic, health- and work- related risk factors have been shown to influence sickness absence.
The study aimed to find the most important determinants of absenteeism among several known risk factors in Finnish municipal employees.
Chronic diseases, self-perceived work ability and education years remained as the most important determinants of sickness absence rates.
Treatment of chronic medical conditions should be prioritized in order to reduce sickness absence rate.
Materials and methods: Semi-structured interviews with 15?line managers who have had employees on sick leave due to work-related stress. The grounded theory approach was employed.
Results: Even though managers may accept the overall concept of work-related stress, they focus on personality and individual circumstances when an employee is sick-listed due to work-related stress. The lack of a common understanding of stress creates room for this focus. Line managers experience cross-pressure, discrepancies between strategic and human-relationship perspectives and a lack of organizational support in the return to work process.
Conclusion: Organizations should aim to provide support for line managers. Research-based knowledge and guidelines on work-related stress and return to work process are essential, as is the involvement of coworkers. A commonly accepted definition of stress and a systematic risk assessment is also important. Cross-pressure on line managers should be minimized and room for adequate preventive actions should be provided as such an approach could support both the return to work process and the implementation of important interventions in the work environment.
- Implication for rehabilitation
Organizations should aim to provide support for line managers handling the return to work process.
Cross-pressure on line managers should be minimized and adequate preventive actions should be provided in relation to the return to work process.
Research-based knowledge and guidelines on work-related stress and return to work are essential.
A common and formal definition of stress should be emphasized in the workplace.
Objective: The aim of this study was to translate and adapt the scale and to test the translated version for comprehension and suitability in Danish general practice setting.
Design and method: The process involved forward translation, backward translation, and field tests. The field tests included cognitive debriefing interviews. In all 30 general practitioners and 5 non-general practitioners participated in the process of translation. After using the scale among 1652 general practitioners statistical analysis was carried out to test internal consistency.
Setting: The study was carried out in general practice in Denmark.
Results: Several changes made during the process in order to achieve a Danish version that is acceptable, understandable and still capable of measuring medical engagement comparable of the original English version. Analysis of scale internal consistency using Cronbach’s alpha revealed acceptable reliability for all three meta-scales, which ranged from 0.69 to 0.81. The overall tool achieved a Cronbach’s alpha of 0.89.
Conclusion: The Danish version of the Medical Engagement Scale is a valid and reliable tool that is acceptable and relevant for general practice in Denmark.
- Key points
This study describes the cross-cultural adaptation of the Medical Engagement Scale from a UK primary healthcare setting to a Danish primary healthcare setting.
The process produced a relevant and acceptable questionnaire measuring medical engagement.
Internal consistency revealed acceptable reliability
The translation of the scale provides the possibility to use this scale for practical and academic purposes.
Design: Comparative intervention study.
Setting: OOH services in two major Danish healthcare regions.
Intervention: Giving callers the option to bypass the telephone waiting line by introducing an EAB.
Participants: OOH service callers contacting during end of October to mid-December 2017.
Main outcome measures: Proportions of EAB use, waiting time and background information on participants in two settings differing on organisation structure, waiting time and triage personnel.
Results: In total, 97,791 out of 158,784 callers (61.6%) chose to participate. The EAB was used 2905 times out of 97,791 (2.97%, 95%CI 2.86; 3.08). Patient characteristics associated with increased EAB use were male gender, higher age, low education, being retired, and increasing announced estimated waiting time. In one region, immigrants used the EAB more often than native Danish callers.
Conclusion: Only about 3% of all callers chose to bypass the waiting line in the OOH service when given the option. This study suggests that the EAB could serve as a new and simple tool to reduce the waiting time for severely ill patients in an OOH service telephone triage setting.
- Key Points
Acute out-of-hours healthcare is challenged by overcrowding and increasing demand for services.
This study shows that only approximately 3% of callers chose to bypass the telephone waiting queue when given the opportunity through an emergency access button.
An emergency access button may serve as a new tool to help reduce the triage waiting time for severely ill patients in out-of-hours medical facilities.
Design: Qualitative and semi-structured interviews.
Setting: Australian burn and rehabilitation units.
Participants: Twenty-two clinicians working in burns units across disciplines and healthcare settings.
Results: The data portrayed the health professionals’ perspectives of burn care and rehabilitation in Australia. Three themes were identified: (1) interprofessional collaboration; (2) integrated community care, and (3) empowering patients to self-care.
Conclusion: Burn care and rehabilitation remains a complex and a challenging area of care with limited access to burn services especially in rural and remote areas. Interprofessional training and education of health professionals involved with the complex care of burn injury remains a key element to support and sustain the long-term rehabilitation requirements for patients and their families. Empowering patients to develop independence early in their rehabilitation is fundamental to their ongoing recovery. A burns model of care that embraces a multidisciplinary collaboration and integrated care across the continuum has the potential to positively impact recovery and improve health outcomes.
- Implications for rehabilitation
Burn care and rehabilitation remains a complex and challenging area of care.
Managing the rehabilitation phase after burn injury can be as complex as managing the acute phase.
Interprofessional collaboration, integrated community care, and empowering patients to self-care are key elements for sustaining the rehabilitation of adults with burn injuries.
Design: A prospective cohort study.
Setting: The cardiac ward at Aarhus University Hospital, Denmark.
Intervention: A socially differentiated CR intervention in addition to the standard CR program.
Subjects: Patients admitted with first-episode myocardial infarction between 2000 and 2004, N?=?379. Patients were defined as socially vulnerable or non-socially vulnerable according to their educational level and extent of social network.
Main outcome measures: Primary outcome was medication adherence to antithrombotics, beta-blockers, statins and angiotensin-converting enzyme inhibitors. Secondary outcomes were biological and lifestyle risk factors defined as; total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, glycated hemoglobin, blood pressure and smoking status.
Results: No significant long-term effect of the intervention was found.
Conclusions: The results indicate a non-significant effect of the intervention. However, it was found that equality in health was improved in the study population except concerning smoking. General practitioners manage to support the long-term secondary cardiovascular disease prevention in all patients regardless of social status.
- Key points
The socially differentiated intervention did not significantly improve medication adherence or biological and lifestyle risk factors.
Despite the non-significant effect of the intervention, equality in health was improved except concerning smoking.
General practitioners managed to support the long-term secondary cardiovascular disease prevention in all patients regardless of social status.
Methods: A motor skill training intervention was implemented to modify the altered alignment and movement patterns he used during the performance of his painful and limited activities.
Results: The patient was seen for six visits in 12 weeks. The patient reported decreased pain and medication use, as well as improved function immediately, 3-, and 9-months post-intervention.
Conclusion: Individuals with low back pain report limitation in ability to perform everyday functions and demonstrate altered patterns of movement and alignment during these activities. This case report describes an innovative motor skill training intervention that directly addresses the performance of functional activities and the application of motor learning principles.
- Implications for rehabilitation
Low back pain is a chronic condition that limits function.
The chief reason individuals with chronic low back pain seek care is difficulty performing everyday functional activities.
Motor skill training is a novel approach that directly addresses the performance of painful and limited functional activities through challenging practice to improve performance and decrease pain.
Design: General practitioners (GPs) handed out the MDI to patients aged 18–65 years on clinical suspicion of depression.
Setting: Thirty-seven general practices in the Central Denmark Region participated in the study.
Patients: Data for 363 patients (65% females, mean age: 49.8 years, SD: 17.7) consulting their GP were included in the analysis.
Main outcome measures: The overall fit to the Rasch model, individual item and person fit, and adequacy of response categories were tested. Statistical tests for local dependency, unidimensionality, differential item functioning, and correct targeting of the scale were performed. The person separation reliability index was calculated. All analyses were performed using RUMM2030 software.
Results: Items 9 and 10 demonstrated misfit to the Rasch model, and all items demonstrated disordered response categories. After modifying the original six-point to a five-point scoring system, ordered response categories were achieved for all 10 items. The MDI items seemed well targeted to the population approached. Model fit was also achieved for core symptoms of depression (items 1–3) and after dichotomization of items according to diagnostic procedure.
Conclusion: Despite some minor problems with its measurement structure, the MDI seems to be a valid instrument for identification of depression among adults in primary care. The results support screening for depression based on core symptoms and dichotomization of items according to diagnostic procedure.
- Key points
The Major Depression Inventory (MDI) is widely used for screening, diagnosis and monitoring of depression in general practice.
This study demonstrates misfit of items 9 and 10 to the Rasch model and a need to modify the scoring system
The findings support screening for depression based on core symptoms and dichotomization of items according to diagnostic procedure.
Minor problems with measurement structure should be addressed in future revisions of the MDI.
Design: The Dutch KERNset tool was translated into Danish and supplemented with items from other existing tools. Face validity, content validity and applicability in OOH telephone triage (OOH-TT) were secured through a two-round Delphi process involving relevant stakeholders. Forty-eight OOH patient contacts were assessed by 24 assessors in test-retest and inter-rater designs.
Setting: OOH-TT services in Denmark conducted by GPs, nurses or doctors with varying medical specialisation.
Patients: Audio-recorded OOH patient contacts.
Main outcome measures: Test-retest and inter-rater reliability were analysed using ICCagreement, Fleiss’ kappa and percent agreement.
Results: Major adaptations during the Delphi process were made. The 24-item assessment tool (Assessment of Quality in Telephone Triage – AQTT) measured communicative quality, health-related quality and four overall quality aspects. The test-retest ICCagreement reliability was good for the overall quality of communication (0.85), health-related quality (0.83), patient safety (0.81) and efficiency (0.77) and satisfactory when assessing specific aspects. Inter-rater reliability revealed reduced reliability in ICCagreement and in Fleiss’ kappa. Percent agreement revealed satisfactory agreements when differentiating between ‘poor’ and ‘sufficient’ quality).
Conclusion: The AQTT demonstrated high face, content and construct validity, satisfactory test-retest reliability, reduced inter-rater reliability, but satisfactory percent agreement when differentiating between ‘poor’ and ‘sufficient’ quality. The AQTT was found feasible and clinically relevant for assessing the quality of GP- and nurse-led OOH-TT.
- KEYPOINTS
Comparative knowledge is sparse regarding quality of out-of-hours telephone triage conducted by general practitioners and nurses.
The assessment tool (AQTT) enables assessment of quality in OOH telephone triage conducted by nurses and general practitioners
AQTT is feasible and clinically relevant for assessment of communication, patient safety and efficiency.
AQTT can be used to identify areas for improvement in telephone triage
Design: Nationwide population-based, cross-sectional survey. Data was collected in 2012.
Setting: The general Danish population.
Subjects: A total of 48,910 randomly selected men aged 20+.
Main Outcome Measures: (1) Odds ratios for reporting LUTS by lifestyle and SES, and (2) Odds ratios for GP contact with bothersome LUTS by lifestyle and SES.
Results: 23,240 men participated (49.8%). Nocturia was the most commonly experienced LUTS (49.8%). Incontinence was most often reported as bothersome (64.1%) and nocturia less often reported as bothersome (34.2%). Only about one third of the men reporting a bothersome LUTS contacted their GP. Odds for reporting LUTS significantly increased with increasing age, obesity, and lack of labor market affiliation. Increasing age and symptom burden significantly increased the odds for GP contact regarding bothersome LUTS. No overall associations were found between lifestyle, SES, and GP contact.
Conclusion: Bothersome LUTS are common among Danish men. Concern and influence of LUTS on daily activities are important determinants of GP contact, yet only one in three bothersome LUTS are discussed with a GP. Advanced age and symptom burden were significantly associated with GP contact.
Implications: Information on treatment options for LUTS might be desirable among Danish men regardless of SES and lifestyle.
- Key points
Urological symptoms are common among men in the Danish population and are often managed without contacting healthcare professionals.
Increasing age and symptom burden significantly increase the likelihood of consulting a general practitioner regarding bothersome urological symptoms
Healthcare-seeking behavior with bothersome urological symptoms is not influenced by lifestyle or socioeconomic status among Danish men;
Information about available, effective treatment options for urological symptoms might be desirable among men regardless of socioeconomic status and lifestyle
Design and setting: A cross-sectional study based on a structured telephone interview and an online questionnaire. Participants were recruited by social media and by the Norwegian patient’s organization for HG.
Subjects: Norwegian women that experienced HG.
Main outcome measure: Women’s perspectives on management and consequences of HG.
Results: The study included 107 women. Maternal morbidity was profound; about 3/4 of participants were hospitalized due to HG, and the majority showed clinical signs of dehydration (79%), ketonuria (75%), and >5% weight loss (84%). Antiemetics were used by >90% and frequently prescribed “as needed”. Metoclopramide (71%) and meclozine (51%) were most commonly used. Participants described HG as having severe psychosocial consequences and profound impact on daily activities. Almost two out of five reported thoughts of elective abortion, and 8 women had at least one elective pregnancy termination due to HG. Overall, 20 women (19%) changed GPs due to dissatisfaction with HG management.
Conclusion: Despite the high psychosocial burden and major impact on daily activities, many women with HG reported a lack of support from healthcare professionals and suboptimal management. Greater awareness and knowledge among healthcare professionals is needed to improve care for women with HG.
- Key Points
There is a paucity of studies on management and the consequences of HG on women’s daily lives and psychosocial burden. We found that:
??Many women described HG as one of their worst life experiences with profound morbidity.
??Many women reported suboptimal management of HG and lack of support from healthcare professionals.
??Greater understanding of patient perspectives among healthcare professionals is important to improve care and management for HG patients.
Design: General practitioners (GPs) handed out the MDI to patients aged 18–65 years on clinical suspicion of depression.
Setting: Thirty-seven general practices in the Central Denmark Region participated in the study.
Patients: Data for 363 patients (65% females, mean age: 49.8 years, SD: 17.7) consulting their GP were included in the analysis.
Main outcome measures: The overall fit to the Rasch model, individual item and person fit, and adequacy of response categories were tested. Statistical tests for local dependency, unidimensionality, differential item functioning, and correct targeting of the scale were performed. The person separation reliability index was calculated. All analyses were performed using RUMM2030 software.
Results: Items 9 and 10 demonstrated misfit to the Rasch model, and all items demonstrated disordered response categories. After modifying the original six-point to a five-point scoring system, ordered response categories were achieved for all 10 items. The MDI items seemed well targeted to the population approached. Model fit was also achieved for core symptoms of depression (items 1–3) and after dichotomization of items according to diagnostic procedure.
Conclusion: Despite some minor problems with its measurement structure, the MDI seems to be a valid instrument for identification of depression among adults in primary care. The results support screening for depression based on core symptoms and dichotomization of items according to diagnostic procedure.
- Key points
The Major Depression Inventory (MDI) is widely used for screening, diagnosis and monitoring of depression in general practice.
This study demonstrates misfit of items 9 and 10 to the Rasch model and a need to modify the scoring system
The findings support screening for depression based on core symptoms and dichotomization of items according to diagnostic procedure.
Minor problems with measurement structure should be addressed in future revisions of the MDI.
Design: Prospective diagnostic study using paired samples.
Setting/Intervention: Three general practices in Copenhagen. Each woman delivered FVU and MSU samples from the same void. As a reference standard, 8?ml of MSU was sent for culture at the Microbiology Department.
Patients: 117 women with one or more symptoms of UTI.
Main outcome measures: Sensitivity, specificity and agreement with the reference standard of FVU and MSU with different time delays (zero vs. one vs. four hours) as compared to reference standard (MSU at time zero in boric acid tubes).
Results: All three POC tests performed on MSU were significantly more in agreement with the reference than when performed on FVU when analysis was done immediately. The error rate was 16% for MSU vs. 23% for FVU with POC culture, 27% vs. 40% with microscopy and 25% vs. 33% with dipstick testing. Delay of analysis up to four hours did not decrease agreement with the reference.
Conclusion/Implication: MSU samples should be used in general practice for optimal accuracy of POC tests. Analysis can be delayed up to four hours.
- Key points
Point-of-care tests (dipstick testing, microscopy and culture) for diagnosing urinary tract infection performed on mid-stream urine samples are significantly more accurate than when performed on first-void urine samples.
Delay of analysis up to four hours did not decrease the accuracy of any of the point-of-care tests.
Point-of-care culture was more accurate than dipstick and microscopy both when performed on mid-stream urine and first-void urine
The main contaminant in first-void urine samples was Enterococci spp., which contributed to the majority of false positives.
Purpose: Review of the literature on joint hypermobility and EDS hypermobility-type concerning psychological factors linked to pain chronicity and disability.
Methods: A comprehensive search was performed using scientific online databases and references lists, encompassing publications reporting quantitative and qualitative research as well as unpublished literature.
Results: Despite scarce research, psychological factors associated with EDS hypermobility-type that potentially affect pain chronicity and disability were identified. These are cognitive problems and attention to body sensations, negative emotions, and unhealthy patterns of activity (hypo/hyperactivity).
Conclusions: As in other chronic pain conditions, these aspects should be more explored in EDS hypermobility-type, and integrated into chronic pain prevention and management programs.
- Implications for Rehabilitation
Clinicians should be aware that joint hypermobility may be associated with other health problems, and in its presence suspect a heritable disorder of connective tissue such as the Ehlers–Danlos syndrome (EDS) hypermobility-type, in which chronic pain is one of the most frequent and invalidating symptoms.
It is necessary to explore the psychosocial functioning of patients as part of the overall chronic pain management in the EDS hypermobility-type, especially when they do not respond to biomedical approaches as psychological factors may be operating against rehabilitation.
Further research on the psychological factors linked to pain chronicity and disability in the EDS hypermobility-type is needed.
Materials and methods: We analyzed a population-based cohort of 397 pregnant women with spina bifida and 1,083,211 without spina bifida who delivered infants in hospitals in Quebec, Canada, 1989-2013. Outcomes included maternal and infant morbidity and mortality at delivery. We used log-binomial regression models to estimate prevalence ratios (PR) and 95% confidence intervals (CI) for the association of maternal spina bifida with pregnancy outcomes, accounting for maternal characteristics.
Results: Women with spina bifida had a higher prevalence of several adverse outcomes compared with women who had no birth defects. Maternal risks were highest for intensive care unit admission during the delivery hospitalization (PR 3.41, CI 95% 1.56–7.43) and respiratory morbidity (PR 9.46, CI 95% 3.31–26.99). Infant risks were greatest for intracranial hemorrhage (PR 6.85, CI 95% 2.23–21.08), birth hypoxia (PR 1.64, CI 95% 1.21–2.22), and hospital length of stay?≥14 days (PR 2.56, CI 95% 1.58–4.15). After adjustment for confounders, maternal spina bifida was associated with risk of oral clefts and abdominal wall defects in infants.
Conclusions: Women with spina bifida have an increased risk of severe maternal and infant complications at delivery, compared with no spina bifida.
- Implications for Rehabilitation
A growing number of women with spina bifida achieve pregnancy, but pregnancy outcomes are poorly understood.
In a large pregnancy cohort, women with spina bifida had a high risk of severe maternal and infant morbidity at delivery.
Women with spina bifida may benefit from enhanced periconceptional counseling and obstetric monitoring by health professionals.
Guidelines should be developed for rehabilitation care providers to improve the obstetric management of women with spina bifida.
Design: A self-report survey of parents in a primary health care setting and a hospital setting was used to evaluate the use of the BCAP.
Setting: The study population consisted of parents who were visiting one of the following contexts: a primary maternity health care clinic, a child health care clinic, and the maternity outpatient clinic, various pediatric outpatient clinics, the general pediatric ward, the pediatric surgical ward, or the neonatal intensive care unit in a hospital setting.
Subjects: The BCAP was given to parents at the 30–34th week of pregnancy, when the child was 5 months old or all parents depending on the context. The BCAP was delivered to 759 parents. The final size of the sample was 453 respondents.
Main outcome measure: The BCAP, which consisted of 25 items to screen child abuse potential and nine items for evaluation of respondent validity.
Results: The internal consistency of the Abuse Risk Scale was good (.770), and the validity scales worked well. The factor structure mirrors with the original factors structure.
Conclusion: The psychometric properties of the BCAP reported in the analysis suggest that the BCAP could be a valid instrument to detect child abuse potential in the general population in Finnish health care settings. However, among Finnish respondents there is very little variation in some parts of the measure, which suggests that further research should assess the validity of the instrument in representative samples. Further analysis is also needed to evaluate the correct classification rate of the BCAP.
- Key points
Identification of families at risk of child maltreatment requires valid tools to recognize risk within the general population, as part of child and family needs and risk assessments in family services.
1. The BCAP is valid, reliable, and useful in bringing parental worries under discussion in child and family services.
2. Results of this study can be used for a more systematic and valid child maltreatment risk assessment for identifying families who need help managing their everyday lives.
Design: A self-report survey of parents in a primary health care setting and a hospital setting was used to evaluate the use of the BCAP.
Setting: The study population consisted of parents who were visiting one of the following contexts: a primary maternity health care clinic, a child health care clinic, and the maternity outpatient clinic, various pediatric outpatient clinics, the general pediatric ward, the pediatric surgical ward, or the neonatal intensive care unit in a hospital setting.
Subjects: The BCAP was given to parents at the 30–34th week of pregnancy, when the child was 5 months old or all parents depending on the context. The BCAP was delivered to 759 parents. The final size of the sample was 453 respondents.
Main outcome measure: The BCAP, which consisted of 25 items to screen child abuse potential and nine items for evaluation of respondent validity.
Results: The internal consistency of the Abuse Risk Scale was good (.770), and the validity scales worked well. The factor structure mirrors with the original factors structure.
Conclusion: The psychometric properties of the BCAP reported in the analysis suggest that the BCAP could be a valid instrument to detect child abuse potential in the general population in Finnish health care settings. However, among Finnish respondents there is very little variation in some parts of the measure, which suggests that further research should assess the validity of the instrument in representative samples. Further analysis is also needed to evaluate the correct classification rate of the BCAP.
- Key points
Identification of families at risk of child maltreatment requires valid tools to recognize risk within the general population, as part of child and family needs and risk assessments in family services.
The BCAP is valid, reliable, and useful in bringing parental worries under discussion in child and family services.
Results of this study can be used for a more systematic and valid child maltreatment risk assessment for identifying families who need help managing their everyday lives.