GPs’ experiences with enhanced collaboration between psychiatry and general practice for children with ADHD

Background: Most general practitioners (GPs) do not feel comfortable with diagnosing and treating children with attention deficit hyperactivity disorder (ADHD). This is problematic since ADHD is a prevalent disorder and an active role of GPs is desired. In the Netherlands a collaborative ADHD programme was established, comprising of shortened diagnostic assessment in specialized mental healthcare followed by psycho-education in mental healthcare and pharmacological treatment by pre-trained GPs.

Objectives: To explore the experiences of GPs regarding the diagnosis and treatment of children with uncomplicated ADHD within this programme.

Methods: Semi-structured interviews with 15 GPs were conducted. The GPs participated in an evaluation of the collaborative ADHD programme. Data was analysed using the principles of constant comparative analysis.

Results: Most participating GPs expressed reluctance to diagnose ADHD themselves. The reluctance was due to a lack of time, knowledge and experience. The GPs welcomed the collaborative programme because it met their need for both quick and adequate diagnosis by a specialist. Furthermore, an online ADHD course, offered by the programme, gave them the confidence to start and monitor ADHD medication. Finally, they appreciated the possibility of consulting a specialist when necessary.

Conclusion: GPs preferred that ADHD was diagnosed by a specialist. In the context of the ADHD collaborative programme, they felt competent and comfortable to start and monitor medication in children with uncomplicated ADHD.

• Key Messages

• Within a collaborative ADHD programme for children, participating GPs were positive about a quick and specialist diagnostic process within secondary care.

• After an online course, GPs felt confident to start and monitor ADHD medication in children with uncomplicated ADHD.

• GPs were content about the collaboration between primary and secondary care.

     

Perceived needs for attaining a ‘new normality’ after surviving myocardial infarction: A qualitative study of patients’ experience

Background: A comprehensive understanding of the various aspects of patients’ myocardial infarction (MI) experiences may help to guide these patients and their relatives through the many uncertainties they face and help them to stabilize their lives after the disruption they experienced.

Objectives: To explore MI patients’ experiences of life with MI, the challenges they face during the process of accepting their condition, and the setting and resetting of their personal goals.

Methods: Thirty semi-structured, individual interviews were conducted. The grounded theory method was used, and Atlas.ti qualitative data analysis software was used to facilitate the analysis.

Results: Three main themes and explanatory models emerged from the data analysis: a good adaptation – the ‘new normality;’ maladjustment – a continuous search for a ‘new normality;’ and perceived needs in the search for a new normality. Patients perceived several areas of need that they felt must be met before they could reach the state of a new normality. These needs included overcoming the anxiety of a possible MI recurrence; acquiring knowledge about MI in general and about ‘my MI’ in particular; the need for a timeline; for patience and steadiness; for both objective and subjective health status improvement; for taking control over the disease; and living within a supportive context.

Conclusion: When faced with a dramatic life event, most patients succeed in achieving a new normality in which they live changed but still satisfying lives. The needs experienced by patients when searching for a new normality may guide practitioners in leading patient-centred consultations.

KEY MESSAGES

• Most MI patients achieve a new normality.

• My physical identity is new: my body is different but still functional.

• My personal identity is new: I am not the same as before, the disease is part of me, but I retain parts of my previous self.

     

How do general practitioners recognize the definition of multimorbidity? A European qualitative study

Background: Multimorbidity is a challenging concept for general practice. An EGPRN working group has published a comprehensive definition of the concept of multimorbidity. As multimorbidity could be a way to explore complexity in general practice, it was of importance to explore whether European general practitioners (GPs) recognize this concept and whether they would change it.

Objectives: To investigate whether European GPs recognize the EGPRN concept of multimorbidity and whether they would change it.

Methods: Focus group meetings and semi-structured interviews as data collection techniques with a purposive sample of practicing GPs from every country. Data collection continued until saturation was reached in every country. The analysis was undertaken using a grounded theory based method. In each national team, four independent researchers, working blind and pooling data, carried out the analysis. To ensure the internationalization of the data, an international team of 10 researchers pooled the axial and selective coding of all national teams to check the concept and highlight emerging themes.

Results: The maximal variation and saturation of the sample were reached in all countries with 211 selected GPs. The EGPRN definition was recognized in all countries. Two additional ideas emerged, the use of Wonca’s core competencies of general practice, and the dynamics of the doctor–patient relationship for detecting and managing multimorbidity and patient’s complexity.

Conclusion: European GPs recognized and enhanced the EGPRN concept of multimorbidity. These results open new perspectives regarding the management of complexity using the concept of multimorbidity in general practice.

Key Messages

• European general practitioners recognize the EGPRN enhanced, comprehensive concept of multimorbidity.

• They add the use of Wonca’s core competencies and the patient–doctor relationship dynamics for detecting and managing multimorbidity.

• The EGPRN concept of multimorbidity leads to new perspectives for the management of complexity.

     

Mentor mother support for mothers experiencing intimate partner violence in family practice: A qualitative study of three different perspectives on the facilitators and barriers of implementation

Background: Intimate partner violence (IPV) is highly prevalent and associated with physical and mental health problems. Mentor mother support is a low threshold intervention in family practice consisting of support by non-professionals trained to support mothers experiencing IPV. A mentor mother support study showed reduced exposure to IPV and decreased symptoms of depression.

Objectives: Identify factors determining implementation success of mentor mother support in family practice.

Methods: Individual interviews were conducted with 12 family physicians, 16 abused mothers and three mentor mothers. Four mentor mothers participated in a focus group. Qualitative content analysis was used to analyse the data.

Results: The identification and discussion of abuse is hindered by family physicians’ attitudes because they considered mothers experiencing IPV as a difficult target group with a responsibility of their own to break out of their violent situation. Some family physicians doubted the partner’s violence because he was known as a patient as well. Acceptance of mentor mother support is related to the readiness for change of mothers experiencing IPV. Mentor mothers facilitate acceptance and completion of their support by connecting as a friend who is equal and less threatening than professionals.

Conclusion: To improve successful implementation of mentor mother support in primary care, we should focus on family physicians’ attitudes towards IPV. To change these attitudes, we recommend continuous training of family physicians. By being paraprofessional friends, mentor mothers offer low threshold support that is complementary to professional support and should be embedded more widely in primary care.

KEY MESSAGES

• We need to focus on family physicians’ attitudes towards IPV to improve the support for mothers experiencing IPV.

• As ‘paraprofessional friends,’ mentor mothers offer low-threshold support that is complementary to professional support.

     

Reducing the use of out-of-hours primary care services: A survey among Dutch general practitioners

Background: Out-of-hours primary care services have a high general practitioner (GP) workload with increasing costs, while half of all contacts are non-urgent.

Objectives: To identify views of GPs to influence the use of the out-of-hours GP cooperatives.

Methods: Cross-sectional survey study among a random sample of 800 GPs in the Netherlands.

Results: Of the 428 respondents (53.5% response rate), 86.5% confirmed an increase in their workload and 91.8% felt that the number of patient contacts could be reduced. A total of 75.4% GP respondents reported that the 24-h service society was a ‘very important’ reason why patients with non-urgent problems attended the GP cooperative; the equivalent for worry or anxiety was 65.8%, and for easy accessibility, 60.1%. Many GPs (83.9%) believed that the way telephone triage is currently performed contributes to the high use of GP cooperatives. Measures that GPs believed were both desirable and effective in reducing the use of GP cooperatives included co-payment for patients, stricter triage, and a larger role for the telephone consultation doctor. GPs considered patient education, improved telephone accessibility of daytime general practices, more possibilities for same-day appointments, as well as feedback concerning the use of GP cooperatives to practices and triage nurses also desirable, but less effective.

Conclusion: This study provides several clues for influencing the use of GP cooperatives. Further research is needed to examine the impact and safety of these strategies.

Key Messages

• GPs believe that the number of patient contacts with the GP cooperative could be reduced.

• Strategies to reduce the use of GP cooperatives perceived as both effective and advisable by GPs are introducing co-payment for patients, stricter triage and a larger role for the telephone consultation doctor.

     

A new comprehensive model for Continuous Professional Development

Background: It is generally agreed that continuing professional development (CPD) for GPs is important for quality of care. Internationally, however, different approaches to identify the learning objectives and the CPD content have been chosen.

Objectives: To improve GPs’ CPD in Denmark we explore how general practitioners’ (GPs) self-experienced learning needs can be combined with learning needs experienced from a societal perspective and still make sense for GPs.

Methods: We performed a multi-dimensional learning needs analysis with a modified Delphi method in a participatory action research set-up. Twenty practice-based small learning groups and a group appointed by the Danish public health service were asked to identify learning needs with the Danish family medicine curriculum as reference. Then we asked a group of GP researchers and hospital consultants, a group of GPs with interests in narrative, person-centred medicine and a group of GP educators, and administrative staff, to triangulate the initial findings.

Results: We identified educational themes through a defined collaborative consensus oriented process. Examples of themes are the diagnostic challenge, care for patients with multi-morbidity, elderly patients and children. Due to variation in requested learning objectives, the identified themes do not cover all relevant areas for CPD training. The identified themes will only make sense if seen as supplementary to other CPD activities based on GPs individual needs analyses.

Conclusion: It is possible to identify prioritized educational themes for GPs through a process involving the majority of stakeholders. Nevertheless, CPD should also include activities based on individual needs analysis.

KEY MESSAGES

• When developing a continuing professional development programme for GPs, educational themes can be identified by a multi-dimensional needs analysis involving different stakeholders.

• GPs might benefit from activities based on a consensus-based curriculum combined with an individual needs analysis, thus exposing individual GPs to both recognized and non-recognized relevant learning needs.

     

Variation in the use of point-of-care ultrasound in general practice in various European countries. Results of a survey among experts

Background: Before implementing point-of-care ultrasound in general practice in Denmark, we sought inspiration from other countries/regions.

Objectives: To collect information about the use and organizational aspects of point-of-care ultrasound in general practice in different European countries/regions.

Methods: Fifteen key persons with knowledge about the use of ultrasound in general practice in Austria, Catalonia, Denmark, Finland, Germany, Greenland, Iceland, the Netherlands, Norway, Scotland, Sweden, and Switzerland were included. Participants received a link to a web-based questionnaire. The primary outcome measures were educational aspects regarding the use of point-of-care ultrasound; clinical application and use; financial aspects; and main barriers to using ultrasound in general practice.

Results: In eight out of 12 countries/regions there were national societies for the use of ultrasound in general practice. The respondents from three countries/regions reported that the use of ultrasound was integrated into undergraduate medical education. In nine of the countries/regions, there was formalized training for general practitioners, but only three reported this to be part of the specialization to become a general practitioner. In seven out of 12 countries/regions, general practitioners received payment for ultrasound scans. However, the payment and the requirements for reimbursement differed between countries. Lack of time, lack of training, and financial aspects were important common barriers across countries/regions.

Conclusion: There were significant differences regarding the use and organizational aspects of point-of-care ultrasound in general practice in Europe. Lack of time and training as well as financial aspects were important barriers to the use of point-of-care ultrasound in general practice.

KEY MESSAGES

• Point-of-care ultrasound is used differently in different countries/regions.

• Significant differences exist between countries/regions regarding the organization of national societies for the use of point-of-care ultrasound in general practice.

• Respondents cited financial aspects, time use and lack of skills as the greatest barriers to general practitioners’ use of point-of-care ultrasound.

     

The readiness of German GPs to recommend and conduct cancer screening is associated with patient–physician gender concordance. Results of a survey

Background: Cancer screening participation rates in Germany differ depending on patients’ gender. International studies have found that patient–physician gender concordance fosters recommendation and conducting of cancer screening, and especially cancer screening for women.

Objectives: We aimed to ascertain whether gender concordance influences general practitioners' (GPs’) rating of the usefulness of cancer screening, as well as their recommendations and readiness to conduct cancer screening in general practice in Germany.

Methods: For an exploratory cross-sectional survey, 500 randomly selected GPs from all over Germany were asked to fill in a questionnaire on cancer screening in general practice between March and June 2015. We asked them to rate the usefulness of each cancer screening examination, how frequently they recommended and conducted them and whether they viewed GPs or specialists as responsible for carrying them out. We used multiple logistic regression to analyse gender effect size by calculating odds ratios.

Results: Our study sample consisted of 139 GPs of which 65% were male. Male and female GPs did not differ significantly in their rating of the general usefulness of any of the specified cancer screening examinations. Male GPs were 2.9 to 6.8 times as likely to consider GPs responsible for recommending and conducting PSA testing and digital rectal examinations and were 3.7 to 7.9 times as likely to recommend and conduct these examinations on a regular basis.

Conclusion: Patient–physician gender concordance made it more likely that male-specific cancer screenings would be recommended and conducted, but not female-specific screenings.

KEY MESSAGES

• Male GPs are more likely than female GPs to view GPs as responsible for recommending and conducting male-specific cancer screening.

• Men consult urologists less frequently than women consult gynaecologists, so male GPs seem to take on the role of ‘doctor for men’.

     

Family physicians’ perspectives on clinical guidelines,a survey from the Republic of Srpska,Bosnia and Herzegovina

Background: Despite considerable efforts to promote and support clinical practice guidelines (CPGs) use, adherence has often been suboptimal universally.

Objectives: The aim of this study was to assess to which extent family physicians (FPs) in Republic of Srpska (RS), Bosnia and Herzegovina (BiH) accept or reject the concept and practice of CPGs and evidence-based medicine (EBM).

Methods: A cross-sectional survey was conducted among FPs from the RS, BiH in the period between January and March 2014. Recruitment of FPs was performed combining two different strategies, in-person recruitment at family medicine conferences and mailed invitations. The Questionnaire included19 questions from the existing Healthcare Monitor Questionnaire, divided into four thematic blocks and 11 self-designed questions.

Results: Seventy-seven per cent of 131 interviewed physicians reported already using guidelines in the treatment of patients, while 22.9% of them are undecided or disagree. As the reason for rejecting guidelines, 13.0% of the physicians stated they did not support their content, 12.2% found that limited knowledge about guidelines prevented their application, and another 12.2% reported that the current guidelines were not practical enough. All groups would rather not use guidelines developed by a governmental institution.

Conclusion: Most physicians in the RS, BiH accept and declare application of CPG. However, a substantial percentage remains sceptical, using CPGs only as an exception, or rejecting them due to their content or impracticability.

Key Messages

• Most physicians declare application of clinical practice guidelines.

• Substantial percentage of physicians remains sceptical, using CPGs only exceptionally.

• Further studies are needed to promote the use of CPG and the concept of EBM.

     

Access to diagnostic tests during GP out-of-hours care: A cross-sectional study of all GP out-of-hours services in the Netherlands

Background: In general practice, excluding serious conditions is one of the cornerstones of the consultation. Diagnostic tests are widely used to assist the decision-making process in these cases. Little is known about general practitioners’ (GPs) access to diagnostic tests at GP out-of-hours services.

Objectives: To determine GPs’ access to diagnostic tests—imaging, function tests, laboratory tests, and point-of-care tests (POCT)—during GP out-of-hours care and to assess whether access to diagnostic facilities differs between services located adjacent to or separate from an accident and emergency (A&E) department.

Methods: Cross-sectional survey of all 117 GP out-of-hours services in the Netherlands in 2014.

Results: One-hundred-seventeen GP out-of-hours services participated in the survey; response rate 100%. Access to diagnostic tests during GP out-of-hours care varied across services, although generally there was limited access. Electrocardiography was available in 26% (30/117) of all services, conventional radiography in 19% (22/117), laboratory tests between 37% (43/117) and 65% (76/117). All services had glucose POCT and urine dipstick tests available while none utilized troponin POCT. We observed no relevant differences in access to diagnostic tests between services adjacent to or separate from an A&E department.

Conclusion: GPs in the Netherlands had limited and varying access to diagnostic tests during GP out-of-hours care in 2014. Out-of-hours services adjacent to A&E departments do not offer wider access to diagnostic tests. Further research on the accessibility of diagnostic tests in other European countries with similar and different GP out-of-hours care systems could shed further light on the effects of accessibility to diagnostic tests.

Key Messages

• Our study shows that in 2014, GPs in the Netherlands had limited and varying access to diagnostic tests (imaging, function tests, laboratory tests and point-of-care tests) during GP out-of-hours care.

• Diagnostic tests are not more widely available to GPs working at GP out-of-hours services adjacent to hospitals with an accident and emergency department.

     

Cannabis use frequency and use-related impairment among African-American and White users: the impact of cannabis use motives

Objectives. Cannabis use motives are differentially related to cannabis-related impairment and coping motives appear to have the strongest relation to use-related impairment. However, it is currently unknown whether African-American individuals differ from White persons in reasons for using cannabis. It is also unknown whether motives’ relations to cannabis use and related impairment vary as a function of race. The present study examined the role of race on cannabis use motives and tested whether motives’ relations with cannabis use and related impairment differed by race.

Design. The sample consisted of 111 (67.6% non-Hispanic White, 32.4% African-American) current cannabis-using adults.

Results. African-American participants did not significantly differ from White participants on cannabis use frequency or use-related impairment. African-American participants endorsed more social motives than White participants. Race interacted with social, coping, and conformity motives to predict cannabis-related impairment such that these motives were positively related to cannabis impairment among African-American, but not White, participants.

Conclusion. Although African-American and White participants do not differ in their cannabis use frequency or cannabis-related impairment, they appear to use cannabis for different reasons. Further, conformity, coping, and social motives were differentially associated with cannabis-related impairment as a function of race. Findings suggest motives for cannabis use should be contexualised in the context of race.     

Occupational problems and barriers reported by individuals with obesity

Background: Even if occupational therapists meet many people with obesity in the course of their work, a majority of them do not seem to view weight management as within their area of professional practice.

Aim: To explore the occupational problems and barriers among persons with severe obesity from an occupational therapy perspective.

Materials and methods: The study used the Canadian Model of Occupation and Engagement (CMOP-E) and Canadian Occupational Performance Measure (COPM) to identify and analyze prioritized occupational performance problems and barriers perceived by 63 individuals with obesity.

Results: The occupational problems individuals with obesity most frequently prioritized comprised playing with (grand)children, purchasing clothes, implementing regular meals and going to the swimming pool, while the barriers they most frequently described were dyspnea, musculoskeletal disorders, narrow chairs and seats, fear of glances and comments from others, and social anxiety.

Conclusion: Persons with obesity struggle with a large variety of occupational performance problems, which occur in the dynamic relationship between these individuals, their environment and their occupation. Occupational therapists have the skills to take more active role in helping persons with obesity to perform valued occupations and establish healthier everyday routines.     

Expanding beyond individualism: Engaging critical perspectives on occupation

Background: Perspectives that individualize occupation are poorly aligned with socially responsive and transformative occupation-focused research, education, and practice. Their predominant use in occupational therapy risks the perpetuation, rather than resolution, of occupational inequities.

Aim: In this paper, we problematize taken-for-granted individualistic analyses of occupation and illustrate how critical theoretical perspectives can reveal the ways in which structural factors beyond an individual’s immediate control and environment shape occupational possibilities and occupational engagement.

Method: Using a critically reflexive approach, we draw on three distinct qualitative research studies to examine the potential of critical theorizing for expanding beyond a reliance on individualistic analyses and practices.

Results: Our studies highlight the importance of addressing the socio-historical and political contexts of occupation and demonstrate the contribution of critical perspectives to socially responsive occupational therapy.

Conclusion and significance: In expanding beyond individualistic analyses of occupation, critical perspectives advance research and practices towards addressing socio-political mediators of occupational engagement and equity.     

Occupations,perceived stress,and stress-related disorders among women and men in the public sector in Sweden

Background: Stress-related disorders are a public health problem and represent a significant burden to individuals and society. It is, therefore, of importance to regard stress in a wider context and identify risk factors not only at work but in all occupations in everyday life, to prevent ill health.

Aim/objective: The aim of this study was to examine potential associations between everyday occupations, perceived stress, and stress-related disorders as well as potential gender differences.

Material and methods: A survey was mailed to a random selection of 3481 employees in the public sector in Western Sweden. Cox regressions with constant time at risk were used, in order to calculate prevalence ratios (PR) and their 95% confidence intervals (CI).

Results: The results showed a clear association between reporting imbalance between different everyday occupations and both perceived stress and stress-related disorders among men and women.

Conclusion: Imbalance between different everyday occupations seems to be an important risk factor for perceived stress and stress-related disorder among both women and men.

Significance: To enable people to achieve balance between different everyday occupations may be a useful way to prevent stress, stress-related disorders, and sick leave, and to promote better health and well-being.     

A tool to enhance occupational therapy reasoning from ICF perspective: The Hasselt Occupational Performance Profile (H-OPP)

Background: In order to enhance occupational therapy reasoning in clinical practice, different elements such as client-centred approach, evidence-based care and interdisciplinary work should be taken into account, but is a challenge.

Aim: To describe the development of the digital Hasselt Occupational Performance Profile (H-OPP^©) that enhances occupational therapy reasoning from ICF perspective.

Method: A participative qualitative design was used to create the H-OPP^© in an iterative way in which occupational therapy lectures, ICF experts, students and occupational therapists in the field were involved.

Results: After linking occupational therapy terminology to the ICF, different stages of the H-OPP were identified and elaborated with main features: generating an occupational performance profile based on inventarization of problems and possibilities, formulating an occupational performance diagnosis and enabling to create an intervention plan. In all stages, both the perspectives of the client and the occupational therapist were taken into account. To increase practical use, the tool was further elaborated and digitalized.

Conclusion: The H-OPP^© is a digital coach that guides and facilitates professional reasoning in (novice) occupational therapists. It augments involvement of the client system. Furthermore, it enhances interdisciplinary communication and evidence-based care.     

A Delphi study of occurring information in housing adaptation certificates

Background: Since 1993, the Housing Adaptation Act has provided disabled people the opportunity to receive grants for adapting their homes. A housing adaptation certificate certifying the necessity of adaptations must accompany any application and if information in housing adaptation certificates is not sufficient, the applicant is risking not having necessary housing adaptations.

Objective: The aim of this study was to identify and describe what information is missing, unnecessary or vague, in the housing adaptation certificates; to determine how often this occur, and how problematic this can be for the decision process.

Material and methods: 105 housing adaptation grant managers took part in a three-round Delphi survey.

Results: At least 65% consensus was reached regarding the following six statements: missing information about disability duration, possession of relevant assistive devices, consequences of the disability in housing, prognosis of consequences, who the informant is, or contains preferences for specific solutions. Missing, unnecessary or vague information pose serious or less serious problems and 38–72% of the participants reported that this often or always occur.

Conclusion: Housing adaptation certificates need to be improved.

Significance: The results of this study are used to design a checklist for use by housing adaptation certificate writers.     

Managing occupations in everyday life for people with advanced cancer living at home

Background: People with advanced cancer are able to live for extended periods of time. Advanced cancer can cause functional limitations influencing the ability to manage occupations. Although studies have shown that people with advanced cancer experience occupational difficulties, there is only limited research that specifically explores how these occupational difficulties are managed.

Objective: To describe and explore how people with advanced cancer manage occupations when living at home.

Material and methods: A sub-sample of 73 participants from a larger occupational therapy project took part in the study. The participants were consecutively recruited from a Danish university hospital. Qualitative interviews were performed at the homes of the participants. Content analysis was applied to the data.

Results: Managing occupations were manifested in two main categories; (1) Conditions influencing occupations in everyday life and (2) Self-developed strategies to manage occupations.

Significance: The findings suggest that people with advanced cancer should be supported to a greater extent in finding ways to manage familiar as well as new and more personally meaningful occupations to enhance quality of life.     

Strategies to manage activities in everyday life after a pain rehabilitation program

Background: Owing to the complexity of the pain experience, it is important to understand how persons with chronic pain manage their condition, in order to provide an indication of how occupational therapists can enable participation in meaningful everyday activities during pain rehabilitation.

Aim: The aim of this study was to explore how persons with chronic pain reason about their use and choice of strategies to manage activities of everyday life.

Materials and methods: A qualitative approach was used to capture experiences of strategies employed to manage activities while living with chronic pain. Eight persons agreed to participate.

Results: An overall theme, ‘adjusting to life with chronic pain’, encompasses the underlying meaning and the relations between the categories: finding new ways to perform activities, reaching for a reasonable balance of activities and using activities to achieve other purposes.

Conclusion and significance: Persons with chronic pain use various strategies as means to enable performance in activities of everyday life despite living with pain, which supports the conception that occupational therapists should focus on activities and strategies rather than the pain condition during pain rehabilitation.