Course of glycaemia in poorly controlled type 2 diabetes patients 2.5 years after optimizing oral treatment in general practice

Abstract

Objective: To investigate GPs’ perceptions of consultation outcomes and to investigate the associations between these and outcomes perceived by the patients. Design: 25 GPs and 10 patients for each GP filled in a questionnaire about the outcome of the same consultation. The questions in the questionnaires were formulated from concepts found in preceding qualitative studies. Their answers were analysed and compared. Setting: GPs and patients from 16 group practices in Norrbotten, Sweden. Results: The GPs had the apprehension that their consultations would lead to cure/symptom relief in half of their consultations. They believed that their patients were satisfied up to 90% and that up to 75% had been reassured, understood more or could cope better. The GPs were satisfied themselves with up to 95% of the consultations, they enhanced their relationship to their patient up to 70%. Their affirmative concordance with their patients was high regarding satisfaction, intermediate regarding patient reassurance and patient understanding and lowest regarding cure/symptom relief.

Conclusion: The GPs’ were lacking in their ability to assess the patients’ increased understanding and the concordance between their own and the patients’ expectation of cure/symptom relief was low.     

Experiences of hospital-based multidisciplinary team meetings in oncology: An interview study among participating general practitioners

Background: Cancer care has become complex, requiring healthcare professionals to collaborate to provide high-quality care. Multidisciplinary oncological team (MDT) meetings in the hospital have been implemented to coordinate individual cancer patients’ care. General practitioners (GPs) are invited to join, but their participation is minimal.

Objectives: Aim of this study is to explore participating GPs’ perceptions of their current role and to understand their preferences towards effective role execution during MDT meetings.

Methods: In May to June 2014, semi-structured interviews (n?=?16) were conducted involving GPs with MDT experience in Belgium. The analysis was done according to qualitative content analysis principles.

Results: Attendance of an MDT meeting is perceived as part of the GP’s work, especially for complex patient care situations. Interprofessional collaborative relationships and the GP’s perceived benefit to the MDT meeting discussions are important motivators to participate. Enhanced continuity of information flow and optimized organizational time management were practical aspects triggering the GP’s intention to participate. GPs valued the communication with the patient before and after the meeting as an integral part of the MDT dynamics.

Conclusion: GPs perceive attendance of the MDT meeting as an integral part of their job. Suggestions are made to enhance the efficiency of the meetings.     

Medical errors: Preliminary results of a study among Turkish family medicine residents

Abstract

Background: Regular use of evidence-based medicine (EBM) among general practitioners (GP) is insufficient.

Objective: To analyse whether knowledge and attitudes about EBM can be improved among mentors in general practice by involving sixth-year medical students as academic detailers.

Methods: An interventional non-randomized before-and-after study included 98 GPs (49 in the intervention group of mentors and 49 controls) and 174 medical students attending family medicine clinical rotations. A telephone survey on knowledge and attitudes towards EBM was conducted among participating physicians before, and six months after the rotation. During the rotation, each mentor chose two cases from real life, and the students’ task was to form an answerable clinical question, find the evidence-based answer and to write a brief report. The mentor reviewed the report and discussed it with the student.

Results: Students’ EBM detailing intervention led to significant improvement in knowledge and attitudes about EBM in the intervention group of mentors in general practice compared to control GPs (relative increase in knowledge was 20 ± 46.9% vs 6 ± 12.1%, respectively; P = 0.042). Among participants with Ph.D. or specialization in family medicine, the observed effects of the intervention were similar as in the total sample, and statistically significant, but not in the group of participants with neither scientific degree nor specialization in family medicine.

Conclusion: Knowledge and attitudes of GP mentors towards EBM can be improved by involving medical students as academic detailers. Further studies should explore the effectiveness of this method among GPs that are not mentors, and who do not have a specialization or research degree.     

Even if they are not aware of it,general practitioners improve well-being in their adolescent patients

Background: Most adolescents consult their general practitioner (GP) for common reasons, somatic or administrative but many of them have hidden feelings of distress.

Objectives: To assess the immediate impact of ‘ordinary’ consultations on feelings of distress among adolescents and to compare adolescents experiencing difficulties (D) to those with no difficulties (N). To analyse how accurately GPs assess the impact of their consultation on adolescents’ feelings.

Methods: GPs were randomly selected from two non-contiguous French administrative areas between April and June 2006. Fifty-three GPs gave two questionnaires to the first 10 to 15 adolescents aged 12 to 20 seen in consultation. One questionnaire was issued before the consultation and the other one afterwards. Adolescents had to position themselves about different aspects of well-being and say where they would seek help if they had problems. A GP questionnaire assessed how well they estimated their impact on the adolescent’s feeling of well-being.

Results: Six hundred and sixty-five adolescents were assessed. They reported feeling better about their health, being able to talk, having someone to talk to or to confide in and on feeling understood. The D group (n?=?147) felt significantly better compared to the N group (n?=?518). GPs tended to underestimate this improvement, especially regarding adolescents in the D group feeling better about their health.

Conclusions: Consulting a GP generates increased well-being among adolescents, especially for those experiencing difficulties. GPs tend to underestimate the positive impact they may have. Further studies are needed to explore if this benefit is permanent over time.     

Emergency anaphylaxis protocols: A cross-sectional analysis of general practice surgeries and pharmacies in both the urban and rural setting in Ireland

Background: The incidence of anaphylaxis appears to be increasing worldwide with cases in the community outnumbering those in the hospital setting. General practice (GP) surgeries and pharmacies, based in the community, are often the first point of contact for many patients suffering from anaphylaxis.

Objectives: To determine if studied GP surgeries and pharmacies have an anaphylaxis protocol on site and have access to an anaphylaxis kit; to explore GP’s and pharmacists’ personal experiences with management of anaphylaxis.

Methods: A cross-sectional, questionnaire-based study was performed examining anaphylaxis protocols in a sample of general practices and pharmacies from some counties in Ireland. This consisted of a sample from rural and urban settings. The study commenced in October 2014.

Results: Nineteen of 24 GPs (79%) and 9 (29%) pharmacies had an anaphylaxis protocol (P?<?0.001). Twenty-four (100%) GP practices and 12 pharmacies (39%) surveyed had an anaphylaxis kit on site. Twelve GPs (50%) had treated a patient with anaphylaxis in the surgery while 8 (33%) had treated a patient in the community. One pharmacist (3%) had witnessed anaphylaxis in practice. Two pharmacies and one GP had been contacted by local businesses to alert them to a case of anaphylaxis.

Conclusion: In contrast to national and international guidelines only 79% of GPs and 29% of pharmacies in this study from Ireland had an anaphylaxis protocol onsite.     

GPs’ experiences with out-of-hours GP cooperatives: A survey study from the Netherlands

Background: Out-of-hours primary care has been provided by general practitioner (GP) cooperatives since the year 2000 in the Netherlands. Early studies in countries with similar organizational structures showed positive GP experiences. However, nowadays it is said that GPs experience a high workload at the cooperative and that they outsource a considerable part of their shifts.

Objectives: To examine positive and negative experiences of GPs providing out-of-hours primary care, and the frequency and reasons for outsourcing shifts.

Methods: A cross-sectional observational survey among 688 GPs connected to six GP cooperatives in the Netherlands, using a web-based questionnaire.

Results: The response was 55% (n = 378). The main reasons for working in GP cooperatives were to retain registration as GP (79%) and remain experienced in acute care (74%). GPs considered the peak hours (81%) and the high number of patients (73%) as the most negative aspects. Most GPs chose to provide the out-of-hours shifts themselves: 85% outsourced maximally 25% of their shifts. The percentage of outsourced shifts increased with age. Main reasons for outsourcing were the desire to have more private time (76%); the high workload in daytime practice (71%); and less the workload during out-of-hours (46%).

Conclusion: GPs are motivated to work in out-of-hours GP cooperatives, and they outsource few shifts. GPs consider the peak load and the large number of (non-urgent) help requests as the most negative aspects. To motivate and involve GPs for 7 × 24-h primary care, it is important to set limits on their workload.     

Women’s beliefs about what causes obesity: variation by race/ethnicity and acculturation in a Washington State sample

ABSTRACT

Objective: Individuals’ beliefs about the causes of multifactorial health conditions (causal attributions) shape how they conceptualize and respond to health threats and are therefore important for health promotion. Studies of racial/ethnic and cultural variation in obesity causal beliefs, however, are scarce. To address this gap, this study described beliefs about the underlying causes of obesity (genetic inheritance, diet, and physical activity) in Hispanic and non-Hispanic White women participating in a longitudinal cohort study in South King County, Washington State (n?=?1,002).

Design: Analysis of baseline survey data. Self-reported obesity causal beliefs were compared by race/ethnicity and acculturation indicators (survey language and nativity) using marginal effect estimates generated from multinomial logistic regression models.

Results: Hispanic women had a higher probability of not believing ‘at all’ in inheritance and physical activity as causes of obesity – an absolute increase of 33% and 5% over non-Hispanic White women, respectively. Both acculturation indicators were also associated with a higher probability of not believing ‘at all’ in inheritance as a cause of obesity, though Hispanic women who completed the survey in English and were born in the United States had genetic causal beliefs similar to non-Hispanic White women. Behavioral attributions did not vary by acculturation indicators in Hispanic women.

Conclusions: Differences in obesity casual beliefs, particularly genetic attributions, exist and may be important for developing and delivering effective obesity-related health promotion interventions. Identifying the determinants and public health consequences of cultural variation in obesity attributions should be the focus of future research.     

A management programme for suspected heart failure in primary care in cooperation with specialists in cardiology

Abstract

Background: Acute anterior uveitis (AAU) is a potentially serious ocular condition, which frequently presents to the General Practitioner (GP). In some cases, it can be misdiagnosed with consequent delay in the initiation of appropriate treatment.

Objectives: To analyse the diagnostic features of AAU presenting to the emergency service at Manchester Royal Eye Hospital; to investigate the prior management of AAU in the community and identify management problems amenable to constructive feedback. Methods: A list of reasonable standards expected from primary carers was compiled and information collected prospectively by nurse practitioners over two months using a specifically designed pro-forma. Data was analysed against these standards and compared to the relevant literature.

Results: Of the AAU patients 18/69 had previously seen the GP. 14 had first episodes, 4 were recurrent. Mean interval between symptom onset and eye emergency attendance was 9.2 days compared to 4.3 days for those not seen by GP. Symptoms elicited, in those previously seen by a GP, were: ocular pain (18/18); photophobia (17/18); unilateral red eye (17/18); and blurred vision (15/18). GP performed ocular examination in 12 patients. Seven patients were not treated by GP but referred on the same day. The other 11 patients were prescribed topical antibiotics by GP and 2/11 also received topical steroid. 9 of these 11 patients eventually self-checked into eye emergency, whereas two were subsequently referred after re-visiting the GP.

Conclusion: A significant number of AAU patients present to the GP and may be misdiagnosed with an alternative condition such as conjunctivitis. Awareness of AAU presentation and the need for prompt referral, to avoid potential visual loss, needs to be improved by providing feedback to GPs following patient attendance to eye emergency services.     

Development of the EMAP tool facilitating existential communication between general practitioners and cancer patients

Background: General practice recognizes the existential dimension as an integral part of multidimensional patient care alongside the physical, psychological and social dimensions. However, general practitioners (GPs) report substantial barriers related to communication with patients about existential concerns.

Objectives: To describe the development of the EMAP tool facilitating communication about existential problems and resources between GPs and patients with cancer.

Methods: A mixed-methods design was chosen comprising a literature search, focus group interviews with GPs and patients (n?=?55) and a two-round Delphi procedure initiated by an expert meeting with 14 experts from Denmark and Norway.

Results: The development procedure resulted in a semi-structured tool containing suggestions for 10 main questions and 13 sub-questions grouped into four themes covering the existential dimension. The tool utilized the acronym and mnemonic EMAP (existential communication in general practice) indicating the intention of the tool: to provide a map of possible existential problems and resources that the GP and the patient can discuss to find points of reorientation in the patient’s situation.

Conclusion: This study resulted in a question tool that can serve as inspiration and help GPs when communicating with cancer patients about existential problems and resources. This tool may qualify GPs’ assessment of existential distress, increase the patient’s existential well-being and help deepen the GP–patient relationship.     

Experiences of general practitioners participating in oncology meetings with specialists to support GP-led survivorship care; an interview study from the Netherlands

Background: Due to ageing, increasing cancer incidence and improved treatment, the number of survivors of cancer increases. To overcome the growing demand for hospital care survivorship by the involvement of the general practitioner (GP) has been suggested. Dutch GPs started a project to offer survivorship care to their patients with the help of monthly oncology meetings with hospital specialists.

Objectives: To evaluate the experiences of GPs with monthly oncology meetings in a GP-practice to support GP-led survivorship care of colon cancer patients.

Methods: This is a qualitative study in primary care centres in a region in the Netherlands around one hospital. GPs were recruited from practices organizing monthly oncology meetings with hospital specialists. Ten of 15 participating GPs were interviewed until saturation. The interviews were transcribed verbatim and two independent researchers analysed the data.

Results: The oncology meetings and individual care plans attributed to a feeling of shared responsibility for the patients by the GP and the specialist. The meetings helped the GPs to be informed about the patients in the diagnostic and treatment phase, which was followed by a clear moment of transfer from hospital to primary care. GPs were better equipped to treat comorbidity and were more confident in providing survivorship care. Due to lack of reimbursement for survivorship care, the internal motivation of the GP must high.

Conclusion: The oncology meetings fulfil the need for information and communication. Close cooperation between GPs and oncology specialists appears to be an essential factor for GPs to value GP-led survivorship care positively.     

The role of general practitioners in the initial management of women with urinary incontinence in France,Germany, Spain and the UK

Objective: To describe the role of general practitioners (GPs) in the initial management of women with urinary incontinence (UI) in four European countries with different healthcare systems. Methods: Cross-sectional community postal survey of 2953 women with UI in France, Germany, Spain and the UK. Results: Forty-eight per cent of community-dwelling women with UI had discussed their UI with a doctor. More women discussed UI in France and Germany than in the UK and Spain. The patient usually raised the issue during consultations for some other reason. Fear of or actual deterioration in UI was the most important reason for discussing UI. Overall, 52% of incontinent women first discussed their UI with a GP, and almost a third of women reported having all their UI discussions in a GP setting. Twenty-nine per cent of women reported that GPs had either recommended treatment or monitoring of their condition before beginning treatment, and 24% reported that the GP had referred them to another doctor for evaluation and treatment. Most women in the UK first discussed UI with a GP, whereas in Germany most discussed UI with a specialist. In Spain and France, about half the women first discussed their UI with a GP.

Conclusion: GPs are involved to varying degrees in the initial management of UI in France, Germany, Spain and the UK. Even in countries where women have a choice of whether to see a GP or specialist about UI, many choose to have their first contact with a GP.     

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.

     

Culture,causal attributions to visual impairments,and stigma: A mediation model

BackgroundCausal attributions are central to the understanding of public reactions to disability (that is, disability-related stigma). Research shows that culture and ethnicity were found to play a significant role in both causal attributions of disability and disability-related stigma.Disability-related stigma was found to influence physical and mental health. Nevertheless, to the best of our knowledge, the relationships linking culture, causal attributions of disability and disability-related stigma, have not been previously examined.ObjectiveThe study examined whether causal attributions (natural, mystic, punitive and emotional) to a specific disability-visual impairments - mediate the relationship between culture and stigma towards individuals with visual impairments.MethodsA quota sample comprised of 305 university and college students was drawn. Data were collected via a self-reported questionnaire.ResultsThe main findings indicated that emotional and punitive causal attribution to visual impairments mediated the relationship between culture and visual impairments-stigma; Israeli Arab-Palestinians had a higher tendency to attribute higher levels of punitive and emotional causes to visual impairments compared to Israeli Jews. Higher levels of punitive and emotional attributed causes for visual impairments were correlated with higher levels of visual impairments-stigma. Israeli Arab-Palestinians have a higher tendency to attribute visual impairments to mystic causes compared to Israeli Jews. However, this type of perceived causation was unrelated to visual impairments-stigma.ConclusionsInterventions to reduce visual impairments-stigma should focus on misconceptions concerning causation. It is especially important to design culturally sensitive interventions for visual impairments stigma reduction among Israeli Arab-Palestinians, which will focus on de-psychologizing visual impairments.     

Primary prevention of cardio-metabolic diseases in general practice: A Dutch survey of attitudes and working methods of general practitioners

Abstract

Background: To study the attitudes and working methods of general practitioners (GPs) in primary prevention of cardiovascular diseases, diabetes mellitus and chronic kidney diseases. Methods: A questionnaire with questions about attitude and working methods in the primary prevention of cardiovascular diseases, diabetes mellitus and chronic kidney diseases in general practice was sent to a representative sample of 1,100 Dutch GPs. The questionnaire was developed in collaboration with experts in general practice, cardiovascular disease, diabetes and kidney disease. Results: A total of 330 GPs completed and returned the questionnaire (30% response). Only a quarter of the GP's actively invite patients for preventive measurements. Preventive measures are mainly performed by the GP when a patient asks for it or when patients visit a GP for other complaints. The main reasons for performing preventive tests were a positive family history, obesity and smoking. Most GPs consider detection of these diseases as worthwhile, but detection should particularly focus on the group of patients with the highest risk on these diseases.

Conclusion: GPs have a positive attitude towards primary prevention of cardiovascular diseases, diabetes mellitus and chronic kidney diseases, but primary prevention should be focused on patients at risk.     

The frequency and outcome of acute dyspnoea in primary care: An observational study

Background: Little is known about the occurrence of acute dyspnoea in primary care and its underlying causes.

Objectives: What are the occurrence and most frequent causes of acute dyspnoea in primary care, predictors of referral, hospitalization, death and possible underlying causes?

Methods: Twenty-five general practitioners (GPs) in Flanders (Belgium) recorded patient contacts for four periods of two weeks during one year. They recorded patients presenting with acute dyspnoea, location of contact (surgery versus home visit), new dyspnoea versus exacerbation, tentative diagnosis, referral to a specialist and hospital, and one month later final diagnosis, its justification, referral, hospitalization and death.

Results: Twenty-two GPs recorded 14,620 patient contacts. Acute dyspnoea was encountered in 317 patient–doctor contacts (2.2%; 95%CI: 1.9–2.4), without significant association between the acute dyspnoea frequency, and age and gender. Immediate referral and hospitalization were most frequent in patients 61 to 90 years old. Forty-five patients (14.2%; 95%CI: 10.4–18.0) were referred to a specialist immediately and an additional 34 (10.7%; 95%CI: 7.3–14.1) by one month follow-up. Fourteen patients (4.4%) were hospitalized immediately, and 11 (3.5%) within one month. Six patients (1.9%), all 61 to 90 years old, died within one month.

Conclusion: Dyspnoea occurs in about two per cent of consultations. Serious cases are rare and are much more likely in the older age group. Twenty-five per cent of the contacts concerning acute or worsening dyspnoea were referred to a specialist or hospitalized. In daily practice, the risk of immediate referral, hospitalization and death is higher in men and older patients, especially if the contact is at the patient’s home.

Key Messages

• Acute dyspnoea was encountered in 2.2% of patient–doctor contacts.

• The risk of immediate referral, hospitalization and death was higher in men and patients 61 to 90 years old, especially if the contact was at the patient’s home.

• There is no association between the acute dyspnoea frequency and age and gender.

     

More counselling for end-of-life decisions by GPs with own advance directives: A postal survey among German general practitioners

Background: Although general practitioners (GPs) are among the preferred contact persons for discussing end-of-life issues including advance directives (ADs), there is little data on how GPs manage such consultations.

Objectives: This postal survey asked German GPs about their counselling for end-of-life decisions.

Methods: In 2015, a two-sided questionnaire was mailed to 959 GPs. GPs were asked for details of their consultations on ADs: frequency, duration, template use, and whether they have own ADs. Statistical analysis evaluated physician characteristics associated with an above-average number of consultations on AD.

Results: The participation rate was 50.3% (n?=?482), 70.5% of the GPs were male; the average age was 54 years. GPs had an average of 18 years of professional experience, and 61.4% serve more than 900 patients per three months. Most (96.9%) GPs perform consultations on living wills (LW) and/or powers of attorney (PA), mainly in selected patients (72.3%). More than 20 consultations each on LWs and PAs are performed by 60% and 50% of GPs, respectively. The estimated mean duration of consultations was 21?min for LWs and 16?min for PAs. Predefined templates were used in 72% of the GPs, 50% of GPs had their ADs. A statistical model showed that GPs with ADs and/or a qualification in palliative medicine were more likely to counsel ≥20 patients per year for each document.

Conclusion: The study confirmed that nearly all German GPs surveyed provide counselling on ADs. Physicians with ADs counsel more frequently than those without such documents.     

Deciding whether to consult the GP or an emergency department: A qualitative study of patient reasoning in Switzerland

Background: Non-urgent care is an important factor responsible for rising healthcare costs and general practitioners (GPs) are known to be more cost-effective than emergency departments (EDs).

Objectives: To understand the reasons why patients confronted with a medical problem perceived as urgent choose to consult either a GP or an ED.

Methods: We conducted a qualitative study in Switzerland, using data collected between 2014 and 2015 through semi-structured interviews of adults with non-vital medical problems. Half were recruited after an ambulatory consultation in an ED, and half were patients who consulted their GP. The audio-recorded interviews were transcribed, coded, and analysed according to the constant comparative method.

Results: The main reason given by patients who consulted their GP first was the quality of the relationship. The more meaningful the relationship, the more likely patients were to seek advice from their GP. One marker of a privileged relationship was GPs supplying their mobile phone number to the patient. The perceived nature of the complaint, for example, symptoms considered as life-threatening or severe pain, together with the expected waiting time in an ED were additional factors influencing the patients’ choice.

Conclusion: Our study showed that when patients are confronted with what they perceive as a medical emergency, the quality of the relationship with the GP, in particular the continuity of care provided, seem to be the major reasons why they consult their GP rather than an ED.