Balancing trust and power: a qualitative study of GPs perceptions and strategies for retaining patients in preventive health checks

Objective: Little is known about how strategies of retaining patients are acted out by general practitioners (GPs) in the clinical encounter. With this study, we apply Grimens’ (2009) analytical connection between trust and power to explore how trust and power appear in preventive health checks from the GPs’ perspectives, and in what way trust and power affect and/or challenge strategies towards retaining patients without formal education.

Design: Data in this study were obtained through semi-structured interviews with GPs participating in an intervention project, as well as observations of clinical encounters.

Results: From the empirical data, we identified three dimensions of respect: respect for the patient’s autonomy, respect for professional authority and respect as a mutual exchange. A balance of respect influenced trust in the relationship between GP and patients and the transfer of power in the encounter. The GPs articulated that a balance was needed in preventive health checks in order to establish trust and thus retain the patient in the clinic. One way this balance of respect was carried out was with the use of humour.

Conclusions: To retain patients without formal education in the clinical encounter, the GPs balanced trust and power executed through three dimensions of respect. In this study, retaining patients was equivalent to maintaining a trusting relationship. A strategic use of the three dimensions of respect was applied to balance trust and power and thus build or maintain a trusting relationship with patients.

• KEY POINTS

• Little is known about how strategies for retaining patients are acted out by GPs in preventive health checks.

• ?? Retaining patients requires a balance of trust and power, which is executed through three dimensions of respect by the GPs.

• ?? Challenges of recruiting and retaining patients in public health initiatives might be associated with the balance of respect.

     

Contact with primary health care physicians before an acute hospitalisation

Abstract

Objectives: To assess contacts with general practitioners (GPs), both regular GPs and out-of-hours GP services (OOH) during the year before an emergency hospital admission.

Design: Longitudinal design with register-based information on somatic health care contacts and use of municipality health care services.

Setting: Four municipalities in central Norway, 2012–2013.

Subjects: Inhabitants aged 50 and older admitted to hospital for acute myocardial infarction, hip fracture, stroke, heart failure, or pneumonia.

Main outcome measures: GP contact during the year and month before an emergency hospital admission.

Results: Among 66,952 identified participants, 720 were admitted to hospital for acute myocardial infarction, 645 for hip fracture, 740 for stroke, 399 for heart failure, and 853 for pneumonia in the two-year study period. The majority of these acutely admitted patients had contact with general practitioners each month before the emergency hospital admission, especially contacts with a regular GP. A general increase in GP contact was observed towards the time of hospital admission, but development differed between the patient groups. Patients admitted with heart failure had the steepest increase of monthly GP contact. A sizable percentage did not contact the regular GP or OOH services the last month before admission, in particular men aged 50–64 admitted with myocardial infarction or stroke.

Conclusion: The majority of patients acutely admitted to hospital for different common severe emergency diagnoses have been in contact with GPs during the month and year before the admission. This points towards general practitioners having an important role in these patients’ health care.

• KEY MESSAGES

• There is scarce knowledge about primary health care contact before an emergency hospital admission.

• The percentage of patients with contacts differed between patient groups, and increased towards hospital admission for most diagnoses, particularly heart failure.

• More than 50% having monthly general practitioner contact before admission underscores the general practitioners’ role in these patients’ health care.

• Our results underscore the need to consider medical diagnosis when talking about the role of general practitioners in preventing emergency hospital admissions.

     

Factors correlating to the propensity of general practitioners to substitute borderline vitamin B12 deficiency

Objective: This study aims to identify factors which correlate to the propensity of general practitioners (GPs) to prescribe supplementation for borderline vitamin B12 deficiency.

Design: Cross-sectional surveys were distributed in person.

Setting: Conferences held in Cairns, Palm Cove Beach, Mt Isa; educational meetings in Atherton; and meetings with individual general practices within the Cairns and Hinterland region. All located in Queensland, Australia.

Subjects: 128 practicing GP specialists and registrars (practitioners in training).

Main outcome measures: Responses to the Likert scale statements with its five options scaling from ‘strongly disagree’ to ‘strongly agree’ were recoded to have binary outcomes for analysis.

Results: A survey response rate of 89% was achieved. Participants who felt patient demands influence the management of borderline vitamin B12 deficiency were more likely to prescribe supplementation (OR 2.4, p?=?0.037). Participants who perceived an overuse of vitamin B12 were less likely to prescribe B12 (OR 0.39, p?=?0.019). Participants who often saw patients with vitamin B12 deficiency were less likely to request for the complementary biomarkers plasma methylmalonic acid or total homocysteine (OR 0.41, p?=?0.045).

Conclusions: The identified disparity to prescribe vitamin B12 for borderline deficiency may be described as an attempt in the GP collective to seek a balance between being the patient’s or the society’s doctor. We propose that relevant authorities try to reduce this disparity by describing a management strategy for borderline vitamin B12 deficiency.

• Key points

• General practitioners hold different thresholds for commencing supplementation in cases of borderline vitamin B12 deficiency.

• Participants from Australia were asked to fill out a cross-sectional survey to explore factors which correlate with the propensity to prescribe in clinical practice.

• Our study identified that patient demands and a practitioner’s perception of whether there is an overuse of vitamin B12 in the community influenced the propensity to treat for deficiency.

• The results give insight into reasons for initiating supplementation, and will help inform general practitioners on their current management.

     

School success and participation for students with cerebral palsy: a qualitative study exploring multiple perspectives

Purpose: This qualitative study investigated perceived successful school experiences for students with cerebral palsy in Australia. Participation and appropriate support in school are complex concepts, although few studies have investigated all stakeholders’ perspectives.

Methods: Phenomenology informed the study that centered on the concept of a successful school experience. In-depth interviews occurred with students (n?=?7), parents (n?=?11), teachers (n?=?10), school principals (n?=?9) and allied health practitioners (n?=?10) to gain the perspective from multiple vantage points. Specific research questions, interview guides and demographic questionnaires were configured for each group. Interviews were analyzed thematically within and between groups.

Results: Three key themes emerged: Collaborative partnerships between families, schools and outside organizations; School culture and attitude is key; and, allied health practitioners are part of home and school teams.

Conclusions: Student and school success was impacted substantially by the capacity of adults in the student’s life to collaborate – family, school professionals and allied health practitioners. An inclusive school culture was crucial to students with cerebral palsy. All parties needed to prioritize promotion of an open and positive school culture built around problem-solving inclusive practices. Involved people, such as allied health practitioners, bring knowledge and skills that are not otherwise readily available in school environments.

• Implications for rehabilitation

• Students with cerebral palsy have high needs at school and allied health practitioners have a role advocating for, educating and providing support to students within the school.

• Teachers of students with cerebral palsy need education, training and support from allied health practitioners.

• The need for allied health and rehabilitation services continues for children and youth with cerebral palsy outside of school and across the schooling years.

• School professionals; allied health practitioners; families and students can work together to improve the student experience

     

What information do patients need following a whiplash injury? The perspectives of patients and physiotherapists

Purpose: The aims of the present study were to identify information that individuals with whiplash associated disorders (WAD) need to know in the early stages of recovery and to establish whether there is a difference between what physiotherapists and whiplash-injured patients perceive as important information.

Method: Forty-one participants were recruited (20 whiplash-injured patients, 21 physiotherapists). Participants were asked to provide five statements to one open-ended question about what they believe is the most important information individuals with WAD need to know in the early stages of recovery. Participants provided 182 statements which were reviewed independently and organised into themes by two of the authors.

Results: Six key themes emerged from the statements. These included general information about whiplash injury, treatment and recovery, reassurance, provision of poor information and patients’ interaction with general practitioners, maintaining daily activities, and compensation claims and litigation. Both patients and physiotherapists agreed on the type of general whiplash information that should be provided however, major differences were found with regard to information pertaining to compensation claims and litigation and maintaining daily activities.

Conclusions: The findings of this study provide some insight into the type of information that WAD individuals require in the early stages of recovery.

• Implications for Rehabilitation

• The provision of reassurance can be an effective communication tool to decrease patients concerns about their injury and help strengthen the patient–health practitioner relationship.

• Although clinical guidelines for the management of whiplash injuries recommend that individuals must remain physically active post-injury, statements from the patient group indicate that this information is not always provided and clearly explained to patients.

• Keeping in line with the patient centred care approach of being responsive to patient needs and values, it is essential for health practitioners to be attentive to patients’ preferences regarding the level of participation in treatment decisions.

• Processes need to be developed to deliver individuals with WAD accurate information regarding compensation claims so that these factors do not distract from focusing on recovery.

     

The impact of primary care organization on avoidable hospital admissions for diabetes in 23 countries

Objective: Diabetes is a so-called ambulatory care sensitive condition. It is assumed that by appropriate and timely primary care, hospital admissions for complications of such conditions can be avoided. This study examines whether differences between countries in diabetes-related hospitalization rates can be attributed to differences in the organization of primary care in these countries. Design: Data on characteristics of primary care systems were obtained from the QUALICOPC study that includes surveys held among general practitioners and their patients in 34 countries. Data on avoidable hospitalizations were obtained from the OECD Health Care Quality Indicator project. Negative binomial regressions were carried out to investigate the association between characteristics of primary care and diabetes-related hospitalizations. Setting: A total of 23 countries. Subjects: General practitioners and patients. Main outcome measures: Diabetes-related avoidable hospitalizations. Results: Continuity of care was associated with lower rates of diabetes-related hospitalization. Broader task profiles for general practitioners and more medical equipment in general practice were associated with higher rates of admissions for uncontrolled diabetes. Countries where patients perceive better access to care had higher rates of hospital admissions for long-term diabetes complications. There was no association between disease management programmes and rates of diabetes-related hospitalization. Hospital bed supply was strongly associated with admission rates for uncontrolled diabetes and long-term complications. Conclusions: Countries with elements of strong primary care do not necessarily have lower rates of diabetes-related hospitalizations. Hospital bed supply appeared to be a very important factor in this relationship. Apparently, it takes more than strong primary care to avoid hospitalizations.

• Key points

• Countries with elements of strong primary care do not necessarily have lower rates of diabetes-related avoidable hospitalization.

• Hospital bed supply is strongly associated with admission rates for uncontrolled diabetes and long-term complications.

• Continuity of care was associated with lower rates of diabetes-related hospitalization.

• Better access to care, broader task profiles for general practitioners, and more medical equipment in general practice was associated with higher rates of admissions for diabetes.

     

Risk factors for failure to enter vocational rehabilitation services among individuals with disabilities

Purpose: To investigate the risk factors for failure of individuals with disabilities to enter the vocational rehabilitation (VR) programme, including the cases where they had been formally accepted but were yet to receive any service.

Methods: We used prospective cohort data from a Midwestern US state, and analysed 126,251 and 94,517 individuals, respectively, for acceptance and admission into VR services. Statistical analysis was conducted using Poisson regression models with robust variance estimator.

Results: Individuals with blind/visual disability, had prior history of employment, and who received public support tended to have lower risks of non-acceptance and non-admission. Being non-White, at higher education, ever/currently married, and with physical/orthopaedic disability appeared to increase the risks of both outcomes. The adjusted relative risk of non-acceptance was 0.58 (95% confidence interval: 0.52, 0.64) if the individuals had 4 or more functional limitations as compared with those with fewer limitations. This factor was not significant for VR admission.

Conclusion: Disability factors, demographic determinants, and certain miscellaneous characteristics were associated with the risks of non-acceptance and non-admission into VR.

• Implications for Rehabilitation

• Individuals with disabilities are more likely to be unemployed than the population without disabilities, and they are thus more prone to adverse health effects of unemployment.

• Vocational rehabilitation (VR) is a proven intervention to improve employment outcomes among individuals with disabilities.

• Our study indicates that the complexity of the selection process for entering VR and various factors beyond disability may prevent individuals to benefit from the VR programme.

• Rehabilitation programme authorities need to monitor and simplify the selection process into VR services and, together with rehabilitation practitioners, promote a selection process that pays careful attention on the factors that are related to individual risk of failure for entering VR.

     

‘I’ve put diabetes completely on the shelf till the mental stuff is in place’. How patients with doctor-assessed impaired self-care perceive disease,self-care,and support from general practitioners. A qualitative study

Objective: This paper investigated patients’ experiences of disease and self-care as well as perceptions of the general practitioner’s role in supporting patients with impaired self-care ability.

Design: Qualitative interviews with 13 patients with type 2 diabetes, concurrent chronic diseases, and impaired self-care ability assessed by a general practitioner. We analyzed our data using systematic text condensation. The shifting perspectives model of chronic illness formed the theoretical background for the study.

Results: Although most patients experienced challenges in adhering to recommended self-care activities, many had developed additional, personal self-care routines that increased wellbeing. Some patients were conscious of self-care trade-offs, including patients with concurrent mental disorders who were much more attentive to their mental disorder than their somatic diseases. Patients’ perspectives on diseases could shift over time and were dominated by emotional considerations such as insisting on leading a normal life or struggling with limitations caused by disease. Most patients found support in the ongoing relationship with the same general practitioner, who was valued as a companion or appreciated as a trustworthy health informant.

Conclusion: Patient experiences of self-care may collide with what general practitioners find appropriate in a medical regimen. Health professionals should be aware of patients’ prominent and shifting considerations about the emotional aspects of disease. Patients valued the general practitioner’s role in self-care support, primarily through the long-term doctor-patient relationship. Therefore, relational continuity should be prioritized in chronic care, especially for patients with impaired self-care ability who often have a highly complex disease burden and situational context.

• Key points

• Little is known about the perspectives of disease and self-care in patients with a doctor-assessed impaired ability of self-care.

• ??Although patients knew the prescribed regimen they often prioritized self-care routines that increased well-being at the cost of medical recommendations.

• ??Shifting emotional aspects were prominent in patients’ considerations of disease and sustained GPs’ use of a patient-centred clinical method when discussing self-care.

• ??Relational continuity with general practitioners was a highly valued support and should be prioritized for patients with impaired self-care.

     

The HPV vaccine: knowledge and attitudes among public health nurses and general practitioners in Northern Norway after introduction of the vaccine in the school-based vaccination programme

Objective: To investigate knowledge of and attitudes to human papillomavirus (HPV) infection, HPV vaccination, cervical cancer, related sources of information and factors associated with willingness to vaccinate one’s own daughter among primary health care (PHC) personnel.

Design: Cross-sectional study.

Setting: PHC.

Subjects: All public health nurses (PHNs) and general practitioners (GPs) in Northern Norway were invited to answer a structured electronic questionnaire; 31% participated (N?=?220).

Main outcome measures: Self-reported and actual knowledge, information sources, attitudes and willingness to vaccinate their (tentative) daughter.

Results: 47% of respondents knew that HPV infection is a necessary cause of cervical cancer. PHNs had higher self-reported and actual knowledge about HPV vaccination and cervical cancer than GPs. PHNs used the Norwegian Institute of Public Health’s numerous information sources on HPV, while GPs had a low user rate. 88% of PHNs and 50% of GPs acquired information from the pharmaceutical industry. 93% PHNs and 68% of GPs would vaccinate their 12-year-old daughter. In a multivariate logistic regression analysis, willingness to vaccinate one’s daughter was positively associated with younger age, being PHN (OR?=?5.26, 95%CI 1.74–15.94), little concern about vaccine side effects (OR?=?3.61, 95%CI 1.10–11.81) and disagreement among experts (OR?=?7.31, 95%CI 2.73–19.60).

Conclusions: Increased knowledge about HPV infection and vaccination is needed, particularly among GPs. Those least concerned about side effects and disagreements among experts were most likely to vaccinate their daughter. These findings are of interest for public health authorities responsible for the Norwegian vaccination and cervix cancer screening programmes, and providers of training of PHC personnel.

• Key points

• One year after introduction of HPV vaccination among 12-year-old schoolgirls in Norway, a cross-sectional study in Northern Norway among general practitioners (GPs) and public health nurses (PHNs) showed that

• ??barely half of PHC professionals knew the causal relationship between HPV infection and cervical cancer

• ??PHNs and GPs had higher self-reported than actual knowledge about HPV vaccination and cervical cancer

• nearly all PHNs and two thirds of GPs wanted to vaccinate their 12-year-old daughter. Those most concerned about side effects and disagreement among experts were less likely to vaccinate.

     

General practitioners’ views on leadership roles and challenges in primary health care: a qualitative study

Objective: To explore general practitioners’ (GPs) views on leadership roles and leadership challenges in general practice and primary health care.

Design: We conducted focus groups (FGs) with 17 GPs.

Setting: Norwegian primary health care.

Subjects: 17 GPs who attended a 5 d course on leadership in primary health care.

Results: Our study suggests that the GPs experience a need for more preparation and formal training for the leadership role, and that they experienced tensions between the clinical and leadership role. GPs recognized the need to take on leadership roles in primary care, but their lack of leadership training and credentials, and the way in which their practices were organized and financed were barriers towards their involvement.

Conclusions: GPs experience tensions between the clinical and leadership role and note a lack of leadership training and awareness. There is a need for a more structured educational and career path for GPs, in which doctors are offered training and preparation in advance.

• KEY POINTS

• Little is known about doctors’ experiences and views about leadership in general practice and primary health care. Our study suggests that:

• There is a lack of preparation and formal training for the leadership role.

• GPs experience tensions between the clinical and leadership role.

• GPs recognize leadership challenges at a system level and that doctors should take on leadership roles in primary health care.

     

Optimizing health system response to patient’s needs: an argument for the importance of functioning information

Background: Current health systems are increasingly challenged to meet the needs of a growing number of patients living with chronic and often multiple health conditions. The primary outcome of care, it is argued, is not merely curing disease but also optimizing functioning over a person’s life span. According to the World Health Organization, functioning can serve as foundation for a comprehensive picture of health and augment the biomedical perspective with a broader and more comprehensive picture of health as it plays out in people’s lives. The crucial importance of information about patient’s functioning for a well-performing health system, however, has yet to be sufficiently appreciated.

Methods: This paper argues that functioning information is fundamental in all components of health systems and enhances the capacity of health systems to optimize patients’ health and health-related needs.

Results and conclusion: Beyond making sense of biomedical disease patterns, health systems can profit from using functioning information to improve interprofessional collaboration and achieve cross-cutting disease treatment outcomes.

• Implications for rehabilitation

• Functioning is a key health outcome for rehabilitation within health systems.

• Information on restoring, maintaining, and optimizing human functioning can strengthen health system response to patients’ health and rehabilitative needs.

• Functioning information guides health systems to achieve cross-cutting health outcomes that respond to the needs of the growing number of individuals living with chronic and multiple health conditions.

• Accounting for individuals functioning helps to overcome fragmentation of care and to improve interprofessional collaboration across settings

     

History of violence and subjective health of mother and child

Objective: To study the self-reported prevalence of experienced violence among a cohort of women about two years after giving birth, their health during pregnancy, pregnancy outcomes and their experience of their child’s health.

Setting and subjects: In 2011, a total of 657 women participated in phase III of the Childbirth and Health Cohort Study in Icelandic Primary Health Care, 18 to 24 months after delivery. The women had previously participated in phase I around pregnancy week 16 and phase II 5–6 months after delivery. Data were collected by postal questionnaires.

Main outcome measures: Women’s reported history of experienced violence, sociodemographic and obstetric background, self-perceived health, the use of medications and their child’s perceived health.

Results: In phase III, 16% of women reported experiencing violence. These women felt less support from their current partner (p?p?p?p?p?p?=?0.008).

Conclusions: Our study confirms that a history of violence is common among women. A history of violence is associated with various maternal health problems during and after pregnancy, a higher rate of caesarean sections and maternal reports of health problems in their child 18–24 months after birth.

• KEY POINTS

• Violence is a major concern worldwide. Understanding the impact of violence on human health and developing effective preventive measures are important elements of any public health agenda.

• ??The reported prevalence of experiencing violence was 16% among women attending antenatal care in the primary health care setting in Iceland.

• ??Women with a history of violence reported worse health in general during pregnancy and delivered more often by caesarean section, compared to women with no such history.

• ??Mothers with a history of violence also evaluated the general health of their child as worse than women with no such history.

• ??The findings of this study support the importance of recognizing and addressing experienced violence among women in primary care.

     

Patients’ ideas,concerns, expectations and satisfaction in primary health care – a questionnaire study of patients and health care professionals’ perspectives

Abstract

Objective: Explore the perceptions of patients and health care professionals about patients’ ideas, concerns, expectations (ICE), and satisfaction in consultations with general practitioners (GPs), district nurses (DNs) and physiotherapists (PTs).

Design: Cross-sectional questionnaire study of participants in planned consultations.

Setting: Five primary health care centers and two rehabilitation centers in Stockholm, Sweden.

Subjects: Pairs of patients and GPs (n?=?156), patients and DNs (n?=?73), and patients and PTs (n?=?69).

Main outcome measures: Multiple-choice questions about patients’ ICE and satisfaction.

Results: Approximately 75% of patients and GPs reported that patients’ thoughts and explanations about their symptoms emerged during the consultation. For patient-DN pairs, the figure was 60%, and for patient-PT pairs, 80%. A majority of patients reported not having concerns and anxiety about the investigation/treatment, whereas health care professionals thought patients were more concerned. One-third of patients consulting GPs and PTs expected to receive a reason/explanation for their symptoms. Figures were lower for the DNs. About 70% of patients were satisfied with the consultation.

Conclusions: Most patients expressed their ideas, a minority had concerns, and a minority expected an explanation of their illness. Patients and health care professionals rated patient satisfaction high, but health care professionals tended to believe patients were less satisfied than patients reported they were.

• Key points

• Patient surveys show that important aspects of patient-centeredness remain weak in Swedish primary health care; for example, shared decision-making.

• In this study of planned consultations, few patients expected to receive an explanation of their symptoms, but most were satisfied with the consultation.

• Health care professionals thought patients’ experiences were more negative than they were.

• This discrepancy was observed in responses to questions about patients’ concerns, expectations and satisfaction.

     

Schizophrenia and attendance in primary healthcare: a population-based matched cohort study

Abstract

Objective: Schizophrenia is associated with high mortality, somatic comorbidity and reduced life expectancy. The general practitioner (GP) plays a key role in the treatment of mental and physical multimorbidity. Nevertheless, it is unclear how much individuals with schizophrenia use primary healthcare. This study aims to investigate the yearly numbers of consultations in general practice for individuals with schizophrenia.

Design and Setting: We performed a population-based matched cohort study of 21,757 individuals with schizophrenia and 435,140 age- and gender-matched references from Danish National Registers. Monthly general practice consultations were analysed using a generalized linear model with log link and assuming negative binomial distribution.

Main outcome measures: Consultation rates in general practice up to17 years after index diagnosis.

Results: Individuals with schizophrenia attended their GP more than references throughout the study period. The cases had 82% (95% CI: 78-87) and 76% (95% CI: 71-80) more consultations in primary care after 1 year and 5 years, respectively. Individuals with both schizophrenia and comorbid somatic illness attended even more.

Conclusion: Individuals with schizophrenia are in regular contact with their GP, especially if they have comorbid illnesses. Whether an average of six consultations per year for individuals with schizophrenia is sufficient is up for debate. The study demonstrates a potential for an increased prevention and treatment of individuals with schizophrenia in general practice.

• KEY POINTS

• Schizophrenia is associated with high mortality, somatic comorbidity and reduced life expectancy. Little is known about the attendance pattern in primary care for individuals with schizophrenia.

• ?We found high attendance rates in primary care for individuals diagnosed with schizophrenia from index diagnosis and at least 17 years after diagnosis, which suggests opportunities for earlier intervention to improve their somatic health.

• ?We found an association between high illness comorbidity and increased risk of not attending the general practitioner. The most severely somatically and mentally ill individuals may thus be difficult to reach and support in the current healthcare system.

     

Doctors’ characteristics and the use of long consultations at out-of-hours services 2008–2017: a registry-based follow-up study in Norway

Abstract

Objective: The aim was to analyse whether there was a change in percentage of long consultations over a 10-year period, and whether individual doctors changed their use of time as they got more experience and specialisation during the same period.

Design and setting: This is a registry based study encompassing all consultations in primary care out-of-hours service in Norway in 2008 and 2017.

Subjects: For both years all doctors were included in cross sectional analyses. In addition, doctors who participated both years were included in a separate follow-up analysis.

Main outcome measures: Long consultations (>20?min) were identified by a time fee in the claims’ database.

Results: There were 4610 doctors in 2008 and 5620 in 2017, 904 participated both years. In 2008 a time fee was claimed in 38% of consultations, in 2017 in 47%. Older doctors made less use of the time fee, as did doctors who had many consultations, regular general practitioners, and general practice specialists. The general practitioners who participated both years increased their use of the time fee from 33% to 38% of consultations. Those who specialised in general practice during the 10-year period increased their use of the time fee from 34% to 37%.

Conclusions: Experienced doctors have fewer long consultations than inexperienced doctors. Over years there is a strong trend towards increasing the use of time fee during out-of-hours consultations. This trend is only partly offset by increasing the experience of the doctors.

• KEY POINTS

• Although consultation length may be associated with patient satisfaction there is also a cost-efficiency aspect to be taken into account

• ?Percentage long consultations out-of-hours increased from 38% in 2008 to 47% in 2017

• ?Experienced doctors had fewer long consultations

• ?Experience only partly offset the trend towards more long consultations

     

Narrative environments and the capacity of disability narratives to motivate leisure-time physical activity among individuals with spinal cord injury

Abstract

Purpose: Few individuals with spinal cord injury (SCI) engage in the recommended amount of leisure time physical activity (LTPA). Yet little is known about how, and why, active individuals engage in specific types of LTPA. This study explored how a unique narrative environment and disability narratives motivated individuals with SCI to engage in LTPA. Method: Fourteen individuals with SCI from a physical activity program participated in approximately hour-long interviews. Interviews were then subjected to a narrative analysis. Results: Individuals who used a restitution narrative (n?=?6) were motivated to engage in functional LTPA because of the desire to maintain the body and restore the past self. The individual who used the chaos narrative (n?=?1) preferred solitary LTPA as exposure to others with SCI was a constant reminder of the lost, pre-injury self. Individuals who used a quest narrative (n?=?7) explored LTPA options that fit with their interests; these individuals were open to new types of LTPA, such as sport and outdoor recreation. Conclusion: The plot of three disability narratives can all motivate the pursuit of LTPA; however, not all types of LTPA are seen as equal. LTPA interventions can be enhanced through the lessons learned from this unique type of environment.

• Implications for Rehabilitation

• Despite individuals’ views about their disability, they can still be motivated to engage in routine LTPA.

• Different theoretical determinants, such as health or social benefits, hold different relevance for LTPA among individuals with differing disability narratives.

• The environment provided by practitioners can therefore elicit some stories of SCI while stifling others. Open narrative environment will attract individuals to listen and maintain involvement in LTPA.

     

Reasons for attending a general emergency outpatient clinic versus a regular general practitioner – a survey among immigrant and native walk-in patients in Oslo,Norway

Objective: To explore reasons for attending a general emergency outpatient clinic versus a regular general practitioner (RGP).

Design: Cross-sectional study using a multilingual anonymous questionnaire.

Setting: Native and immigrant walk-in patients attending a general emergency outpatient clinic in Oslo (Monday–Friday, 08:00–23:00) during 2 weeks in September 2009.

Subjects: We included 1022 walk-in patients: 565 native Norwegians (55%) and 457 immigrants (45%).

Main outcome measures: Patients’ reasons for attending an emergency outpatient clinic versus their RGP.

Results: Among patients reporting an RGP affiliation, 49% tried to contact their RGP before this emergency encounter: 44% of native Norwegian and 58% of immigrant respondents. Immigrants from Africa [odds ratio (OR)?=?2.55 (95% confidence interval [CI]: 1.46–4.46)] and Asia [OR?=?2.32 (95% CI: 1.42–3.78)] were more likely to contact their RGP before attending the general emergency outpatient clinic compared with native Norwegians. The most frequent reason for attending the emergency clinic was difficulty making an immediate appointment with their RGP. A frequent reason for not contacting an RGP was lack of access: 21% of the native Norwegians versus 4% of the immigrants claimed their RGP was in another district/municipality, and 31% of the immigrants reported a lack of affiliation with the RGP scheme.

Conclusions and implications: Access to primary care provided by an RGP affects patients’ use of emergency health care services. To facilitate continuity of health care, policymakers should emphasize initiatives to improve access to primary health care services.

• KEY POINTS

• Access to immediate primary health care provided by a regular general practitioner (RGP) can reduce patients’ use of emergency health care services.

• The main reason for attending a general emergency outpatient clinic was difficulty obtaining an immediate appointment with an RGP.

• A frequent reason for native Norwegians attending a general emergency outpatient clinic during the daytime is having an RGP outside Oslo.

• Lack of affiliation with the RGP scheme is a frequent reason for attending a general emergency outpatient clinic among immigrants.

     

“The complaining women”: health professionals’ perceptions on patients with fibromyalgia in Spain

Purpose: The aim of this study is twofold: (1) to explore health service providers’ perceptions regarding fibromyalgia patients in Spain and (2) to analyze possible consequences of these perceptions in terms of how health service providers construct the disease and treat their patients.

Design: Qualitative study.

Subjects/Patients: Twelve health service providers (eight men, four women) involved in the care of fibromyalgia patients. Providers were from different disciplines and included general practitioners, rheumatologists, occupational doctors, psychologists, psychiatrists, physiotherapists and behavioral specialists from Spain.

Method: We performed individual semistructured interviews, which were recorded and transcribed to conduct a qualitative content analysis supported by Atlas.ti-7.

Results: We identified three categories from the interviews: (1) the fibromyalgia patient prototype: the complaining woman, (2) fibromyalgia is considered a women’s health issue, but male patients are a privileged minority, and (3) health professionals’ attitudes toward fibromyalgia patients: are they really suffering or pretending?

Conclusion: The uncertainty surrounding fibromyalgia together with the fact that those affected are primarily women, seem to influence professional practice in terms of lack of recognition of Fibromyalgia as a severe disease. Increased training of all health professionals is essential to improving the support and attention given to patients suffering from fibromyalgia.

• Implications for rehabilitation

• Fibromyalgia

• ??In order to improve fibromyalgia patients´ attention, health providers should learn how to assist patients without prejudices.

• ??Training programs for health providers should include sensitization about the severity of fibromyalgia.

• ??Health providers should be aware of the existence of stereotypes about women suffering from fibromyalgia.

• ??Fibromyalgia protocols should give skills to health providers to avoid offering a gender-biased attention to patients.

     

Integrative intervention: a new perspective and brief review in aphasia

Purpose: While integrative treatment practices have become a popular treatment in different areas of study, its use in the field of aphasiology is still limited. The following paper is an attempt to address the different alternative practices that could potentially be used to remediate aphasia.

Method: A narrative review was completed regarding integrative intervention that could potentially apply to aphasia population.

Results: Through this article we have explored various treatment options for integrative health care in aphasiology. Integrative treatments including brain specific antioxidants, progesterone and estradiol therapy, nutrition, synbiotic treatment, exercise, yoga, meditation and positive mood states have demonstrated positive changes in health and behavior in healthy aging or disorders such as stroke and aphasia. Offering integrative treatment for people with aphasia allows potential for high impact gains when combined with current speech language therapeutic practices.

Conclusion: This paper highlights the rehabilitation possibilities for aphasia therapy. Combining complementary and traditional treatment approaches could be viewed as one of the contemporary approaches to clinical practice and research for practitioners and health care systems.

• Implications for Rehabilitation

• There has been very little research that explores the potential of various types of integrative treatment for individuals with aphasia.

• An integrative approach to the treatment of aphasia has potential for future clinical application.

• Combining treatment approaches could be viewed as a viable approach to clinical practice and in the health care system.

     

Variations in older people’s use of general practitioner consultations and the relationship with mortality rate in Vantaa,Finland in 2003–2014

Abstract

Objective: It is generally expected that the growth of the older population will lead to an increase in the use of health care services. The aim was to examine the changes in the number of visits made to general practitioners (GP) by the older age groups, and whether such changes were associated with changes in mortality rates.

Design and setting: A register-based observational study in a Finnish city where a significant increase in the older population took place from 2003 to 2014. The number of GP visits made by the older population was calculated, the visits per person per year in two-year series, together with respective mortality rates.

Subjects: The study population consisted of inhabitants aged 65?years and older (65+) in Vantaa that visited a GP in primary health care.

Main outcome measures: The number of GP visits per person per year in the whole older population during the study years.

Results: In 2009–2010, there was a sudden drop in GP visits per person in the younger (65–74?years) age groups examined. In the population aged 85+, use of GP visits remained at a fairly constant level. The mortality rate decreased until the year 2008. After that, the positive trend ended and the mortality rate plateaued.

Conclusions: Simultaneously with the decline in GP visits per person in the older population, the mortality rate leveled off from its positive trend in 2009–2010. Factors identified being associated with the number of GP consultations were organizational changes in primary health care, economic recession causing retrenchment, and even vaccinations during the swine flu epidemic.

• Key points

• Along with an increasingly ageing population, concern over the supply of publicly funded health care has become more pronounced.

• The amount of GP visits of 65+ decreased in primary health care, especially in the youngest groups.

• However, in the oldest age groups (85+), the use of GPs remained unchanged regardless of changes in service supply.

• As the rate of GP visits among the population of 65+ declined, the positive trend in the mortality rate ceased.