Dementia care initiative in primary practice – study protocol of a cluster randomized trial on dementia management in a general practice setting

Background  

Current guidelines for dementia care recommend the combination of drug therapy with non-pharmaceutical measures like counselling and social support. However, the scientific evidence concerning non-pharmaceutical interventions for dementia patients and their informal caregivers remains inconclusive. Targets of modern comprehensive dementia care are to enable patients to live at home as long and as independent as possible and to reduce the burden of caregivers. The objective of the study is to compare a complex intervention including caregiver support groups and counselling against usual care in terms of time to nursing home placement. In this paper the study protocol is described.     

Dying at home or in the hospital? An observational study in German general practice

Background Although determinants of place of death have been investigated in several studies, there is a lack of knowledge on factors associated with dying at home from the general practice perspective.

Objectives To identify factors associated with dying at home for patients in German general practice.

Methods In a retrospective study, general practitioners of 30 general practices were asked to provide data for all patients aged 18 years or older who died within the last 12 months, using a self-developed questionnaire. ‘Dying in hospital’ was defined as dying in hospital or hospice and ‘dying at home’ as dying at one’s usual residence including the nursing home. Multiple logistic regression analyses were used to determine factors associated with ‘dying at home’; odds ratios (ORs) and their 95% confidence intervals (CI) were calculated as measures of effect size.

Results Of 439 deceased patients, 52.2% died at home, and 47.8% died in hospital or hospice. Determinants for dying at home were patients’ care in the last 48 hours of life by family members (OR: 7.8, 95% CI: 3.4–18.0), by general practitioners (GPs) (OR: 7.3, 4.2–12.9) and living in a nursing home (OR: 3.8, 1.7–8.3). In the adjusted model, low comorbidity was positively associated (OR: 3.2, 1.4–7.0), and low functional health status (Karnofsky performance status) was negatively associated with dying at home (OR: 0.3, 0.1–0.7).

Conclusion Apart from patient-related factors such as comorbidity and health status, care by family members and GPs respectively, were determinants of dying at home.     

Black families’ perceptions of barriers to the practice of a healthy lifestyle: a qualitative study in the UK

While studies have focused on tangible indicators of the practice of healthy lifestyles, there remains a dearth of research exploring the inter-relationships between the practice of healthy lifestyles and the prevailing living circumstances of Black and other visible minority ethnic communities in Western societies. This article presents an account of African Caribbean men and women's beliefs and perceptions about the barriers of practising a healthy lifestyle, focusing specifically on the effects of social exclusion, racism and ethnic identity. A total of 18 participants from the north of England participated in the study, with in-depth interviews conducted in their homes. The participants believed that principles of healthy lifestyles were largely not relevant to their lived experiences because they failed to take into account their experiences of racism, social exclusion, ethnic identity, values and beliefs. Indeed, participants argued that, with their emphasis on illness prevention and perceived Eurocentric approaches, the principles of healthy lifestyle were part of the social exclusion paradigm experienced by their community. The study concludes by suggesting that it is essential to place notions of socio-economic disadvantage, discrimination, marginalisation and racism at the centre rather than the periphery when considering strategies to make healthier choices an easier option for Black and other visible minority ethnic communities.     

Violence in general practice: a gendered risk?

This article focuses on the extent to which violence against family doctors in England is experienced in gendered terms. It draws on data from two studies: a postal survey of 1,300 general practitioners (GPs) (62% response rate) and in‐depth interviews with 26 doctors who have been assaulted or threatened; and 13 focus groups with primary care teams and 19 in‐depth interviews with GPs who had expressed an interest in the topic of violence against doctors. Most GPs, regardless of gender, reported receiving verbal abuse over the last two years, often interpreted as a consequence of declining deference to professionals, while actual physical assaults and threats were much rarer and more likely to be reported by men. Overall, women GPs were much more likely to express concern about violence and to take personal precautions, although younger male GPs working in inner‐city practices also had high levels of concern. The study shows how some aspects of family doctors’ work has been organised on gendered lines and how these contribute to the differences in experience of violence. We suggest that the increasing proportion of women among family doctors may have implications for these, often tacit, organisational routines.     

Geriatric day hospital: opportunity or threat? A qualitative exploratory study of the referral behaviour of Belgian general practitioners

Background  

In order to address the challenges of an ageing population the Belgian government decided to allocate resources to the creation of geriatric day hospitals (GDHs). Although GDHs are meant to be a strategy to support general practitioners (GPs) caring for the frail elderly, few Belgian GPs seem to refer to a GDH. This study aims to explore the barriers and facilitating factors of GPs' referral to GDHs.     

Compassion in healthcare – lessons from a qualitative study of the end of life care of people with dementia

Objectives

A lack of compassion in UK healthcare settings has received much recent attention. This study explores the experiences of people with dementia in the last year of life and time surrounding death and how the presence and lack of compassion, kindness and humanity influenced the experience of care.

Design

Qualitative in-depth interviews with bereaved informal carers of people with dementia.

Setting

United Kingdom.

Participants

Forty bereaved carers – 31 women and nine men – with an age range of 18–86 years and from wide socioeconomic backgrounds participated.

Main outcome measures

Experiences of carers of care for person with dementia during last year of life.

Results

The interviews highlighted differences and challenges in care settings in providing compassionate, humanistic care and the impact of the care experienced by the person with dementia during the last year of life on informal carers during the bereavement period and beyond. Excellent examples of compassionate care were experienced alongside very poor and inhumane practices.

Conclusion

The concepts of compassion, kindness and humanity in dementia care are discussed within the paper. The ability to deliver care that is compassionate, kind and humanistic exists along a continuum across care settings – examples of excellent care sit alongside examples of very poor care and the reasons for this are explored together with discussion as to how health and social care staff can be trained and supported to deliver compassionate care.     

Can we import quality tools? a feasibility study of European practice assessment in a country with less organised general practice

Background  

Quality is on the agenda of European general practice (GP). European researchers have, in collaboration, developed tools to assess quality of GPs. In this feasibility study, we tested the European Practice Assessment (EPA) in a one-off project in Belgium, where general practice has a low level of GP organisation.     

Why do patients want to have their blood tested? A qualitative study of patient expectations in general practice

Background

While in general practice chronic non-specific abdominal complaints are common, there is insufficient data on the clinical course and the management of these complaints. Aim of this study was to present a primary care based profile of these chronic complaints including health care involvement, health status and clinical course.

Methods

Thirty general practitioners (GPs) and patients from their practices participated in a prospective follow-up study. All patients and GPs were asked to complete questionnaires at baseline and at 6, 12 and 18 months of follow-up. The GPs provided information on diagnostic and therapeutic management and on referral concerning 619 patients with chronic non-specific abdominal complaints, while 291 patients provided information about health status and clinical course of the complaints.

Results

When asked after 18 months of follow-up, 51,7% of the patients reported an equal or worsened severity of complaints. General health perception was impaired and patients had high scores on SCL-anxiety and SCL-depression scales. Diagnostic tests other than physical examination and laboratory tests were not frequently used. Medication was the most frequent type of treatment. The persistence of chronic non-specific abdominal complaints was quite stable.

Conclusion

Once non-specific chronic abdominal complaints have become labelled as chronic by the attending physician, little improvement can be expected. The impact on patients' physiological and psychological well-being is large. GPs use a variety of diagnostic and therapeutic strategies. Research into the evidence base of currently applied management strategies is recommended.     

Quantitative and qualitative approaches in the study of poverty and adolescent development: separation or integration?

This paper examines the use of quantitative and qualitative approaches to study the impact of economic disadvantage on family processes and adolescent development. Quantitative research has the merits of objectivity, good predictive and explanatory power, parsimony, precision and sophistication of analysis. Qualitative research, in contrast, provides a detailed, holistic, in-depth understanding of social reality and allows illumination of new insights. With the pragmatic considerations of methodological appropriateness, design flexibility, and situational responsiveness in responding to the research inquiry, a mixed methods approach could be a possibility of integrating quantitative and qualitative approaches and offers an alternative strategy to study the impact of economic disadvantage on family processes and adolescent development.     

Clinical essentialising: a qualitative study of doctors’ medical and moral practice

While certain substantial moral dilemmas in health care have been given much attention, like abortion, euthanasia or gene testing, doctors rarely reflect on the moral implications of their daily clinical work. Yet, with its aim to help patients and relieve suffering, medicine is replete with moral decisions. In this qualitative study we analyse how doctors handle the moral aspects of everyday clinical practice. About one hundred consultations were observed, and interviews conducted with fifteen clinical doctors from different practices. It turned out that the doctors’ approach to clinical cases followed a rather strict pattern across specialities, which implied transforming patients’ diverse concerns into specific medical questions through a process of ‘essentialising’: Doctors broke the patient’s story down, concretised the patient’s complaints and categorised the symptoms into a medical sense. Patients’ existential meanings were removed, and the focus placed on the patients’ functioning. By essentialising, doctors were able to handle a complex and ambiguous reality, and establish a medically relevant problem. However, the process involved a moral as well as a practical simplification. Overlooking existential meanings and focusing on purely functional aspects of patients was an integral part of clinical practice and not an individual flaw. The study thus questions the value of addressing doctors’ conscious moral evaluations. Yet doctors should be aware that their daily clinical work systematically emphasises beneficence at the expense of others—that might be more important to the patient.     

GPs working in solo practice: obstacles and motivations for working in a group? A qualitative study

OBJECTIVE: Our aim was to analyse the obstacles and eventual motivations of solo GPs for working in group practice. METHODS: A qualitative study using 12 focus groups was carried out in primary care in French-speaking Belgium. The subjects comprised four samples of GPs: 20 GP trainers, 18 GP trainees, 25 women GPs and 25 other GPs. The focus groups were taped and transcribed. Two independent researchers carried out the analysis using the QSR NUD.IST software. RESULTS: The participants (88 GPs) did not share a common definition of group practice-in particular multidisciplinary working-the need for a common pool of patients and shared premises. Their main sources of motivation for eventually setting up a group practice were better quality of life, continuity of care and sharing professional knowledge. The main obstacles were a required agreement between colleagues, the loss of a personal patient-GP relationship, budgetary constraints, and divergent views on group practice and GPs' profession (especially true for the association of GPs from different age groups). CONCLUSION: The current study shows that GPs working solo have divergent views of group practice. However, they clearly perceive advantages to this type of association (e.g. better quality of life and continuity of care). This study also confirms the high level of stress and tiredness felt by GPs and especially senior practitioners.