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.
Objective: To examine the associations between patients’ self-rated health and their sleep problems, somatic health complaints, and unmet needs in interpersonal relationships.
Design: We collected data via questionnaires for this cross-sectional study from general practice.
Setting: Primary health care in Norway.
Subjects: 1302 consecutive patients participated.
Main outcome measures: The questionnaire included a single question about SRH, the Bergen Insomnia Scale (BIS), five questions on somatic health complaints, and three questions from the Basic Psychological Needs Scale (BPNS) pertaining to the relationships domain. We analyzed our data using ordinal logistic regression models.
Results: Our response rate was 74%. The prevalence of fair/poor SRH was 26%, with no gender differences. We revealed a significant association between increasing age and reduced SRH. The study showed that sleep problems and somatic health complaints were strongly associated with SRH, and unmet needs in relationships were also significantly and independently associated with reduced SRH in a full model analysis.
Conclusion: Sleep problems, somatic health complaints, and unmet needs in interpersonal relationships were all associated with reduced SRH. These factors are all modifiable and could be managed both within and outside a primary care setting in order to improve SRH.
- Key Points
There was a high prevalence of reduced SRH in clinical general practice
Sleep problems, somatic health complaints, and unmet needs in interpersonal relationships were all associated with reduced SRH
These predictors are all modifiable with a potential to improve SRH
Methods: Five individuals were trained using priming techniques including virtual reality (VR) based visual mirror feedback and contralaterally controlled passive movement strategies prior to training with an active pinch force modulation task. Clinical, kinetic, and neurophysiological measurements were taken pre and post the training period. Clinical measures were taken at six months post training.
Results: The two priming simulations and active training were well tolerated early after stroke. Priming effects were suggested by increased maximal pinch force immediately after visual and movement based priming. Despite having no clinically observable movement distally, the subjects were able to volitionally coordinate isometric force and muscle activity (EMG) in a pinch tracing task. The Root Mean Square Error (RMSE) of force during the pinch trace task gradually decreased over the training period suggesting learning may have occurred. Changes in motor cortical neurophysiology were seen in the unaffected hemisphere using Transcranial Magnetic Stimulation (TMS) mapping. Significant improvements in motor recovery as measured by the Action Research Arm Test (ARAT) and the Upper Extremity Fugl Meyer Assessment (UEFMA) were demonstrated at six months post training by three of the five subjects.
Conclusion: This study suggests that an early hand-based intervention using visual and movement based priming activities and a scaled motor task allows participation by persons without the motor control required for traditionally presented rehabilitation and testing.
- Implications for Rehabilitation
Rehabilitation of individuals with severely paretic upper extremities after stroke is challenging due to limited movement capacity and few options for therapeutic training.
Long-term functional recovery of the arm after stroke depends on early return of active hand control, establishing a need for acute training methods focused distally.
This study demonstrates the feasibility of an early hand-based intervention using virtual reality based priming and scaled motor activities which can allow for participation by persons without the motor control required for traditionally presented rehabilitation and testing.
Methods: This study adopted a single group pre-test–post-test design. Twenty-five PwMS (50.3 years SD 14.1) received vibration training on a side-alternating vibration platform. Each training session was repeated three times every week for 8 weeks. Prior to and following the 8-week training course, a battery of fall risk factors were evaluated: the body balance, functional mobility, muscle strength, range of motion, and fear of falling. Bone density at both calcanei was also assessed.
Results: Twenty-two participants completed the study. Compared with pre-test, almost all fall risk factors and the bone density measurement were significantly improved at post-test, with moderate to large effect sizes varying between 0.571 and 1.007.
Conclusions: The 8-week vibration training was well accepted by PwMS and improved their fall risk factors. The important findings of this study were that vibration training may increase the range of motion of ankle joints on the sagittal plane, lower the fear of falling, and improve bone density.
- IMPLICATIONS FOR REHABILITATION
An 8-week vibration training course could be well-accepted by people with multiple sclerosis (MS).
Vibration training improves the risk factors of falls in people living with MS.
Vibration training could be a promising rehabilitation intervention in individuals with MS.
Methods: Seven pwMS with varied demographic and disease characteristics completed the 8-week home-based program alongside 3 hours of telephone support. Online questionnaires were completed every four days for 16 weeks (4-weeks baseline, 8-weeks treatment, 4-weeks follow-up). The primary outcomes were pain severity and pain interference. Psychological process variables drawn from the MS pain model were also completed, and post-treatment qualitative interviews conducted.
Results: Simulation modeling analysis (SMA) showed three patients had large improvements in pain outcomes, two showed no change and two worsened. Five participants showed significant change on various psychological process variables. Change in pain catastrophizing was the most consistent finding.
Conclusions: The findings suggest a self-management program for MS pain with minimal therapy support may be effective for some pwMS, but not those with more complex comorbidities. The participants suggested web-based delivery may simplify the approach, and therapist telephone contact was highly valued.
- Implications for Rehabilitation
This case series suggests a hybrid CBT/ACT self-management workbook program for MS pain improves severity and impact of pain in some pwMS.
Pain-related catastrophizing reduced in most pwMS, whilst change in other ACT and CBT process variables varied across the individuals.
PwMS feedback suggests a tailored web-based delivery of the program with therapist telephone support may be optimal.
PwMS with serious co-morbid depression and very advanced disease may not respond well to this self-management approach.
Design: Randomised survey study.
Setting: Denmark.
Subjects: A random sample of women from the birth cohorts 1993, 1994 and 1995 drawn from the general population.
Interventions: A web-based questionnaire and information intervention. We randomised potential respondents to one of the following four different information modules about benefits and harms of cervical screening: no information; non-numerical information; and two numerical information modules. Moreover, we provided HPV-vaccinated women in one of the arms with numerical information about benefits and harms in two steps: firstly, information without consideration of HPV vaccination and subsequently information conditional on HPV vaccination.
Main outcome measure: Self-reported intention to participate in cervical screening.
Results: A significantly lower proportion intended to participate in screening in the two groups of women receiving numerical information compared to controls with absolute differences of 10.5 (95% CI: 3.3–17.6) and 7.7 (95% CI: 0.4–14.9) percentage points, respectively. Among HPV-vaccinated women, we found a significantly lower intention to participate in screening after numerical information specific to vaccinated women (OR of 0.38).
Conclusions: Women are sensitive to numerical information about the benefits and harms of cervical screening. Specifically, our results suggest that HPV-vaccinated women are sensitive to information about the expected changes in benefits and harms of cervical screening after implementation of HPV vaccination.
- KEY POINTS
Women were less likely to participate in cervical screening when they received numerical information about benefits and harms compared to non-numerical or no information.
Specifically, numerical information about the potential impact of the reduced risk of cervical cancer among HPV-vaccinated women reduced the intention to participate among vaccinated women.
Design: A cross-sectional population study.
Setting: The municipality of Naestved, Denmark.
Subjects: We studied 907 patients with type 2 diabetes identified from a random sample of 21,205 Danish citizens.
Main outcome measures: The proportion of patients who were not achieving goals for diabetes care based on their HbA1c, LDL-cholesterol, blood pressure, and lifestyle, and the proportion of patients who were treated with antihypertensive and cholesterol- and glucose-lowering medication.
Methods: We investigated the association of the socioeconomic factors such as age, gender, education, occupation, income, and civil status and attainment of treatment goals and pharmacotherapy in logistic regression analyses. We investigated effect modification of cardiovascular disease and kidney disease.
Results: Middle age (40–65 years), low education level (i.e. basic schooling), and low household income (i.e. less than 21,400 € per year) were associated with nonattainment of goals for diabetes care. The association of socioeconomic factors with attainment of individual treatment goals varied. Patients with low socioeconomic status were more often obese, physically inactive, smoking, and had elevated blood pressure. Socioeconomic factors were not associated with treatment goals for hyperglycemia. Socioeconomic factors were inconsistently associated with pharmacotherapy. There was no difference in contacts to general practitioners according to SES.
Conclusions: In a country with free access to health care, the socioeconomic factors such as middle age, low education, and low income were associated with nonattainment of goals for diabetes care.
- KEY POINTS
Middle age, low education, and low income were associated with nonattainment of goals for diabetes care, especially for lifestyle goals.
Patients with low socioeconomic status were more often obese, physically inactive, smoking, and had elevated blood pressure.
Association of socioeconomic factors with pharmacotherapy was inconsistent.
Method: Four databases were searched for studies published before August 2016 using database-specific keywords and synonyms for amputation, cardiovascular diseases and mobility. Assessment of the publications was performed based on predefined criteria; first title and abstract and thereafter the full text.
Results: Of the 1704 titles and abstracts, 51 full texts were assessed. Ten studies were included. Cardiovascular diseases were associated with cardiac complications during rehabilitation. Prosthetic training improved cardiac function. Seven studies showed that cardiovascular diseases were associated with a smaller chance of becoming a prosthetic walker, and with poorer mobility outcomes.
Conclusion: Evidence for effects of cardiovascular diseases on mobility in persons with a lower limb amputation is heterogeneous. Cardiovascular diseases reduce the chance of becoming a prosthetic walker and reduce mobility outcomes after a lower limb amputation. More research with adequate quality about cardiovascular diseases in persons requiring a lower limb amputation is needed, to enable informed choices in the pre- and post-amputation rehabilitation.
- Implications for rehabilitation
Data about the effect of cardiovascular diseases on mobility in persons with a lower limb amputation is limited.
More research about cardiovascular diseases in persons requiring a lower limb amputation is needed, to enable informed choices in the pre- and post-amputation rehabilitation.
Design: Population-based questionnaire study.
Setting: Central Denmark Region with approximately 1.3 million inhabitants.
Subjects: All 843 active GPs in the Central Denmark Region were sent a questionnaire by mail.
Main outcome measures: Responses to 18 items concerning four aspects: provision of EOL care to patients with different diagnosis, confidence with being a key worker, organisation of EOL care and EOL skills (medical and psychosocial).
Results: In total, 573 (68%) GPs responded. Of these, 85% often/always offered EOL care to cancer patients, which was twice as often as to patients with non-malignancies (34–40%). Moreover, 76% felt confident about being a key worker, 60% had a proactive approach, and 58% talked to their patients about dying. Only 9% kept a register of patients with EOL needs, and 19% had specific EOL procedures. GP confidence with own EOL skills varied; from 55% feeling confident using terminal medications to 90% feeling confident treating nausea/vomiting. Increasing GP age was associated with increased confidence about being a key worker and provision of EOL care to patients with non-malignancies. In rural areas, GPs were more confident about administering medicine subcutaneously than in urban areas.
Conclusion: We found considerable diversity in self-reported EOL care competences. Interventions should focus on increasing GPs’ provision of EOL care to patients with non-malignancies, promoting better EOL care concerning organisation and symptom management.
- KEY POINTS
GPs are pivotal in end-of-life (EOL) care, but their involvement has been questioned. Hence, GPs’ perceived competencies were explored.
GPs were twice as likely to provide EOL care for patients with cancer than for patients with non-malignancies.
EOL care was lacking clear organisation in general practice in terms of registering palliative patients and having specific EOL procedures.
GPs were generally least confident with their skills in terminal medical treatment, for example, using medicine administered subcutaneously.
Method: We conducted an outpatient two-part rehabilitation intervention that involved six weeks of therapeutic supervised training (part one) and six weeks of unsupervised training in a local gym following a training protocol (part two).
Results: Predefined feasibility objectives of safety (100%), consent rate (>80%), drop-out (<20%), adherence (>80%) and patient satisfaction (>80%) was achieved at part one. However, the failure to meet predefined feasibility objectives of drop-out, adherence and patient satisfaction of the unsupervised intervention at part two have led to a protocol revision for a future randomized controlled trial.
Conclusion: This study demonstrates that an intensive rehabilitation intervention of physical therapy and occupational therapy in the initial treatment phase of patients with gliomas whose Karnofsky performance status is ≥70 is safe and feasible, if relevant inclusion criteria and precautionary screening are made. With the revised protocol, we are confident that the foundation for conducting a successful randomized controlled trial among these vulnerable patients has been established.
- Implications for rehabilitation
Brain tumors constitute some of the most challenging cancer diagnoses presenting for rehabilitation intervention.
Patients with gliomas experiences limitations in physical functioning, cognition, and emotional wellbeing.
In a relatively small sample this study shows that supervised physical- and occupational therapy in patients with gliomas is safe and feasible in the initial treatment phase.
Patients with gliomas can potentially improve functioning through interdisciplinary rehabilitation
Design: Prospective study.
Setting: MEDLINE (PubMed) and Google Scholar were searched for relevant publications from 1 January 2009 up until 31 August 2014.
Methods: Abstracts accepted for oral or poster presentation were identified from the original congress booklets from the Nordic Congresses of General Practice in 2009 and 2011. Based on PubMed and Google Scholar searches, we subsequently identified full journal publications within a 36-month follow-up from both congresses. In cases of doubt, the first author was contacted directly.
Main outcome measures: Full journal publication within 36 months after the congress.
Results: A total of 200 abstracts were analyzed. Of these, 85 (42.5%) were identified with a full publication within 36 months after the congress. More abstracts from the 2011 congress were published compared to the 2009 congress odds ratio (OR) 1.97, 95% confidence interval (CI) (1.10; 3.50). Abstracts accepted for oral presentation were more often published OR 1.94, 95% CI (1.08; 3.50) than accepted poster abstracts. In the multivariate analysis, a university affiliation for both first and last author increased the probability for publication OR 4.23, 95% CI (1.71; 10.42), as well as more than two authors. An optimal number, based on the highest OR, seems to be 3–4 authors with OR 2.43, 95% CI (1.07; 5.54). Qualitative studies were published at the same frequency as quantitative studies OR 1.36, 95% CI (0.57; 3.24).
Conclusion: Less than half of the abstracts accepted for oral or poster presentation at two consecutive Nordic Congresses of General Practice were published as full text articles within 36 months.
- Key points
Congress abstracts accepted for Nordic Congress of General Practice are not indexed in international search databases.
Less than half of the abstracts accepted for oral or poster presentation at two consecutive Nordic Congresses of General Practice were published as full text articles within 36 months.
Future congress committees could address this aspect in order to increase the visibility of and accessibility to research within the field of general practice.
Methods: Semi-structured interviews, subject to general inductive analysis with 20 Clinicians’ working in three UK based stroke rehabilitation teams (one in-patient ward and two community based rehabilitation teams).
Results: There were three key themes that impacted on the patients active involvement in setting goals for rehabilitation after stroke: Patient barriers to goal setting (knowledge of the patient and family, who is the patient and the stroke’s impact); How we work as a team (the role of the patient in setting goals, the effect of clinician attributes on goal setting); and How systems impact goal setting (goal-setting practice, home versus hospital, and professional/funder expectations of clinicians’).
Conclusions: Goal setting served a range of different, sometimes conflicting, functions within rehabilitation. Clinicians’ identified the integral nature of goals to engage and motivate patients and to provide direction and purpose for rehabilitation. Further, there was an identified need to consider the impact of prioritizing clinician-derived goals at the expense of patient-identified goals. Lastly the reliance on the SMART goal format requires further consideration, both in terms of the proposed benefits and whether they disempower the patient during rehabilitation.
- Implications for rehabilitation
Goal setting is often promoted as a relatively simple, straightforward way to structure interactions with patients
Patient-related factors together with resourcing constraints are significant barriers to patient-centered goal setting, particularly during inpatient rehabilitation
Clinicians need to have pragmatic tools that can be integrated into practice to ensure that goal-setting practice can be maximized for patients with different intrinsic characteristics
Method: An uncontrolled pre- and post-assessment design was employed to study the use of unmodified, low-cost, off-the-shelf smartphones combined with Internet-calendars as a compensatory memory strategy in community-dwelling patients with traumatic brain injury. Thirteen participants received a 6-week group-based intervention with pre-, post- and 2-month follow-up-assessments by questionnaires and by daily assessment of target behaviors for 2-week periods.
Results: Participants reported significantly fewer retro- and prospective memory problems on questionnaires after the intervention and at follow-up with large effect sizes. The performance of target behaviors, however, improved insignificantly with moderate effect sizes. There were no changes in quality of life or symptoms of emotional distress.
Conclusions: This study adds to a growing body of evidence that smartphones are a useful compensatory aid in rehabilitation of prospective memory that should routinely be considered in rehabilitation of traumatic brain injury patients.
- Implication for rehabilitation
Smartphones are easy-to-use and accessible assistive technology for compensatory memory rehabilitation to most traumatic brain injury patients.
By using low-cost, off-the-shelf devices, the technology becomes available to a broader range of patients.
By combining smartphones with Internet-based and cross-platform services (e.g., calendars, contacts) the participants are less device-dependent and less vulnerable to data loss.
Smartphones should routinely be considered as compensatory aid in rehabilitation of prospective memory of traumatic brain injured patients.
Method: Alvesson and Sandberg’s method of problematisation was used. We began with a historical overview of stroke rehabilitation, and proceeded through five steps undertaken in an iterative fashion: literature search and selection; data extraction; syntheses across texts; identification of assumptions informing the literature and; generation of alternatives.
Results: Discussion of risk in stroke rehabilitation is largely implicit. However, two prominent conceptualisations of risk underpin both knowledge development and clinical practise: the risk to the individual stroke survivor of remaining dependent in activities of daily living and the risk that the health care system will be overwhelmed by the costs of providing stroke rehabilitation.
Conclusions: Conceptualisation of risk in stroke rehabilitation, while implicit, drives both research and practise in ways that reinforce a focus on impairment and a generic, decontextualised approach to rehabilitation.
- Implications for rehabilitation
Much of stroke rehabilitation practise and research seems to centre implicitly on two risks: risk to the patient of remaining dependent in ADL and risk to the health care system of bankruptcy due to the provision of stroke rehabilitation.
The implicit focus on ADL dependence limits the ability of clinicians and researchers to address other goals supportive of a good life following stroke.
The implicit focus on financial risk to the health care system may limit access to rehabilitation for people who have experienced either milder or more severe stroke.
Viewing individuals affected by stroke as possessing a range of independence and diverse personally valued activities that exist within a network of relations offers wider possibilities for action in rehabilitation.
Design: An observational study.
Setting: Register-based retrospective quasi-experimental longitudinal follow-up study based on a before–after setting in a Finnish city.
Subjects: Patients who consulted different doctors in a local health care unit.
Main outcome measures: Numbers of monthly visits to different doctor groups in public and private primary care, and numbers of monthly referrals to secondary care ED from different sources of primary care were recorded before and after abrupt implementation of the reverse triage.
Results: The beginning of reverse triage decreased the number of patient visits to a primary ED doctor without increasing mortality. Simultaneously, there was an increase in doctor visits in the adjacent secondary care ED and local private sector. The number of patients who came to secondary care ED without a referral or with a referral from the private sector increased.
Conclusions: The data suggested that the reverse triage causes redistribution of the use of doctors’ services rather than a true decrease in the use of these services. 相似文献
Method: Semi-structured interviews were completed with 18 neurological physiotherapists (2–22 years experience) from SCI centres in the United Kingdom and Ireland. Framed by interpretivism, an inductive thematic analysis was conducted.
Results: Three themes were identified: (1) perceived importance of PA; (2) inconsistent PA promotion efforts; and (3) concern regarding community PA.
Conclusions: This article makes a significant contribution to the literature by identifying that although physiotherapists value PA, active promotion of PA remains largely absent from their practice. To enable physiotherapists to promote and prescribe PA as a structured and integral component of their practice, effective knowledge strategies need designing and implementing at the macro, meso, and micro levels of healthcare.
- Implications for Rehabilitation
Physiotherapists are well placed to promote a physically active lifestyle and are perceived as valued and trusted messengers of physical activity (PA).
The importance of PA for patients with spinal cord injury (SCI) is valued by physiotherapists yet PA promotion is largely absent from their practice.
Physiotherapists lack specific education and training on PA and SCI and hold certain beliefs which restrict their promotion of PA.
Knowledge translation across the macro, meso, and micro levels of healthcare are essential to facilitate effective PA promotion.