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

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

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

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

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

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

Key Messages

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

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

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

     

HoMER - an opportunity or threat to general practice research?

The National Health and Medical Research Council (NHMRC) Harmonisation of Multicentre Ethical Review (HoMER) project aims to implement a 'single ethical review', where the outcome of an ethical and scientific review by a single recognised Human Research Ethics Committee (HREC) will enable multiple institutions to decide whether or not to participate in a given study. The desired process will include agreement on time frames, authority of the reviewing HREC, respect among the jurisdictions, verification by independent organisations, and compliance with the national statement and relevant statutory and administrative frameworks. However, there appears to be little discourse on the implications for general practice research in the research community.     

Sooner or later? Issues in the early diagnosis of dementia in general practice: a qualitative study

OBJECTIVE: The aim of this study was to explore the perspectives of primary care practitioners on the early diagnosis of dementia. METHODS: A total of 247 GPs, 146 community nurses, 36 practice nurses, 79 community mental health nurses and others working in a range of hospital, residential and community settings attended 24 one-day workshops in 21 cities and towns in the UK. A nominal group approach was used relating to the early diagnosis of dementia in the community. RESULTS: Groups agreed on the benefits and risks of early diagnosis of dementia; disagreed about screening for dementia, and about professional resistance to making the diagnosis; constructed comprehensive guidelines on diagnosis, but without much reference to resource implications; yet described actual local resource limitations in detail; and avoided dilemmas about dementia care by framing it as a specialist activity. CONCLUSION: Practitioners situate dementia in a family context but do not yet use a disablement model of dementia which might reduce tensions about early diagnosis and the disclosure of the diagnosis. The term diagnosis could usefully be replaced by recognition, to aid this shift in model. Service gaps may emerge or widen if earlier diagnosis of dementia is pursued as a policy objective.     

Alcohol education for general practitioners in the United Kingdom - a window of opportunity?

Alcohol misuse is a major public health problem. In the UK, general practitioners are perceived as key players in prevention and management of alcohol problems, but may not be prepared sufficiently to undertake this work. A systematic review of the literature by computerized search of the Medline database, hand search of review article citations and a survey of relevant educational and training organizations and agencies were undertaken. Although there is no shortage of educational materials, there has been little evaluation of their effectiveness. A need for more training and support has been identified, but this requires better co-ordination and a more multidisciplinary approach. Forthcoming changes in the National Health Service and the organization of continuing professional development offer a unique opportunity to advance this agenda.     

Patient preferences in randomised trials: threat or opportunity?

OBJECTIVES: To assess whether it is feasible to elicit patients' preferences for treatments and then to proceed with randomisation which may allocate those with preferences to their less preferred treatment; and to describe which prognostic variables were associated with such preferences within the context of a randomised trial of an exercise programme for back pain. METHODS: The first 97 patients enrolled in a randomised controlled trial (RCT) for the treatment of back pain were asked about their preferences, health characteristics and other prognostic variables. RESULTS: Fifty-eight (60%) patients preferred to be allocated to the exercise programme whilst 38 (39%) were indifferent; one patient preferred conventional general practitioner (GP) management. No patient refused randomisation. Comparing patients preferring the exercise programme with indifferent patients showed that the former had a higher belief in the effectiveness of the new treatment (P < 0.01), tended to have worse back pain (P = 0.09), had back pain for a shorter duration (P = 0.04), and tended to have had more GP home visits (P = 0.06). CONCLUSIONS: For many randomised trials preference may be an important prognostic variable. In such circumstances, preference should be taken into account in the final analysis. This study demonstrates it is sometimes feasible to randomise patients to their less preferred treatment, thus allowing more robust statistical comparisons between randomised groups. This modification may make RCTs more rigorous and improve their external validity.     

Centralized or decentralized? A case study of Norwegian hospital reform

In recent years, decentralization of financial and political power has been perceived as a useful means to improve outcomes of the health care sector of many European countries. Such reforms could be the result of fashionable policy trends, rather than being based on knowledge of "what works". If decentralization is the favored strategy in health care, studies of countries that go against the current trend will be of interest and importance as they provide information about the potential drawbacks of decentralization. In Norway, specialized health care has recently been recentralized. In this paper, we review some of the evidence now available on the economic effects of recentralization. Although recentralization has been associated with improvements in both cost efficiency and technical efficiency this may have been caused by the increasing role of activity-based funding methods used in the allocation of health care resources. However, recentralization was also associated with an increase in the rate of growth of real resources and the proportion of total costs being met by supplementary funding. As a result, recentralization failed to address the issues of cost containment and reductions in budget deficits.     

Elder abuse: do general practitioners know or care?

A pilot survey in Tower Hamlets, London, indicated that many general practitioners (GPs) might not be recognizing abuse of elderly patients through lack of training. The survey was replicated on a large scale in Birmingham, to allow further analysis. 561 Birmingham GPs were mailed questionnaires and responses from 291 were analysed, providing data from 95% of the practices. The findings were similar to those in Tower Hamlets: just under half had diagnosed elder abuse in the previous year. Regression analysis of the combined data-sets (n = 363) indicated that the strongest factor predicting GP diagnosis of abuse was knowledge of 5 or more risk situations (odds ratio 6.77, 95% confidence interval 4.19, 10.93). The findings of these surveys suggest that research-based education and training would help GPs to become better at identifying and managing elder abuse.     

Cooperation between general practitioners and occupational health physicians in Germany: how can it be optimised? A qualitative study

Purpose

General practitioners (GPs) and occupational health physicians (OPs) have several overlapping work fields, such as important functions in prevention, rehabilitation and reintegration into the workplace. In Germany, however, cooperation between GP and OP is often lacking or suboptimal. In this article, we analysed the suggestions for optimisation of cooperation.

Methods

Three focus groups were interviewed: GP, OP and medical doctors working in both fields. A qualitative content analysis was performed.

Results

Categories of suggestions could be assigned to five issues: the “Systemic View” concerning the state and/or employer (e.g. the system of remuneration for GPs), “Inter-collegial Contact” (e.g. fostering “friendly exchanges” between both groups), “Medical Education” (e.g. introducing joint quality circles), “Contents of both Specialities” (e.g. necessity of communicating respective contents and competences), and “Patient-centred Care” (e.g. reintegration into workplace after longer periods of illness). The optimisation of cooperation was considered necessary by the OPs, whereas its necessity was sometimes questioned in the GPs’ group.

Conclusion

In many aspects, the present data agree with results of studies from other countries addressing the cooperation between GPs and OPs and/or other specialists. Many suggestions obtained in this study are practical and could be implemented into daily routine. Future quantitative research is required to better assess the relative weight of the suggestions presented here.     

Medical overuse and quaternary prevention in primary care – A qualitative study with general practitioners

Background

Medical overuse is a topic of growing interest in health care systems and especially in primary care. It comprises both over investigation and overtreatment. Quaternary prevention strategies aim at protecting patients from unnecessary or harmful medicine. The objective of this study was to gain a deeper understanding of relevant aspects of medical overuse in primary care from the perspective of German general practitioners (GPs). We focused on the scope, consequences and drivers of medical overuse and strategies to reduce it (=quaternary prevention).

Methods

We used the qualitative Grounded Theory approach. Theoretical sampling was carried out to recruit GPs in Bavaria, Germany. We accessed the field of research through GPs with academic affiliation, recommendations by interview partners and personal contacts. They differed in terms of primary care experience, gender, region, work experience abroad, academic affiliation, type of specialist training, practice organisation and position. Qualitative in-depth face-to-face interviews with a semi-structured interview guide were conducted (n =?13). The interviews were audiotaped and transcribed verbatim. Data analysis was carried out using open and axial coding.

Results

GPs defined medical overuse as unnecessary investigations and treatment that lack patient benefit or bear the potential to cause harm. They observed that medical overuse takes place in all three German reimbursement categories: statutory health insurance, private insurance and individual health services (direct payment). GPs criticised the poor acceptance of gate-keeping in German primary care. They referred to a low-threshold referral policy and direct patient access to outpatient secondary care, leading to specialist treatment without clear medical indication. The GPs described various direct drivers of medical overuse within their direct area of influence. They also emphasised indirect drivers related to system or societal processes. The proposed strategies for reducing medical overuse included a well-founded wait-and-see approach, medical education, a trustful doctor-patient relationship, the improvement of primary/health care structures and the involvement of patients and society.

Conclusions

GPs are frequently located at the starting point of the diagnostic and treatment process. They have the potential to play a vital role in quaternary prevention. This requires a debate going beyond the medical profession and involving society as a whole.

     

Positive attitudes of French general practitioners towards A/H1N1 influenza-pandemic vaccination: A missed opportunity to increase vaccination uptakes in the general public?

Attitudes of general practitioners (GPs) towards A/H1N1 pandemic vaccination are unknown. We conducted a cross-sectional survey with computer-assisted telephone interviewing in the French Regional Panel of General Practices from June 16 to September 22, 2009. Of 1434 respondents representative of GPs in four French regions, 885 (61.7%) were willing to accept A/H1N1 pandemic vaccination for themselves. The personal history of seasonal flu vaccination was the strongest independent predictive factor of willingness to accept A/H1N1 pandemic vaccination (p < .0001). GPs receiving seasonal vaccines every year were more likely to accept A/H1N1 pandemic vaccination than those who were never vaccinated in the prior 3 years (adjusted OR = 4.38; 95% CI, 2.44–4.67). Willingness to accept pandemic vaccination was also significantly associated with being on call for emergencies; positive attitudes towards other protective measures against A/H1N1 influenza virus in the practice; and a higher readiness to provide additional consultations in response to the pandemic. In conclusion, GPs showed a high acceptability of A/H1N1 pandemic vaccination. GPs’ involvement in the mass vaccination campaign, which has been neglected by French public health authorities, may have increased uptake rates in the general public.     

Stool submission by general practitioners in SW England ¿ when, why and how? A qualitative study

ABSTRACT: BACKGROUND: We know little about when and why general practitioners (GPs) submit stool specimens in patients with diarrhoea. The recent UK-wide intestinal infectious disease (IID2) study found ten GP consultations for every case reported to national surveillance. We aimed to explore what factors influence GP's decisions to send stool specimens for laboratory investigation, and what guidance, if any, informs them. METHODS: We used qualitative methods that enabled us to explore opinions and ask open questions through 20 telephone interviews with GPs with a range of stool submission rates in England, and a discussion group with 24 GPs. Interviews were transcribed and subjected to content analysis. RESULTS: Interviews: GPs only sent stool specimens to microbiology if diarrhoea persisted for over one week, after recent travel, or the patient was very unwell. Very few had a systematic approach to determine the clinical or public health need for a stool specimen. Only two GPs specifically asked patients about blood in their stool; only half asked about recent antibiotics, or potential food poisoning, and few asked about patients' occupations. Few GPs gave patients advice on how to collect specimens.Results from interviews and discussion group in relation to guidance: All reported that the HPA stool guidance and patient collection instructions would be useful in their clinical work, but only one GP (an interviewee) had previously accessed them. The majority of GPs would value links to guidance on electronic requests. Most GPs were surprised that a negative stool report did not exclude all the common causes of IID. CONCLUSIONS: GPs value stool culture and laboratories should continue to provide it. Patient instructions on how to collect stool specimens should be within stool collection kits. Through readily accessible guidance and education, GPs need to be encouraged to develop a more systematic approach to eliciting and recording details in the patient's history that indicate greater risk of severe infection or public health consequences. Mild or short duration IID (under one week) due to any cause is less likely to be picked up in national surveillance as GPs do not routinely submit specimens in these cases.     

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.