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
Design: A retrospective interrupted times series study.
Setting: Two multidisciplinary general practitioner (GP) practices.
Intervention: An internist provided in-house patient consultations in two GP practices and participated in the multidisciplinary meetings.
Subjects: The referral data extracted from the electronic medical record system of the GP practices, including all referral letters from the GPs to specialist care in the hospital setting.
Main outcome measures: The number of referrals to internal medicine in the hospital setting. This study used an autoregressive integrated moving average model to estimate the effect of the intervention taking account of a time trend and autocorrelation among the observations, comparing the pre-intervention period with the intervention period.
Results: It was found that the referrals to internal medicine did not statistically significant decrease during the intervention period.
Conclusions: This small explorative study did not find any clues to support that an in-house internist at a primary care setting results in a decrease of referrals to internal medicine in the hospital setting.
- Key Points
An in-house internist at a primary care setting did not result in a significant decrease of referrals to specialist care in the hospital setting.
The GPs and internist experience a learning-effect, i.e. an increase of knowledge about internal medicine issues.
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.
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.
Design: A national cross-sectional survey was distributed electronically in December 2013.
Setting: Danish general practice.
Subjects: A population of 3440 GPs (corresponding to approximately 96% of all Danish GPs).
Main outcome measures: GPs’ use and perceived importance of information sources. Multilevel mixed-effects logit models were used to investigate associations with GP characteristics after adjusting for relevant covariates.
Results: A total of 1580 GPs (46.4%) responded to the questionnaire. GPs’ information-seeking behaviour is associated with gender, age and practice form. Single-handed GPs use their colleagues as an information source significantly less than GPs working in partnership practices and they do not use other sources more frequently. Compared with their younger colleagues, GPs aged above 44 years are less likely to seek information from colleagues, guidelines and websites, but more likely to seek information from medical journals. Male and female GPs seek information equally frequently. However, whereas male GPs are more likely than female GPs to find that pharmaceutical sales representative and non-refundable CME meetings are important, they are less likely to find that colleagues, refundable CME meetings, guidelines and websites are important.
Conclusion: Results from this study indicate that GP characteristics should be taken into consideration when disseminating scientific medical information, to ensure that patients receive medically updated, high-quality care.
- KEY POINTS
Research indicates that information-seeking behaviour is associated with GP characteristics. Further insights could provide opportunities for targeting information dissemination strategies.
Single-handed GPs seek information from colleagues less frequently than GPs in partnerships and do not use other sources more frequently.
GPs aged above 44 years do not seek information as frequently as their younger colleagues and prefer other information sources.
Male and female GPs seek information equally frequently, but do not consider information sources equally important in keeping medically updated.
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.
Design: Total population-based case–control study.
Setting and subjects: 4562 cancer patients and 17,979 controls matched by age, sex, and primary care unit. Data were collected from the Swedish Cancer Register and the Regional Healthcare Database.
Method: We identified cancer patients in the Västra Götaland Region of Sweden diagnosed in 2011 with prostate, breast, colorectal, lung, gynaecological, and skin cancers including malignant melanoma. We studied the symptoms and diagnoses identified by diagnostic codes during a diagnostic interval of 12 months before the cancer diagnosis.
Main outcome measures: Consultation frequency, symptom density by cancer type, prevalence and odds ratios (OR) for the diagnostic codes in the cancer population as a whole.
Results: The diagnostic codes with the highest OR were unspecified lump in breast, neoplasm of uncertain behaviour, and abnormal serum enzyme levels. The codes with the highest prevalence were hyperplasia of prostate, other skin changes and abdominal and pelvic pain. The frequency of diagnostic codes and consultations in primary care rose in tandem 50 days before diagnosis for breast and gynaecological cancer, 60 days for malignant melanoma and skin cancer, 80 days for prostate cancer and 100 days for colorectal and lung cancer.
Conclusion: Eighty-seven percent of patients with the most common cancers consulted a general practitioner (GP) a year before their diagnosis. An increase in consultation frequency and presentation of any symptom should raise the GP’s suspicion of cancer.
Key Points
Knowledge about the prevalence of early symptoms and other clinical signs in cancer patients in primary care remains insufficient.
Eighty-seven percent of the patients with the seven most common cancers consulted a general practitioner 12 months prior to cancer diagnosis.
Both the frequency of consultation and the number of symptoms and diseases expressed in diagnostic codes rose in tandem 50–100 days before the cancer diagnosis.
Unless it is caused by a previously known disease, an increased consultation rate for any symptom should result in a swift investigation or referral from primary care to confirm or exclude cancer.
Design: A historical population-based cohort study.
Setting: The Danish CRC screening programme and general practice.
Subjects: The 376,198 individuals invited to the Danish CRC screening programme from 1 March to 31 December 2014.
Main outcome Measures: The diagnostic activity (consultations and haemoglobin measures) in general practice in the year preceding the screening invitation and the cumulated incidence of CRC in the year following the screening invitation.
Results: Screening participants had significantly higher diagnostic activity than non-participants. Individuals with a positive faecal immunochemical test (FIT) had higher diagnostic activity compared to individuals with a negative FIT, and a small increase in the months leading up to the invitation. Individuals with a screen-detected CRC had lower diagnostic activity than individuals with no CRC. In total, 308 (25.3%) of CRCs diagnosed in the invited population were diagnosed outside the screening programme. Non-participants with CRC more often had low socio-economic status, high comorbidity and stage IV CRC than participants with CRC.
Conclusions: There was a tendency that participants and those with a positive FIT had a higher diagnostic activity the year before the screening. This was not seen for those with CRC detected through screening. CRC must still be diagnosed in general practice in the invited population and non-participants are of special interest as they have higher risk of late stage CRC.
- Key Points
Current awareness:Individuals with colorectal cancer (CRC) in screening may be symptomatic and CRC may still occur outside screening in the invited population.
Most important points:The majority of individuals with CRC in screening cannot be expected to be diagnosed on symptomatic presentation in general practice
GPs have to be aware that CRC still occurs outside screening in the invited population
Non-participants with CRC are often deprived and have late stage CRC
Design: A qualitative methodology with semi-structured focus group interviews was employed.
Setting: General practice setting in Denmark.
Subjects: Thirty-one GPs from two Danish regions between 38 and 68 years of age participated in seven focus group interviews.
Results: Although understood to involve broad life conditions such as present and future being and identity, connectedness to a society and to other people, the existential dimension was primarily reported integrated in connection with life-threatening diseases and death. Furthermore, integration of the existential dimension was characterized as unsystematic and intuitive. Communication about religious or spiritual questions was mostly avoided by GPs due to shyness and perceived lack of expertise. GPs also reported infrequent referrals of patients to chaplains.
Conclusion: GPs integrate issues related to the existential dimension in implicit and non-standardized ways and are hindered by cultural barriers. As a way to enhance a practice culture in which GPs pay more explicit attention to the patients’ multidimensional concerns, opportunities for professional development could be offered (courses or seminars) that focus on mutual sharing of existential reflections, ideas and communication competencies.
- Key points
Although integration of the existential dimension is recommended for patient care in general practice, little is known about GPs’ understanding and integration of this dimension in the GP–patient encounter.
The existential dimension is understood to involve broad and universal life conditions having no explicit reference to spiritual or religious aspects.
The integration of the existential dimension is delimited to patient cases where life-threatening diseases, life crises and unexplainable patient symptoms occur. Integration of the existential dimension happens in unsystematic and intuitive ways.
Cultural barriers such as shyness and lack of existential self-awareness seem to hinder GPs in communicating about issues related to the existential dimension. Educational initiatives might be needed in order to lessen barriers and enhance a more natural integration of communication about existential issues.
Design Three nurses were trained, who performed examinations with tympanometry and SG-AR. Pneumatic otoscopy by the study physician served as the diagnostic standard.
Setting Study clinic at primary health care level.
Patients. 281 children 6–35 months of age.
Main outcome measures Predictive values (with 95% confidence interval) for tympanometry and SG-AR, and the clinical usefulness, i.e. the proportion of visits where nurses obtained the exclusive test result from both ears of the child.
Results At 459 visits, the negative predictive value of type A and C1 tympanograms (tympanometric peak pressure >–200 daPa) was 94% (91–97%). Based on type A and C1 tympanograms, the nurse could exclude AOM at 94/459 (20%) of visits. The negative predictive value of SG-AR level 1 result (>95°) was 94% (89–97%). Based on the SG-AR level 1 result, the nurse could exclude AOM at 36/459 (8%) of visits.
Conclusion Type A and C1 tympanograms and SG-AR level 1 results obtained by nurses are reliable test results in excluding AOM. However, the clinical usefulness of these test results is limited by their rarity. Type A and C1 tympanograms were obtained by nurses from both ears of the child only at one-fifth of the symptomatic visits.
- Key Points
Acute otitis media (AOM) is the most prevalent bacterial infection in young children. Nurses’ role in excluding AOM is unknown.
Type A and C1 tympanograms (tympanometric peak pressure >–200 daPa) obtained by nurses are reliable test results in excluding AOM.
With type A and C1 tympanograms, nurses could exclude AOM only at one-fifth of the symptomatic visits.
The clinical usefulness of the exclusion of AOM performed by nurses seems to be limited.
Design: Qualitative study. Focus group discussion and analysis through Systematic Text Condensation.
Setting: Primary Health Care, Region Västra Götaland, Sweden.
Subjects: Nine patients with mild/moderate depression who participated in a RCT evaluating the effects of regular use of the Montgomery-Åsberg Depression Self-assessment scale (MADRS-S) during the GP consultations.
Main Outcome measure: Patients’ experiences and perceptions of the use of MADRS-S in primary care.
Results: Three categories emerged from the analysis: (I) confirmation; MADRS-S shows that I have depression and how serious it is, (II) centeredness; the most important thing is for the GP to listen to and take me seriously and (III) clarification; MADRS-S helps me understand why I need treatment for depression.
Conclusion: Use of MADRS-S was perceived as a confirmation for the patients that they had depression and how serious it was. MADRS-S showed the patients something black on white that describes and confirms the diagnosis. The informants emphasized the importance of patient-centeredness; of being listened to and to be taken seriously during the consultation. Use of self-assessment scales such as MADRS-S could find its place, but needs to adjust to the multifaceted environment that primary care provides.
- Key Points
Patients with depression in primary care perceive that the use of a self-assessment scale in the consultation purposefully can contribute in several ways. The scale contributes to
Confirmation: MADRS-S shows that I have depression and how serious it is.
Centeredness: The most important thing is for the GP to listen to and take me seriously.
Clarification: MADRS-S helps me understand why I need treatment for depression.
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.
Design: Thematic analysis of focus group interviews.
Setting: Four rural casualty clinics in Norway.
Participants: GPs with experience ranging from one to 32 years.
Results: The GPs felt that their role had changed from being the only provider of emergency care to being one of many. In particular, the emergency medical technician teams (EMT) have evolved and often manage well without a physician. Consequently, the GPs get less experience and feel more uncertain when encountering emergencies. Nevertheless, the GPs want to participate in call outs. They believed that their presence contributes to better patient care, and the community appreciates it. Taking part in call outs is seen as being vital to maintaining skills. The GPs had difficulties explaining how to decide whether to participate in call outs. Decisions were perceived as difficult due to insufficient information. The GPs assessed factors, such as distance from the patient and crowding at the casualty clinic, differently when discussing participation in call outs.
Conclusion: Although their role may have changed, GPs argue that they still play a part in emergency medicine. The GPs claim that by participating in call outs, they maintain their skills and improve patient care, but further research is needed to help policy makers and clinicians decide when the presence of a GP really counts.
Norwegian health authorities want to increase participation by general practitioners (GPs) in emergency medicine, but the role of the GP in this context is controversial.
- KEY POINTS
The role of the GP has changed, but GPs argue that they still play an important role in emergency medicine.
GPs believe that their presence on call outs improve patient care, but they find it defensible that patients are tended to by emergency medical technicians (EMTs) only.
GPs offered different assessments regarding whether to participate in call outs in seemingly similar cases.
Design: A RAND/UCLA Appropriateness Method was used.
Setting: General practice.
Subjects: A panel of nine experts, mainly general practitioners, was asked to rate the relevance of 64 quality indicators for the diagnosis and antibiotic treatment of acute respiratory tract infections based on guidelines. Subsequently, a face-to-face meeting was held to resolve misinterpretations and to achieve consensus.
Main outcome measures: The experts were asked to rate the indicators on a nine-point Likert scale. Consensus of appropriateness for a quality indicator was reached if the overall panel median rating was 7–9 with agreement.
Results: A total of 50 of the 64 proposed quality indicators attained consensus. Consensus was achieved for 12 indicators focusing on the diagnostic process and 19 indicators focusing on the decision about antibiotic treatment and choice of antibiotics, respectively.
Conclusion: These newly developed quality indicators may be used to strengthen Danish general practitioners’ focus on their management of patients with acute respiratory tract infections and to identify where there is a need for future quality improvements. 相似文献
Design Data were collected during a three-month prospective, non-randomized follow-up study (Effective Health Centre) using questionnaires and an electronic health record.
Setting Three primary health care practices in Pirkanmaa, Finland.
Subjects Altogether 622 patients were recruited during a one-week period. Inclusion criteria: the patient had a doctor’s or nurse’s appointment on the recruiting day and agreed to participate. Exclusion criteria: patients visiting a specialized health guidance clinic for pregnant women, children, and mothers.
Main outcome measures Patient characteristics, resource use, and costs based on the ICPC-2 EOC classification.
Results On average, the patients had 1.22 EOCs during the three months. Patient characteristics and resource use differed between the EOC chapters. Chapter L, “Musculoskeletal”, had the most episodes (17%). The most common (8%) single EOC was “upper respiratory infection”. The mean cost of an episode (COE) was €389.56 (standard error 61.11) and the median COE was €165.00 (interquartile range €118.46–288.56) during the three-month follow-up. The most expensive chapter was K, “Circulatory”, with a mean COE of €909.85. The most expensive single COE was in chapter K, €32 545.56. The most expensive 1% of the COEs summed up covered 36% of the total COEs.
Conclusion Patient characteristics, resource use, and costs differed between the ICPC-2 chapters, which could be taken into account in service planning and pricing. Future studies should incorporate more specific diagnoses, larger data sets, and longer follow-up times.
- Key points
The most common episodes were under the ICPC-2 “Musculoskeletal” chapter, but the highest mean and single-episode costs were related to the “Circulatory” chapter.
The mean (median) cost of episodes that started in primary care was €390 (€165) during the three-month follow-up.
Patient characteristics, resource use, and costs differed significantly between the ICPC-2 chapters. The most expensive 1% of the episodes covered 36% of the total costs of all the episodes.
Design: Cross sectional observational study.
Setting/subjects: 22 GPs in Southern Norway.
Main outcome measures: The percentage of consultations dealing with sexual concerns during three consecutive working days, as registered by the GPs on a questionnaire.
Results: Out of 1 117 consultations, 47 (4.2%) dealt with sexual concerns, varying from 1.6 to 10.9% of consultations. The concerns brought up varied widely, with erectile dysfunction and pain related to sexual activity in females as the largest groups. Concerns regarding sexual orientation, preferences or behavior were also dealt with, as were problems due to sexual assaults or rape. In 36 (76.6%) of the consultations, discussion of the problem and/or advice was the only action. Medication was prescribed in one third of the consultations. Patients' mean age was 46.7 years, with a span from 17 up to 75 years and 60% were female. We found no associations between GP characteristics and how frequently they dealt with sexual concerns.
Conclusions: In around 4% of consultations, the GPs dealt with a wide variety of sexual concerns. 相似文献