Influence of patient characteristics on preventive service delivery and general practitioners’ preventive performance indicators: A study in patients with hypertension or diabetes mellitus from Hungary

Background: Regular primary healthcare (PHC) performance monitoring to produce a set of performance indicators for provider effectiveness is a fundamental method for improving guideline adherence but there are potential negative impacts of the inadequate application of this approach. Since performance indicators can reflect patient characteristics and working environments, as well as PHC team contributions, inadequate monitoring practices can reduce their effectiveness in the prevention of cardiometabolic disorders.

Objectives: To describe the influence of patients’ characteristics on performance indicators of PHC preventive practices in patients with hypertension or diabetes mellitus.

Methods: This cross-sectional analysis was based on a network of 165 collaborating GPs. A random sample of 4320 adults was selected from GP’s patient lists. The response rate was 97.3% in this survey. Sociodemographic status, lifestyle, health attitudes and the use of recommended preventive PHC services were surveyed by questionnaire. The relationship between the use of preventive services and patient characteristics were analysed using hierarchical regression models in a subsample of 1659 survey participants with a known diagnosis of hypertension or diabetes mellitus.

Results: Rates of PHC service utilization varied from 18.0% to 97.9%, and less than half (median: 44.4%; IQR: 30.8–62.5) of necessary services were used by patients. Patient attitude was as strong of an influencing factor as demographic properties but was remarkably weaker than patient socioeconomic status.

Conclusion: These findings emphasize that PHC performance indicators have to be evaluated concerning patient characteristics.     

The implementation costs of an electronic prevention programme in Belgian general practice

Abstract

Introduction: Guidelines to prevent cardiovascular (CV) disease are widely available. To implement these guidelines an electronic prevention programme (EPP) with a risk calculator for general practitioners (GPs) was developed. The aim of the present study was to calculate the implementation cost per installation. Methods: This cost study is part of a larger clinical trial, studying the effects of interventions in GP-practice on the management of CV risk factors. Participating GPs were asked to install the EPP. They could take part in a group education session or receive education by e-mail, telephone or at home. After a prospective cost registration, the cost per installation and a sensitivity analysis were calculated. Results: 185 GPs participated in the study. The total implementation cost of the EPP was €83,939. As the EPP was successfully installed by 102 GPs, the mean cost equals €823 per GP. Sensitivity analyses showed a decrease in costs due to a decrease of the costs of group education and/or an increase of installations.

Conclusion: This study showed that it is possible to implement an EPP for cardiovascular prevention with an acceptable cost.     

Patient attitudes towards and experiences with an intervention programme to reduce chronic acid-suppressing drug intake in primary care

Abstract

Objective: Many patients are using acid-suppressing drugs (ASD) unnecessary. An insurance company initiated intervention programme aiming at reduction of chronic ASD use, was introduced in primary care-practices. We evaluated the attitude and experiences of the participating patients. Methods: A survey was conducted among a random sample of 2376 long-term ASD users using a validated questionnaire that combined CAHPS and QUOTE methodology. Using a psychometric principal component analysis we assessed the role of GPs in three scales: quality of support; communication and conduct; involvement in decisions. Both the importance of and experiences with quality items, transformed into quality impact indices, were measured. Results: Of 2376 questionnaires distributed, 1808 (76%) were returned, 1270 (54%) were valid. 188 were of patients that participated in the programme. The majority was dissatisfied with the GPs’ support: no information about rebound side effects (76%), lifestyle habits (68%), and reasons to stop (50%). Compared to the non-participants 9% more participants stopped ASD use (P = 0.04).

Conclusion: A majority of patients on chronic ASD was prepared to participate in the drug-reduction programme. Although 16% succeeded in stopping ASD use, the majority was dissatisfied with the role of the GP. Improved GP support might have make more patients stop using ASD.     

Even if they are not aware of it,general practitioners improve well-being in their adolescent patients

Background: Most adolescents consult their general practitioner (GP) for common reasons, somatic or administrative but many of them have hidden feelings of distress.

Objectives: To assess the immediate impact of ‘ordinary’ consultations on feelings of distress among adolescents and to compare adolescents experiencing difficulties (D) to those with no difficulties (N). To analyse how accurately GPs assess the impact of their consultation on adolescents’ feelings.

Methods: GPs were randomly selected from two non-contiguous French administrative areas between April and June 2006. Fifty-three GPs gave two questionnaires to the first 10 to 15 adolescents aged 12 to 20 seen in consultation. One questionnaire was issued before the consultation and the other one afterwards. Adolescents had to position themselves about different aspects of well-being and say where they would seek help if they had problems. A GP questionnaire assessed how well they estimated their impact on the adolescent’s feeling of well-being.

Results: Six hundred and sixty-five adolescents were assessed. They reported feeling better about their health, being able to talk, having someone to talk to or to confide in and on feeling understood. The D group (n?=?147) felt significantly better compared to the N group (n?=?518). GPs tended to underestimate this improvement, especially regarding adolescents in the D group feeling better about their health.

Conclusions: Consulting a GP generates increased well-being among adolescents, especially for those experiencing difficulties. GPs tend to underestimate the positive impact they may have. Further studies are needed to explore if this benefit is permanent over time.     

Potential of pharmacists to help reduce the burden of poorly managed cardiovascular risk

Introduction: Rural areas require better use of existing health professionals to ensure capacity to deliver improved cardiovascular outcomes. Community pharmacists (CPs) are accessible to most communities and can potentially undertake expanded roles in prevention of cardiovascular disease (CVD). Objective: This study aims to establish frequency of contact with general practitioners (GPs) and CPs by patients at high risk of CVD or with inadequately controlled CVD risk factors. Design, setting and participants: Population survey using randomly selected individuals from the Wimmera region electoral roll and incorporating a physical health check and self‐administered health questionnaire. Overall, 1500 were invited to participate. Results: The participation rate was 51% when ineligible individuals were excluded. Nine out of 10 participants visited one or both types of practitioner in the previous 12 months. Substantially more participants visited GPs compared with CPs (88.5% versus 66.8%). With the exception of excess alcohol intake, the median number of opportunities to intervene for every inadequately controlled CVD risk factor and among high risk patient groups at least doubled for the professions combined when compared with GP visits alone. Conclusion: Opportunities exist to intervene more frequently with target groups by engaging CPs more effectively but would require a significant attitude shift towards CPs. Mechanisms for greater pharmacist integration into primary care teams should be investigated.     

Development of the EMAP tool facilitating existential communication between general practitioners and cancer patients

Background: General practice recognizes the existential dimension as an integral part of multidimensional patient care alongside the physical, psychological and social dimensions. However, general practitioners (GPs) report substantial barriers related to communication with patients about existential concerns.

Objectives: To describe the development of the EMAP tool facilitating communication about existential problems and resources between GPs and patients with cancer.

Methods: A mixed-methods design was chosen comprising a literature search, focus group interviews with GPs and patients (n?=?55) and a two-round Delphi procedure initiated by an expert meeting with 14 experts from Denmark and Norway.

Results: The development procedure resulted in a semi-structured tool containing suggestions for 10 main questions and 13 sub-questions grouped into four themes covering the existential dimension. The tool utilized the acronym and mnemonic EMAP (existential communication in general practice) indicating the intention of the tool: to provide a map of possible existential problems and resources that the GP and the patient can discuss to find points of reorientation in the patient’s situation.

Conclusion: This study resulted in a question tool that can serve as inspiration and help GPs when communicating with cancer patients about existential problems and resources. This tool may qualify GPs’ assessment of existential distress, increase the patient’s existential well-being and help deepen the GP–patient relationship.     

Increased training of general practitioners in Ireland may increase the frequency of exercise counselling in patients with chronic illness: A cross-sectional study

Background: Recent systematic reviews have established that brief interventions in primary care are effective and economic at promoting physical activity. Lack of training has previously been identified as a barrier to lifestyle counselling in Ireland.

Objectives: This study evaluates frequency of exercise counselling (EC), in patients with six chronic illnesses (type 2 diabetes mellitus, stable coronary heart disease, hypertension, depression, obesity, osteoarthritis) and healthy adults, by general practitioners (GPs) in the mid-west of Ireland, as well as, whether training in EC influences the frequency of EC.

Methods: A questionnaire survey of GPs based in the mid-west of Ireland was conducted during February and March 2012. The questionnaire was distributed to 39 GPs at two continuing medical education meetings and posted to 120 other GPs in the area. The questionnaire assessed the frequency of EC, use of written advice and frequency of recommending resistance exercise in the above patient groups. It also assessed training in EC.

Results: 64% of GPs responded (n = 102). Frequency of EC varied among the chronic illnesses evaluated. Use of written advice and advice on resistance exercise in EC was low. Only 17% of GPs had previous training in EC. If available, 94% of GPs would use guidelines to prescribe exercise in chronic illness. The association of previous training in EC with frequency of EC was variable, with significantly higher counselling rates found in T2DM, obesity and healthy adults.

Conclusion: Improved training of GPs and development of guidelines may increase the frequency of EC in Ireland.     

“There’s always something else”: Patient perspectives on improving the implementation of obesity guidelines in general practice

ObjectivesThe prevalence of obesity in Australia is rising. National guidelines for the management of overweight and obesity exist but our previous work demonstrates poor implementation of key elements in general practice. The aim of this study was to describe patient perspectives on the implementation of obesity guidelines in general practice.MethodsQualitative study of 40 people living with obesity (PwO) who were recruited through general practices in Melbourne, Australia. PwO had a recorded BMI in the overweight range or above (>25), had attended a consultation in the last 6 months and had a diagnosis of at least one of the following: diabetes, kidney disease, hyperlipidemia, hypertension, or cardiovascular disease. Semi-structured telephone interviews were conducted with patients. Interviews were audio-recorded, transcribed verbatim and analysed thematically.ResultsWhile a strong general practitioner (GP)-patient relationship enabled conversation to occur about weight management there was uncertainty as to whether patients or GPs should broach the topic of weight. Patients described complacency regarding their weight and often being unprepared to take up GP advice. Other health issues were felt to take precedence, and patients described inconsistent provision of information and resources to assist them in tackling their weight problems.ConclusionsIt is imperative to take into account patient perspectives on obesity management in general practice in order to improve health outcomes. This study provides valuable insights into how PwO can be better managed. Interventions should also include strategies to help patients maintain motivation in making lifestyle changes to support healthy weight loss.     

General practitioners’ perceptions of treatment of chronically ill patients managed in general practice: An interview study

BackgroundPatients with chronic conditions pose a major challenge to the Danish healthcare system. Since 2018, disease management programmes for patients with chronic obstructive pulmonary disease (COPD) and type 2 diabetes (T2D) were introduced in Denmark. Treatment in hospitals should be reserved for those patients who require specialised treatment. Hence, more patients with COPD and T2D fall within the general practitioners’ (GPs) responsibility.ObjectivesThis study explores GPs’ perceptions of their role as physicians responsible for the disease management programmes on COPD and T2D and their perceptions of the quality of care provided to these patient groups.MethodsBetween November 2019 and January 2020, we conducted semi-structured interviews with 14 GPs from the five regions of Denmark. We analysed the interviews using systematic text condensation inspired by Malterud’s thematic analysis.ResultsThe GPs stated that they have been managing the care of COPD and T2D patients for over a decade, and they considered the quality of care to be high. They believed that managing patient treatment pathways in general practice settings contributes to a heightened sense of security for the patient, mainly because of the long-standing and trusting relationship between the patient and GP.ConclusionAccording to the GPs, they continue to play an important role as treatment coordinators to ensure coherence and high quality in treating patients with COPD and type 2 diabetes.     

Patient and GP agreement on aspects of general practice care

OBJECTIVE: The aim of the present study was to compare patient and GP priorities for general practice care. METHODS: A questionnaire survey was carried out in general practice in Denmark which included 900 consecutive patients aged over 18 years from 15 practices collected in 1995, and 919 randomly sampled GPs in 1999. The postal questionnaire, developed by the EUROPEP group, contained 40 questions about eight aspects of primary care. Participants were asked to state their priorities for each question ranging from "not at all important" to "most important". A reminder questionnaire was sent to non-responders after 2 weeks. Top priority percentages ("very/most important") were calculated for each question as were differences between participant groups. RESULTS: Questionnaires were answered by 771 (85.7%) patients and 584 (64.2%) GPs. Their priorities were highly correlated (r = 0.754, P < 0.001). Patients gave higher priority than GPs to availability and accessibility of the practice and seeing the same GP. The GP should be capable of providing information on illness, investigations and treatments and patient associations, and should know the patient's history and be regularly updated through courses. CONCLUSIONS: Patient and GP priorities for primary care were highly correlated. The higher priority awarded by patients than by GPs to specific aspects of primary care should be acknowledged when organizing and developing general practice.     

Assessment of coronary risk in general practice in relation to the use of guidelines: a survey in Denmark

BACKGROUND: There is a considerable gap between recommended and actually conducted preventive cardiology in general practice. The effect of guidelines is not fully evaluated. METHODS: A questionnaire containing 10 questions on preventive cardiology, including the use of clinical guidelines, together with four case stories for cardiovascular risk estimation was mailed to 205 general practitioners (GPs). RESULTS: Response rate was 81%. Twenty-five percent of the GPs had consultations in preventive cardiology at least once a day and 60% of the GPs thought lifestyle intervention had significant effect on cardiovascular risk. Approximately two-thirds of the GPs were regular users of national guidelines on prevention of cardiovascular disease. While the majority of GPs correctly assigned a patient with multiple risk factors to the high-risk category there was a much larger variation in risk estimations if fewer risk factors were present. GPs who reported use of guidelines overestimated coronary risk twice as frequently as nonusers of guidelines. CONCLUSION: Preventive cardiology in general practice is common and the effect of lifestyle intervention is well accepted. Poor discrimination between high- and low-risk patients may, however, lead to suboptimal preventive care. The use of guidelines does not seem to improve risk estimation and further dissemination of better tools for risk estimation is needed.     

Experiences of general practitioners participating in oncology meetings with specialists to support GP-led survivorship care; an interview study from the Netherlands

Background: Due to ageing, increasing cancer incidence and improved treatment, the number of survivors of cancer increases. To overcome the growing demand for hospital care survivorship by the involvement of the general practitioner (GP) has been suggested. Dutch GPs started a project to offer survivorship care to their patients with the help of monthly oncology meetings with hospital specialists.

Objectives: To evaluate the experiences of GPs with monthly oncology meetings in a GP-practice to support GP-led survivorship care of colon cancer patients.

Methods: This is a qualitative study in primary care centres in a region in the Netherlands around one hospital. GPs were recruited from practices organizing monthly oncology meetings with hospital specialists. Ten of 15 participating GPs were interviewed until saturation. The interviews were transcribed verbatim and two independent researchers analysed the data.

Results: The oncology meetings and individual care plans attributed to a feeling of shared responsibility for the patients by the GP and the specialist. The meetings helped the GPs to be informed about the patients in the diagnostic and treatment phase, which was followed by a clear moment of transfer from hospital to primary care. GPs were better equipped to treat comorbidity and were more confident in providing survivorship care. Due to lack of reimbursement for survivorship care, the internal motivation of the GP must high.

Conclusion: The oncology meetings fulfil the need for information and communication. Close cooperation between GPs and oncology specialists appears to be an essential factor for GPs to value GP-led survivorship care positively.     

Students' and general practitioners' perceptions of a recently introduced clerkship in general practice. A survey from Austria

Abstract

Background: In autumn 2007, the Medical University of Graz (MUG) upgraded the status of general practice in medical training by integrating a compulsory five-week clerkship in general practice surgeries in the sixth and last year of the curriculum. In cooperation with the Styrian Academy of General Practice (STAFAM), more than 200 general practitioners (GPs) had been accredited to introduce medical students to the specific tasks, problems and decision-making process in general practice. Between October 2007 and June 2009, more than 300 students completed the clerkship. Objective: To explore the perceptions of students and GPs towards this new approach to undergraduate teaching in Austrian general practice. Methods: Between March and June 2009, we conducted a cross-sectional survey by using a self-administered questionnaire with 14 items for students as well as GPs. To limit recall bias, we gave the questionnaire to all students (n = 146) and GPs (n = 146) immediately after the clerkship. The response rates were 146/146 (100%) and 114/146 (78%) for students and GPs, respectively. Results: The study results show high satisfaction rates among students as well as GPs. Most of the students and GPs perceive the compulsory clerkship in general practice as an essential part of medical education. The organization of the clerkship had the least positive outcome.

Conclusion: Our survey shows that the clerkship is well accepted among Austrian medical students and GPs.     

Knowledge of the general population about hypertension and diabetes mellitus in South Kivu, Democratic Republic of Congo

BackgroundIn the Democratic Republic of Congo (DRC), a country in a post-conflict period, high priority cannot be given to non-communicable diseases other than to emergencies. This certainly involves inadequacy in raising awareness for prevention of these diseases.ObjectiveTo evaluate the level of knowledge of the Congolese general population on hypertension and diabetes mellitus.MethodsResponses to a questionnaire from 3% of the general population aged 15 and older in the city of Bukavu and two rural areas: Hombo and Walungu (South Kivu, eastern DRC), recruited after stratification by ward in the city of Bukavu and a group of prone villages were expected. The questions focused on identification, testing, causes, complications and treatment of hypertension and diabetes mellitus.ResultsOf the 7770 respondents, screening for hypertension and diabetes mellitus affected only 14.9% and 7.3% of subjects respectively. Knowledge of these two conditions was generally low in the general population, although better in the subgroups of patients and those with higher socioeconomic level (P < 0.05). Use of the medias was also associated with better knowledge (P < 0.05).ConclusionsThis study shows that knowledge about hypertension and diabetes mellitus and their testing in South Kivu is low. It is imperative that the Congolese government includes non-communicable diseases in its priorities of the millennium. Similarly, the WHO should actively contribute to screening for them in low-income countries.     

Course of glycaemia in poorly controlled type 2 diabetes patients 2.5 years after optimizing oral treatment in general practice

Abstract

Objective: To investigate GPs’ perceptions of consultation outcomes and to investigate the associations between these and outcomes perceived by the patients. Design: 25 GPs and 10 patients for each GP filled in a questionnaire about the outcome of the same consultation. The questions in the questionnaires were formulated from concepts found in preceding qualitative studies. Their answers were analysed and compared. Setting: GPs and patients from 16 group practices in Norrbotten, Sweden. Results: The GPs had the apprehension that their consultations would lead to cure/symptom relief in half of their consultations. They believed that their patients were satisfied up to 90% and that up to 75% had been reassured, understood more or could cope better. The GPs were satisfied themselves with up to 95% of the consultations, they enhanced their relationship to their patient up to 70%. Their affirmative concordance with their patients was high regarding satisfaction, intermediate regarding patient reassurance and patient understanding and lowest regarding cure/symptom relief.

Conclusion: The GPs’ were lacking in their ability to assess the patients’ increased understanding and the concordance between their own and the patients’ expectation of cure/symptom relief was low.     

Referral patterns between the child health service,general practitioners,and secondary healthcare: A prospective descriptive study in the Netherlands

Background: In the Netherlands, preventive child health service (CHS) screening plays an important role in the early detection of congenital, developmental, physical, and mental disorders. Objective: To obtain insight into the referral patterns of children from CHS to general practitioners and from general practitioners to medical specialists. Methods: Prospective study over 6 months in a semi-urban area in the Netherlands. All correspondence from the participating doctors was sticker marked and, after each contact, a registration card was sent to a central secretariat. The referral stream between general practitioners and specialists or allied health professionals was extracted from a central database. The general practitioners and the participating paediatricians were asked to complete a questionnaire about the quality and necessity of the referral. Results: Out of an estimated 2600 examinations, 45 children were referred to their general practitioners for further examination. The problems of eight children were settled by the GP, 10 children were referred to allied health professionals, and 24 children were referred to specialists. The median time span of showing up at the GP's office was 6.5 days. Sixteen per cent showed up long after having been referred by the CHS. The parents of three children did not comply. Of the 397 referrals from GPs to medical specialists and allied health professionals, 8.5% were initiated by the CHS.

Conclusion: The amount of referrals from the CHS to GPs and of referrals from GPs to medical specialists and allied health professionals initiated by the CHS is low in terms of absolute percentages. Most referrals by the CHS were considered useful.     

The quality of life of patients with type 2 diabetes mellitus in general practice

Background: Improving patients' duration and quality of life (QoL) is the long-term goal in treatment of diabetes mellitus.

Aim: To estimate the QoL of patients with type 2 diabetes followed in primary care, using the newly developed and validated 'Well-being Enquiry for Diabetes' (WED) questionnaire. The questionnaire evaluates four subscales of QoL: diabetes-related somatic symptoms (Symptoms); diabetes-related worries (Discomfort); mental health (Serenity); familiar relationship and social network (Impact). Patients and methods: We randomly selected 100 patients with type 2 diabetes mellitus in our practice, of whom 98 completed the questionnaire (mean age ±SD: 64.6±9.5; 44 males, 54 females; duration of disease 8.3±6.0 years; 23.5% on diet only, 67.3% on oral hypoglycaemic agents, 5.1% on both oral hypoglycaemic agents and insulin, and 4.1% on insulin monothe-rapy). Micro- or macroangiopathy was present in 33 patients (33.7%, 15 males, 18 females). In each patient we considered the following variables: age, gender, duration of disease, type of treatment in use, presence of complications. Mann-Whitney test, Kruskal-Wallis test and multiple regression analysis were used for statistical analysis (p<0.05 as significant). Results: Females had lower total WED scores than males (p=0.0001) and lower scores in each of the four subscales. Patients with chronic complications had lower scores than patients without complications (p=0.19). Patients on insulin showed lower total WED scores than patients treated with oral hypoglycaemic agents or diet only. Multivariate analysis showed a correlation between WED scores and gender (p=0.0001) or complications (p=0.049), but not with duration of disease (p=0.28) or age (p=0.15). Conclusion: The WED questionnaire appears to be a simple, reliable measure of diabetes-related QoL in primary care. Females had significantly lower scores than males, with the greatest difference in the area of Serenity. This is in accordance with general data showing higher psychiatric morbidity (anxiety, depression, eating disorders) among females. The WED provides GPs with a tool for auditing care of patients with diabetes and to identify type 2 diabetes patients in whom interventions may be needed to improve their QoL. Eur J Gen Pract 2000;6:93–7.     

Cardiovascular health check in the elderly in one general practice: does it offer new information and lead to interventions?

BACKGROUND: Prevention of cardiovascular disease in the elderly is becoming increasingly important. GPs are in a unique position to initiate preventive interventions in this age group. However, it is not clear which strategy a GP should follow to identify patients at increased cardiovascular risk-case finding or screening. OBJECTIVE: We aimed to assess the value of a single cardiovascular health check compared with a normal care case finding and to investigate the diagnostic or therapeutic consequences of detecting new cardiovascular risk indicators. METHODS: In 1991, 1002 persons aged 60 years and over, enlisted in one general practice, were invited. Of the 805 subjects who responded (80%), the cardiovascular risk profile was determined by a research physician. The proportion of newly detected cardiovascular risk indicators was the main outcome measure. A risk indicator was considered newly detected when it was not mentioned in the GP's summary of the patient record, which had been checked by the patient for its completeness. The patient records of participants with newly detected hypertension, diabetes or hypercholesterolaemia were systematically reviewed to detect diagnostic and therapeutic interventions by the GP. RESULTS: In 25.1% of the participants, one or more cardiovascular risk indicators were found which were previously unknown to the GP, including 38 (4.7%) cases of hypertension, 82 (10%) cases of isolated systolic hypertension, 14 (1.7%) cases of diabetes mellitus and 63 (7.8%) cases of hypercholesterolaemia. On the basis of these findings, the GP initiated therapeutic interventions in almost all subjects with newly detected diabetes. However, reports of newly detected hypertension or high cholesterol levels were usually not followed by an intervention. CONCLUSION: A single cardiovascular health check in the elderly can detect a considerable number of risk indicators that are unknown to a patient's GP. In most cases, however, the detection of hypertension or cholesterol > or = 6.5 mmol/l did not lead to interventions by the GP. More efforts are needed to ensure that the beneficial effects of these interventions are not limited to participants in clinical trials but can be extended to patients in general practice.     

One-day general practice morbidity survey in Sri Lanka

BACKGROUND: National morbidity surveys provide valuable data for monitoring the health needs of populations, health policy planning and design of medical curricula. In order to meet a long-standing need for such information in Sri Lanka, a nationwide general practice morbidity survey was conducted for the first time in 1996. OBJECTIVES: We aimed to identify people's needs by determining the reasons for encounter or the demand for care with GPs/family physicians, to illustrate the pattern of morbidity in general practice and to determine the average daily workload of GPs in Sri Lanka. METHOD: A random sample of 75 GPs were requested to complete a Practitioner Profile Questionnaire (PPQ) and to record on an encounter form (EF) the reason/s for encounter (RFE) and problems managed during all consultations on 4 July. Central coding of the RFEs and problems defined was done using the International Classification of Primary Care (ICPC). RESULTS: Forty GPs (53.3%) completed the PPQ, while the EF received a response from 34 (43.3%). The GP profile showed a male to female ratio of 7:1, none below 35 years and none qualified after 1984. The average daily workload was 74. It was estimated that GPs handle at least 26.5% of the primary care morbidity. Children accounted for 32% of consultations. There was a significantly higher proportion of children (P < 0.0001) and of the elderly (P < 0.05) in the consulting population compared with the general population. In 2068 encounters, 3448 RFEs and 2087 problems had been recorded. Respiratory and General chapters included 55% of the RFEs. By ICPC rubrics, 27 of the top thirty RFEs were for common symptoms. In addition to acute illnesses, asthma, hypertension and diabetes as well as preventive care activities were within the top 12 problems managed. CONCLUSIONS: The fact that many common illnesses, chronic diseases and preventive treatments are dealt with in general practice shows the necessity to include family medicine in the undergraduate curriculum of all medical schools. Undergraduate and postgraduate training in family medicine should concentrate more on child care and care of the elderly. Suitable incentives may be necessary to motivate younger doctors to become GPs to meet the medical care needs of the community.      

Evaluation of a policy to strengthen case management and quality of diabetes care in general practice in Denmark

ObjectivesTo evaluate the utilization of a policy for strengthening general practitioner's case management and quality of care of diabetes patients in Denmark incentivized by a novel payment mode. We also want to elucidate any geographical variation or variation on the basis of practice features such as solo- or group practice, size of practice and age of the GP.MethodsOn the basis registers encompassing reimbursement data from GPs and practice specific information about geographical location (region), type of practice (solo- or group-practice), size of practice (number of patients listed) and age of the GP were are able to determine differences in use of the policy in relation to the practice-specific information.ResultsAt the end of the study period (2007–2012) approximately 30% of practices have enrolled extending services to approximately 10% of the diabetes population. There is regional – as well as organizational differences between GPs who have enrolled and the national averages with enrolees being younger, from larger practices and with more patients listed.ConclusionsOur study documents an organizationally and regionally varied and limited utilization with the overall incentive structure defined in the policy not strong enough to move the majority of GPs to change their way of delivering and financing care for patients with diabetes within a period of more than 5 years.