Medical students’ attitudes and wishes towards extending an educational general practice app to be suitable for practice: A cross-sectional survey from Leipzig,Germany

Background: In medical education and practice, smartphone apps are increasingly becoming popular. In general practice, apps could play an important future role in supporting medical education and practice.

Objectives: To explore medical students’ perceptions regarding the potential of a general practice app for training and subsequent work as a physician.

Methods: Cross-sectional survey among Leipzig fourth-year medical students who were provided with an app prototype for a mandatory general practice course.

Results: Response rate was 99.3% (n?=?305/307); 59.0% were female and mean age was 24.5 years. Students certified that the app had a higher potential than textbooks in both education (57.4% vs. 18.0%) and practice (47.1% vs. 22.8%). Students’ most desired possible app extensions when anticipating its use for subsequent work as a physician were looking up information for diagnostics, therapy and prediction (85.1%), access to electronic patient files (48.1%), communication and networking (44.3%), organization of medical training (42.9%) and online monitoring of patients (38.1%). Students experienced with medical smartphone apps were more interested in app extensions. Consideration to use the app to support the opening of their own practice was significantly associated with higher interest in accessing electronic patient files, networking with colleagues and telemedicine.

Conclusion: Fourth year medical students from Leipzig see a high potential in smartphone apps for education and practice and are interested in further using the technology after undergraduate education.     

The value of reasons for encounter in early detection of colorectal cancer

Background: Symptoms with a high predictive power for colorectal cancer (CRC) do not exist.

Objective: To explore the predictive value of patients’ reason for encounter (RFE) in the two years prior to the diagnosis of CRC.

Methods: A retrospective nested case-control study using prospectively collected data from electronic records in general practice over 20 years. Matching was done based on age (within two years), gender and practice. The positive likelihood ratios (LR+) and odds ratios (OR) were calculated for RFE between cases and controls in the two years before the index date.

Results: We identified 184 CRC cases and matched 366 controls. Six RFEs had significant LR?+?and ORs for CRC, which may have high predictive power. These RFEs are part of four chapters in the International Classification of Primary Care (ICPC) that include tiredness (significant at 3–6 months prior to the diagnosis; LR+ 2.6 and OR 3.07; and from 0 to 3 months prior to the diagnosis; LR+ 2.0 and OR 2.36), anaemia (significant at three months before diagnosis; LR+ 9.8 and OR 16.54), abdominal pain, rectal bleeding and constipation (significant at 3–6 months before diagnosis; LR+ 3.0 and OR 3.33; 3 months prior to the diagnosis LR+ 8.0 and OR 18.10) and weight loss (significant at three months before diagnosis; LR+ 14.9 and OR 14.53).

Conclusion: Data capture and organization in ICPC permits study of the predictive value of RFE for CRC in primary care.     

Marketing of a new non-sedating antihistamine (fexofenadine) puts an additional burden on healthcare system resources in Israel

Abstract

Background: Conflicting data on the diagnostic and prognostic value of auscultation abnormalities may be partly explained by inconsistent use of terminology.

Objectives: To describe general practitioners use of chest auscultation abnormality terms for patients presenting with acute cough across Europe, and to explore the influence of geographic location and case mix on use of these terms.

Methods: Clinicians recorded whether ‘diminished vesicular breathing’, ‘wheezes’, ‘crackles’ and ‘rhonchi’ were present in an observational study of adults with acute cough in 13 networks in 12 European countries. We describe the use of these terms overall and by network, and used multilevel logistic regression to explore variation by network, controlling for patients’ gender, age, comorbidities, smoking status and symptoms.

Results: 2345 patients were included. Wheeze was the auscultation abnormality most frequently recorded (20.6% overall) with wide variation by network (range: 8.3–30.8%). There was similar variation for other auscultation abnormalities. After controlling for patient characteristics, network was a significant predictor of auscultation abnormalities with odds ratios for location effects ranging from 0.37 to 4.46 for any recorded auscultation abnormality, and from 0.25 to 3.14 for rhonchi.

Conclusion: There is important variation in recording chest auscultation abnormalities by general practitioners across Europe, which cannot be explained by differences in patient characteristics. There is a need and opportunity for standardization in the detection and classification of lung sounds.     

What can artefact analysis tell us about patient transitions between the hospital and primary care? Lessons from the HANDOVER project

Abstract

Background: Hospital discharge often faces breakdowns in information, communication, and coordination. The European Union FP7 Health Research Programme commissioned the European HANDOVER Project in 2008, a three year, 3.5 million Euro programme to examine transitions of patient care from the hospital to the community care settings. Six European countries—Italy, the Netherlands, Poland, United Kingdom, Spain, and Sweden—participated in this collaborative study.

Objectives: This paper highlights a multi-centre, multi-national research programme. We describe how HANDOVER participants conducted an ‘artefact analysis’ as one element of the mixed methods study to inform opportunities to make patient handovers between hospital and community care more effective.

Methods: The artefact analysis consisted of a four-step process to assess different tools used in communication and treatment and their effects on the communication processes between the hospital and general practice settings.

Results: Four themes emerged from our analysis: (a) The inpatient care of a patient is ‘hospital centric’ whereby the hospital ‘pulls’ information regarding a patient's family physician (b) There are rich cognitive artefacts that support the patient clinician encounter; c) The use of information technology does not necessarily improve the communication process; and (d) There is a role for the patient, albeit not particularly well-defined or explicit, as a conduit for essential information communication.

Conclusion: Cognitive artefact analysis is an innovative method to provide insights into transitions of patient care. It may be most useful to think about interventions at both the individual patient and the system levels that more fully address and overcome the system issues at work.     

The relationship between primary health care organization and quality of diabetes care

Abstract

Background: Despite many quality improvement trials, diabetes care often remains suboptimal. Few studies in a primary care setting have investigated the ‘real life’ association between organizational differences and quality of diabetes care. Methods: Observational study among ten health care centres with a total of 45 general practitioners (GP). We investigated health care organization and related this to quality of care in a total of 1849 electronic patient records. Results: There were large differences among health care centres in the percentage of patients receiving optimal care (range: 8–67%). The odds to receive good quality of care was higher if the health care centre had a diabetes education program (OR: 4.3; CI: 3.4–5.4), when yearly medical check-ups were done by both the GP and nurse practitioner (NP) (OR: 5.5; CI: 4.2–7.3), planned that after the patient visited the NP the patient is discussed with the GP (OR: 1.8; CI: 1.6–2.0), and had structured follow-up measures for compliance to check-ups (OR: 0.7; CI: 0.5–0.9 and OR: 0.59; CI: 0.5–0.7 for respectively one and two active measures compared to three active measures).

Conclusion: Also in real life, quality of care for type 2 diabetic patients is related to health care organization.     

The frequency and outcome of acute dyspnoea in primary care: An observational study

Background: Little is known about the occurrence of acute dyspnoea in primary care and its underlying causes.

Objectives: What are the occurrence and most frequent causes of acute dyspnoea in primary care, predictors of referral, hospitalization, death and possible underlying causes?

Methods: Twenty-five general practitioners (GPs) in Flanders (Belgium) recorded patient contacts for four periods of two weeks during one year. They recorded patients presenting with acute dyspnoea, location of contact (surgery versus home visit), new dyspnoea versus exacerbation, tentative diagnosis, referral to a specialist and hospital, and one month later final diagnosis, its justification, referral, hospitalization and death.

Results: Twenty-two GPs recorded 14,620 patient contacts. Acute dyspnoea was encountered in 317 patient–doctor contacts (2.2%; 95%CI: 1.9–2.4), without significant association between the acute dyspnoea frequency, and age and gender. Immediate referral and hospitalization were most frequent in patients 61 to 90 years old. Forty-five patients (14.2%; 95%CI: 10.4–18.0) were referred to a specialist immediately and an additional 34 (10.7%; 95%CI: 7.3–14.1) by one month follow-up. Fourteen patients (4.4%) were hospitalized immediately, and 11 (3.5%) within one month. Six patients (1.9%), all 61 to 90 years old, died within one month.

Conclusion: Dyspnoea occurs in about two per cent of consultations. Serious cases are rare and are much more likely in the older age group. Twenty-five per cent of the contacts concerning acute or worsening dyspnoea were referred to a specialist or hospitalized. In daily practice, the risk of immediate referral, hospitalization and death is higher in men and older patients, especially if the contact is at the patient’s home.

Key Messages

• Acute dyspnoea was encountered in 2.2% of patient–doctor contacts.

• The risk of immediate referral, hospitalization and death was higher in men and patients 61 to 90 years old, especially if the contact was at the patient’s home.

• There is no association between the acute dyspnoea frequency and age and gender.

     

General practitioners’ perceptions of their role in cancer follow-up care: A qualitative study in the Netherlands

Background: In the last few decades there has been a considerable increase in the number of cancer survivors. Health policy makers would like to see cancer follow-up care moved from secondary to primary care. Method: Between 2008 and 2010, a qualitative study among primary health care professionals was performed to get more insight into the way they care for cancer survivors. Analysed was whether a coordinating role in cancer survivorship care would fit in with the practical logic underlying the way the general practitioners work. Results: In their everyday work, general practitioners are used to provide care in a reactive way. Based on this habitus, they classify their patients into ‘not special’ and ‘special’ ones. Since general practitioners label cancer survivors as ‘not special,’ they expect these patients to take the initiative to ask for help and present their complaints in a clear and complete way. Their habitus as a gatekeeper implies that they are reticent about referring patients to other primary health care professionals. In regard to ‘not special’ patients, such as cancer survivors, general practitioners appear to build on the patients’ own strengths.

Conclusion: The emphasis on a wait-and-see attitude in contemporary Dutch general practice, as well as the general practitioners’ role as a gatekeeper are at odds with the proactive and holistic approach inherent to a coordinating role in cancer follow-up. Therefore, we assume that it will be difficult for general practitioners to shape a pivotal role in this care.     

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.     

Reducing the use of out-of-hours primary care services: A survey among Dutch general practitioners

Background: Out-of-hours primary care services have a high general practitioner (GP) workload with increasing costs, while half of all contacts are non-urgent.

Objectives: To identify views of GPs to influence the use of the out-of-hours GP cooperatives.

Methods: Cross-sectional survey study among a random sample of 800 GPs in the Netherlands.

Results: Of the 428 respondents (53.5% response rate), 86.5% confirmed an increase in their workload and 91.8% felt that the number of patient contacts could be reduced. A total of 75.4% GP respondents reported that the 24-h service society was a ‘very important’ reason why patients with non-urgent problems attended the GP cooperative; the equivalent for worry or anxiety was 65.8%, and for easy accessibility, 60.1%. Many GPs (83.9%) believed that the way telephone triage is currently performed contributes to the high use of GP cooperatives. Measures that GPs believed were both desirable and effective in reducing the use of GP cooperatives included co-payment for patients, stricter triage, and a larger role for the telephone consultation doctor. GPs considered patient education, improved telephone accessibility of daytime general practices, more possibilities for same-day appointments, as well as feedback concerning the use of GP cooperatives to practices and triage nurses also desirable, but less effective.

Conclusion: This study provides several clues for influencing the use of GP cooperatives. Further research is needed to examine the impact and safety of these strategies.

Key Messages

• GPs believe that the number of patient contacts with the GP cooperative could be reduced.

• Strategies to reduce the use of GP cooperatives perceived as both effective and advisable by GPs are introducing co-payment for patients, stricter triage and a larger role for the telephone consultation doctor.

     

Health care use associated with work-related musculoskeletal disorders among hospital workers

Introduction: The purpose of this study was to investigate if work-related musculoskeletal disorders (WMSDs) are associated with increased health care use, over and above workers’ compensation health care benefits, in the period prior to and following a workers’ compensation claim indicating gradual progression and declining function associated with musculoskeletal morbidity. Methods: This study employed secondary analysis of employment data, workers’ compensation claim data and provincial (universal) medical services data for a cohort of health care workers; and investigated rates of medical care contacts among injured workers with a WMSD claim (n=549) compared to a matched group of non-claim workers. Predictors of health care contacts were estimated using general linear regression. Results: WMSD injured workers had significantly higher rates of health care contacts associated with a claim compared to non-injured workers, over and above workers compensation health care benefits. In the final multi-variable model, a WMSD claim among injured workers was associated with an estimated 69% (95% CI, 1.50, 1.91) increase in health care use for the 12-month period immediately after the injury date compared to non injured workers. Conclusion: The pattern of visits for WMSDs suggests that workers visit general practitioners as part of an ongoing pattern of symptoms, resulting in frequent utilization of health services prior to work disability that is also reflected in health care contacts after return-to-work.     

Children in general practice: An exciting area for research. Reflections on the EGPRN meeting in Plovdiv,Bulgaria, May 2010

Abstract

The European General Practice Research Network organized an international research conference on ‘Children in General Practice’ in Plovdiv, Bulgaria, in May 2010. Two of the authors were keynote speakers at the workshop, tasked with summarizing the theme research presentations on each of the two days of the meeting. The theme of the meeting ‘Children in General Practice’ refers to the primary aim for timely and high quality health care for every child and the related general practitioners’ activities. The meeting was an important event, especially for young doctors and investigators from different countries, because they were informed of good practices from other European countries in preventive work with children. All participants shared and learned a lot of good ideas beyond the standards and quality management. Examples of ideas for new research questions that emerged were to study differences in routine check-ups during childhood between European countries; to study the effectiveness of advices given by GPs to (parents of) obese children; and to study adverse events of medication in general practice.

Conclusion: At a European level, the diversity of the ways health care systems deal with health problems in children is striking. We felt great enthusiasm to further develop this research area. Interested family doctors are invited to attend future conferences to develop collaborative research projects on this topic.     

Palliative and terminal care at home as portrayed in Dutch newspapers in 2009 compared to 2000

Abstract

Background: Terminal care at home is receiving increased attention from the Dutch media, which is relevant for primary care providers. Objectives: To explore the portrayal of terminal care at home in newspapers in the Netherlands in 2000 and in 2009. Method: We performed a systematic analysis of documents retrieved from the LexisNexis Academic NL database. We compared data regarding the ‘point of reference’ (or ‘frame’) and the ‘moral judgments’ in articles appearing in the first six months of 2009 to the same period in 2000. Results: In the year 2000, the framing of articles in regional newspapers appeared to be predominantly consumer-oriented (66%) and in national newspapers predominantly contextual (63%). The moral judgment in the regional articles was predominantly positive (66%), in the national newspapers predominantly negative (58%). In 2009, articles in regional and national newspapers were categorized mainly as consumer-oriented (73% and 55%, respectively), and new themes appeared, i.e. self care and medical topics. For moral judgment, again regional articles were mainly positive (76%) and national articles were mainly negative (39%) and neutral (31%).

Conclusion: Regarding the theme ‘terminal care at home’ as published in Dutch newspapers in 2009 as compared to 2000, the diversity of the framing was more prominent and over all moral judgments were more positive, particularly in regional newspapers. Health care providers should realize that the portrayal of palliative and terminal care at home may differ depending on the type of newspaper—regional or national.     

The daily practice of (suspected) coeliac disease management by general practitioners: A qualitative approach

Background: General practitioners (GPs) play a crucial role in diagnosing coeliac disease (CD). However, data on GP management of (suspected) CD patients is sparse.

Objectives: To provide insights into the daily practice of diagnosis, treatment, and follow-up of CD by GPs.

Methods: A qualitative study using topic list-based semi-structured in-depth interviews with Dutch GPs with more than five years’ experience carried out between January and March 2017. GPs were purposively sampled. The number of GPs interviewed depended on when data saturation was reached. We applied content analysis to the semi-structured interviews.

Results: Seven GPs were interviewed, five of whom were female. Analysis of the interviews resulted in three main themes: ‘awareness,’ ‘diagnostics’ and ‘management.’ Vague gastrointestinal symptoms and diarrhoea were often mentioned as a possible presentation of CD. Antibodies were used in CD diagnosis, although some GPs would start a gluten-free diet as a first diagnostic tool. Some GPs diagnosed CD only based on positive antibodies without referring to secondary care or duodenal biopsy analysis. GPs mentioned no role for primary care physicians in the follow-up of CD and noted the important role of dieticians in CD management.

Conclusion: The different views of GPs on how to diagnose and monitor CD could be a basis for further research to improve CD detection rate and CD care.     

Feeling like a stranger: negotiations with culture as experienced by Chilean occupational therapists

Background: Although occupational therapy has begun to focus on the subject of culture, few studies have examined how occupational therapists outside the English-speaking countries reflect on it.

Aim: To explore how Chilean occupational therapists reflect on their personal and professional experiences in regard to the complexity of culture, and its different understandings and expressions.

Methods: This qualitative study uses content analysis to establish common trends in participants’ experiences. A validation phase and data triangulation were implemented to ensure trustworthiness.

Results: Culture is experienced as a continuous negotiation in personal and professional terms. One central theme, ‘negotiating through the dynamism of culture’, and three categories, ‘dealing with power’, ‘understanding local and global identities’, and ‘crossing the boundaries into the client’s land’, emerged. These experiences are complex, chaotic, and highly context-dependent.

Discussion: During therapeutic encounters, practitioners and clients may experience cultural barriers even if their differences are not obvious in cultural terms. As a result of this finding, we recommend the inclusion of culture and cultural issues in professional training. The impact of a multicultural research team is discussed. Future research should explore how the construct of culture is introduced in occupational therapy professional training in Chile.     

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.     

Experiences of hospital-based multidisciplinary team meetings in oncology: An interview study among participating general practitioners

Background: Cancer care has become complex, requiring healthcare professionals to collaborate to provide high-quality care. Multidisciplinary oncological team (MDT) meetings in the hospital have been implemented to coordinate individual cancer patients’ care. General practitioners (GPs) are invited to join, but their participation is minimal.

Objectives: Aim of this study is to explore participating GPs’ perceptions of their current role and to understand their preferences towards effective role execution during MDT meetings.

Methods: In May to June 2014, semi-structured interviews (n?=?16) were conducted involving GPs with MDT experience in Belgium. The analysis was done according to qualitative content analysis principles.

Results: Attendance of an MDT meeting is perceived as part of the GP’s work, especially for complex patient care situations. Interprofessional collaborative relationships and the GP’s perceived benefit to the MDT meeting discussions are important motivators to participate. Enhanced continuity of information flow and optimized organizational time management were practical aspects triggering the GP’s intention to participate. GPs valued the communication with the patient before and after the meeting as an integral part of the MDT dynamics.

Conclusion: GPs perceive attendance of the MDT meeting as an integral part of their job. Suggestions are made to enhance the efficiency of the meetings.