Continuity in general practice as predictor of mortality, acute hospitalisation, and use of out-of-hours care: a registry-based observational study in Norway

General practice undergraduate and vocational training: ambulatory teaching and trainers' curriculum and remuneration - a cross-sectional study among 30 member countries of WONCA Europe

BACKGROUND

After a long phase without any propositions for real ambulatory training inside general practitioners' offices, general practice (GP) vocational training has begun to appear progressively and has been integrated into undergraduate medical programmes. The aim of this study was to provide an overview of GP vocational training and GP trainers in member countries of the World Organization of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians (WONCA) Europe.

METHOD

We carried out this cross-sectional study between September 2018 and March 2020. The participants responded to a questionnaire in real-life conversations, video conferences or e-mail exchanges. The respondents included GP trainers, teachers and general practitioners involved in the GP curriculum recruited during European GP congresses.

RESULTS

Representatives from 30 out of 45 WONCA Europe member countries responded to the questionnaire. Based on their responses, there is a well-established period for GP internships in undergraduate medical programmes, but with varying lengths. The programmes for some countries offer an internship after students graduate from medical school but before GP specialisation to ensure the career choice of the trainees. After specialisation, private practice GP internships are offered; however, in-hospital GP internships are more common. GP trainees no longer have a passive role during their internships. GP trainers are selected based on specific criteria and in countries, they have to follow some teacher training programmes. In addition to income from medical appointments carried out by GP trainees, GP trainers from some countries receive additional remuneration from various organisations.

CONCLUSION

This study collected information on how undergraduate and postgraduate medical students are exposed to GP, how GP training is organised and the actual status of GP trainers among WONCA Europe member countries. Our exploration of GP training provides an update of the data collected by Isabel Santos and Vitor Ramos in the 1990s and describes some specificities that can inspire other organisations to prepare young, highly qualified general practitioners.

Balancing burdens of infection control: Norwegian district medical officers' ethical challenges during the COVID-19 pandemic

BACKGROUND

In several countries, district medical officers (DMOs) are public health experts with duties including infection control measures. The Norwegian DMOs have been key actors in the local handling of the COVID-19 pandemic.

METHODS

The aim of the study was to explore the ethical challenges experienced by Norwegian DMOs during the COVID-19 pandemic, and how the DMOs have handled these challenges. 15 in-depth individual research interviews were performed and analyzed with a manifest approach.

RESULTS

Norwegian DMOs have had to handle a large range of significant ethical problems during the COVID-19 pandemic. Often, a common denominator has been the need to balance burdens of the contagion control measures for different individuals and groups. In another large set of issues, the challenge was to achieve a balance between safety understood as effective contagion prevention on the one hand, and freedom, autonomy and quality of life for the same individuals on the other.

CONCLUSIONS

The DMOs have a central role in the municipality's handling of the pandemic, and they wield significant influence. Thus, there is a need for support in decision-making, both from national authorities and regulations, and from discussions with colleagues.

'Frailty as an adjective rather than a diagnosis'-identification of frailty in primary care: a qualitative interview study

INTRODUCTION

In 2017, NHS England introduced proactive identification of frailty into the General Practitioners (GP) contract. There is currently little information as to how this policy has been operationalised by front-line clinicians, their working understanding of frailty and impact of recognition on patient care. We aimed to explore the conceptualisation and identification of frailty by multidisciplinary primary care clinicians in England.

METHODS

Qualitative semi-structured interviews were conducted with primary care staff across England including GPs, physician associates, nurse practitioners, paramedics and pharmacists. Thematic analysis was facilitated through NVivo (Version 12).

RESULTS

Totally, 31 clinicians participated. Frailty was seen as difficult to define, with uncertainty about its value as a medical diagnosis. Clinicians conceptualised frailty differently, dependant on job-role, experience and training. Identification of frailty was most commonly informal and opportunistic, through pattern recognition of a frailty phenotype. Some practices had embedded population screening and structured reviews. Visual assessment and continuity of care were important factors in recognition. Most clinicians were familiar with the electronic frailty index, but described poor accuracy and uncertainty as to how to interpret and use this tool. There were different perspectives amongst professional groups as to whether frailty should be more routinely identified, with concerns of capacity and feasibility in the current climate of primary care workload.

CONCLUSIONS

Concepts of frailty in primary care differ. Identification is predominantly ad hoc and opportunistic. A more cohesive approach to frailty, relevant to primary care, together with better diagnostic tools and resource allocation, may encourage wider recognition.

Exploring the views of low-acuity emergency department consulters on an educational intervention and general practitioner appointment service: a qualitative study in Berlin, Germany

OBJECTIVES

Low-acuity patients presenting to emergency departments (EDs) frequently have unmet ambulatory care needs. This qualitative study explores the patients' views of an intervention aimed at education about care options and promoting primary care (PC) attachment.

DESIGN

Qualitative telephone interviews were conducted with a subsample of participants of an interventional pilot study, based on a semi-structured interview guide. The data were analysed through qualitative content analysis.

SETTING

The study was carried out in three EDs in the city centre of Berlin, Germany.

PARTICIPANTS

Thirty-two low-acuity ED consulters with no connection to a general practitioner (GP) who had participated in the pilot study were interviewed; (f/m: 15/17; mean age: 32.9 years).

INTERVENTION

In the pilot intervention, ED patients with low-acuity complaints were provided with an information leaflet on appropriate ED usage and alternative care paths and they were offered an optional GP appointment scheduling service. Qualitative interviews explored the views of a subsample of the participants on the intervention.

RESULTS

Interviewees perceived both parts of the intervention as valuable. Receiving a leaflet about appropriate ED use and alternatives to the ED was viewed as helpful, with participants expressing the desire for additional online information and a wider distribution of the content. The GP appointment service was positively assessed by the participants who had made use of this offer and seen as potentially helpful in establishing a long-term connection to GP care. The majority of patients declining a scheduled GP appointment expected no personal need for further medical care in the near future or preferred to choose a GP independently.

CONCLUSIONS

Low-acuity ED patients seem receptive to information on alternative acute care options and prevailingly appreciate measures to encourage and facilitate attachment to a GP. Promoting PC integration could contribute to a change in future usage behaviour.

TRIAL REGISTRATION NUMBER

DRKS00023480.

[ROWING AGAINST THE CURRENT]

At Lalonde we know that the determinants that most influence the health of the population are lifestyle, genetics and the environment. Health represents only 10% and is the determinant that consumes the most resources. It has been shown that a salutogenic approach focused on the social determinants of health and the support of public policies to improve the environment are more efficient in the long term than medicine focused on hospitals, technology and super-specialization. Primary Care (PC) that has an approach centered on the person and families with a community vision, is the ideal level to provide health care, and to influence lifestyles. However it is not invested in PC. In this article we review the socioeconomic and political factors that globally influence the lack of interest in the development of PC.

Video consultation in general practice: a scoping review on use, experiences, and clinical decisions

BACKGROUND

The coronavirus disease 2019 pandemic forced healthcare workers to use alternative consultation approaches. In general practice, the use of video consultations (VCs) increased manyfold as countries were locked down. This scoping review aimed to summarize scientific knowledge concerning the use of VC in general practice and focused on (1) the utilization of VC in general practice, (2) the experiences of the users of VC in general practice, and (3) how VC affected the clinical decision-making of general practitioners (GPs).

METHODS

A scoping review was conducted in accordance with the methodology of Joanna Briggs Institute. Review questions were formulated to match each focus area. A three-step search strategy was employed to search scientific and gray literature sources. MEDLINE, Embase, Scopus, OpenGrey, Google Scholar, and ClinicalTrials.gov were searched from 2010 to March 11^th, 2021, and the search was re-run on August 18^th, 2021. The extracted data were deductively coded into pre-defined main themes, whereas subthemes were inductively synthesized. The data within each subtheme were analysed through descriptive content analysis and presented in a narrative synthesis.

RESULTS

Overall, 13 studies were included after screening 3,624 studies. Most patients were satisfied with VCs. VCs were most suitable for simpler issues, often shorter than face-to-face consultations, and were more likely to be used by younger patients. GPs enjoyed the flexibility and shorter duration of VCs; however, they felt an unsatisfactory deterioration in the GP-patient relationship. Despite the loss of clinical examination, diagnostic assessment was mostly successful, with little fear of missing serious illness. Prior clinical experience and a preexisting relationship with the patient were important factors for successful assessment via VC.

CONCLUSIONS

Both GPs and patients can be satisfied with VC in general practice in specific contexts, and adequate clinical decision-making is possible. However, disadvantages such as a diminishing GP-patient relationship have been highlighted, and the use of VC in non-pandemic settings is limited. The role of VC in the future of general practice remains unclear, and further research is needed on the long-term adoption of VC in general practice.

General Practitioners' Experiences With Potentials and Pitfalls of Video Consultations in Norway During the COVID-19 Lockdown: Qualitative Analysis of Free-Text Survey Answers

BACKGROUND

The use of video consultations (VCs) in Norwegian general practice rapidly increased during the COVID-19 pandemic. During societal lockdowns, VCs were used for nearly all types of clinical problems, as in-person consultations were kept to a minimum.

OBJECTIVE

This study aimed to explore general practitioners' (GPs') experiences of potentials and pitfalls associated with the use of VCs during the first pandemic lockdown.

METHODS

Between April 14 and May 3, 2020, all regular Norwegian GPs (N=4858) were invited to answer a web-based survey, which included open-ended questions about their experiences with the advantages and pitfalls of VCs. A total of 2558 free-text answers were provided by 657 of the 1237 GPs who participated in the survey. The material was subjected to reflexive thematic analysis.

RESULTS

Four main themes were identified. First, VCs are described as being particularly convenient, informative, and effective for consultations with previously known patients. Second, strategically planned VCs may facilitate effective tailoring of clinical trajectories that optimize clinical workflow. VCs allow for an initial overview of the problem (triage), follow-up evaluation after an in-person consultation, provision of advice and information concerning test results and discharge notes, extension of sick leaves, and delivery of other medical certificates. VCs may, in certain situations, enhance the GPs' insight in their patients' relational and socioeconomical resources and vulnerabilities, and even facilitate relationship-building with patients in need of care who might otherwise be reluctant to seek help. Third, VCs are characterized by a demarcated communication style and the "one problem approach," which may entail effectiveness in the short run. However, the web-based communication climate implies degradation of valuable nonverbal signals that are more evidently present in in-person consultations. Finally, overreliance on VCs may, in a longer perspective, undermine the establishment and maintenance of relational trust, with a negative impact on the quality of care and patient safety. Compensatory mechanisms include clarifying with the patient what the next step is, answering any questions and giving further advice on treatment if conditions do not improve or there is a need for follow-up. Participation of family members can also be helpful to improve reciprocal understanding and safety.

CONCLUSIONS

The findings have relevance for future implementation of VCs and deserve further exploration under less stressful circumstances.

Predictors and population health outcomes of persistent high GP turnover in English general practices: a retrospective observational study

OBJECTIVE

English primary care faces significant challenges, including 'persistent high turnover' of general practitioners (GPs) in some partnerships. It is unknown whether there are specific predictors of persistent high turnover and whether it is associated with poorer population health outcomes.

DESIGN

A retrospective observational study.

METHODS

We linked workforce data on individual GPs to practice-level data from Hospital Episode Statistics and the GP Patient Survey (2007-2019). We classified practices as experiencing persistent high turnover if more than 10% of GPs changed in at least 3 consecutive years. We used multivariable logistic or linear regression models for panel data with random effects to identify practice characteristics that predicted persistent high turnover and associations of practice outcomes (higher emergency hospital use and patient experience of continuity of care, access to care and overall patient satisfaction) with persistent high turnover.

RESULTS

Each year, 6% of English practices experienced persistent high turnover, with a maximum of 9% (688/7619) in 2014. Larger practices, in more deprived areas and with a higher morbidity burden were more likely to experience persistent high turnover. Persistent high turnover was associated with 1.8 (95% CI 1.5 to 2.1) more emergency hospital attendances per 100 patients, 0.1 (95% CI 0.1 to 0.2) more admissions per 100 patients, 5.2% (95% CI -5.6% to -4.9%) fewer people seeing their preferred doctor, 10.6% (95% CI-11.4% to -9.8%) fewer people reporting obtaining an appointment on the same day and 1.3% (95% CI -1.6% to -1.1%) lower overall satisfaction with the practice.

CONCLUSIONS

Persistent high turnover is independently linked to indicators of poorer service and health outcomes. Although causality needs to be further investigated, strategies and policies may be needed to both reduce high turnover and support practices facing challenges with high GP turnover when it occurs.

Primary and Community Care Transformation in Post-COVID Era: Nationwide General Practitioner Survey

Introduction: The health emergency caused by COVID-19 has led to substantial changes in the usual working system of primary healthcare centers and in relations with users. The Catalan Society of Family and Community Medicine designed a survey that aimed to collect the opinions and facilitate the participation of its partners on what the future work model of general practitioners (GPs) should look like post-COVID-19. Methodology: Online survey of Family and Community Medicine members consisting of filiation data, 22 Likert-type multiple-choice questions grouped in five thematic axes, and a free text question. Results: The number of respondents to the questionnaire was 1051 (22.6% of all members): 83.2% said they spent excessive time on bureaucratic tasks; 91.8% were against call center systems; 66% believed that home care is the responsibility of every family doctor; 77.5% supported continuity of care as a fundamental value of patient-centered care; and >90% defended the contracting of complementary tests and first hospital visits from primary healthcare (PHC). Conclusions: The survey responses describe a strong consensus on the identity and competencies of the GP and on the needs of and the threats to the PHC system. The demand for an increase in health resources, greater professional leadership, elimination of bureaucracy, an increase in the number of health professionals, and greater management autonomy, are the axes towards which a new era in PHC should be directed.

Experiencing COVID-19, home isolation and primary health care: A mixed-methods study

Objectives

Although the vast majority of COVID-19 cases are treated in primary care, patients' experiences during home isolation have been little studied. This study aimed to explore the experiences of patients with acute COVID-19 and to identify challenges after the initial adaptation of the German health system to the pandemic (after first infection wave from February to June 2020).

Methods

A mixed-method convergent design was used to gain a holistic insight into patients experience. The study consisted of a cross-sectional survey, open survey answers and semi-structured telephone interviews. Descriptive analysis was performed on quantitative survey answers. Between group differences were calculated to explore changes after the first infection wave. Qualitative thematic analysis was conducted on open survey answers and interviews. The results were then compared within a triangulation protocol.

Results

A total of 1100 participants from all German states were recruited by 145 general practitioners from August 2020 to April 2021, 42 additionally took part in qualitative interviews. Disease onset varied from February 2020 to April 2021. After the first infection wave, more participants were tested positive during the acute disease (88.8%; 95.2%; P < 0.001). Waiting times for tests (mean 4.5 days, SD 4.1; 2.7days, SD 2.6, P < 0.001) and test results (mean 2.4 days, SD 1.9; 1.8 days, SD 1.3, P < 0.001) decreased. Qualitative results indicated that the availability of repeated testing and antigen tests reduced insecurities, transmission and related guilt. Although personal consultations at general practices increased (6.8%; 15.5%, P < 0.001), telephone consultation remained the main mode of consultation (78.5%) and video remained insignificant (1.9%). The course of disease, the living situation and social surroundings during isolation, access to health care, personal resilience, spirituality and feelings of guilt and worries emerged as themes influencing the illness experience. Challenges were contact management and adequate provision of care during home isolation. A constant contact person within the health system helped against feelings of care deprivation, uncertainty and fear.

Conclusions

Our study highlights that home isolation of individuals with COVID-19 requires a holistic approach that considers all aspects of patient care and effective coordination between different care providers.

Effect of an educational intervention for telephone triage nurses on out-of-hours attendance: a pragmatic randomized controlled study

BACKGROUND

Telephone triage has been established in many countries as a response to the challenge of non-urgent use of out-of-hours primary care services. However, limited evidence is available regarding the effect of training interventions on clinicians' telephone consultation skills and patient outcomes.

METHODS

This was a pragmatic randomized controlled educational intervention for telephone triage nurses in 59 Norwegian out-of-hours general practitioners' (GPs) cooperatives, serving 59% of the Norwegian population. Computer-generated randomization was performed at the level of out-of-hours GP cooperatives, stratified by the population size. Thirty-two out-of-hours GP cooperatives were randomized to intervention. One cooperative did not accept the invitation to participate in the educational programme, leaving 31 cooperatives in the intervention group. The intervention comprised a 90-minute e-learning course and 90-minute group discussion about respiratory tract infections (RTIs), telephone communication skills and local practices. We aimed to assess the effect of the intervention on out-of-hours attendance and describe the distribution of RTIs between out-of-hours GP cooperatives and list-holding GPs. The outcome was the difference in the number of doctor's consultations per 1000 inhabitants between the intervention and control groups during the winter months before and after the intervention. A negative binomial regression model was used for the statistical analyses. The model was adjusted for the number of nurses who had participated in the e-learning course, the population size and patients' age groups, with the out-of-hours GP cooperatives defined as clusters.

RESULTS

The regression showed that the intervention did not change the number of consultations for RTIs between the two groups of out-of-hours GP cooperatives (incidence rate ratio 0.99, 95% confidence interval 0.91-1.07). The winter season's out-of-hours patient population was younger and had a higher proportion of RTIs than the patient population in the list-holding GP offices. Laryngitis, sore throat, and pneumonia were the most common diagnoses during the out-of-hours primary care service.

CONCLUSIONS

The intervention did not influence the out-of-hours attendance. This finding may be due to the intervention's limited scope and the intention-to-treat design. Changing a population's out-of-hours attendance is complicated and needs to be targeted at several organizational levels.

Impact of Primary Care Attributes on Hospitalization During the COVID-19 Pandemic: A Nationwide Prospective Cohort Study in Japan

PURPOSE

During a pandemic, when there are many barriers to providing preventive care, chronic disease management, and early response to acute common diseases for primary care providers, it is unclear whether primary care attributes contribute to reducing hospitalization. We aimed to examine the association between core primary care attributes and total hospitalizations during the COVID-19 pandemic.

METHODS

We conducted a nationwide prospective cohort study during the pandemic using a representative sample of the Japanese adult population aged 40 to 75 years. Primary care attributes (first contact, longitudinality, coordination, comprehensiveness, and community orientation) were assessed using the Japanese version of Primary Care Assessment Tool (JPCAT). The primary outcome measure was any incidence of hospitalization during a 12-month period from May 2021 through April 2022.

RESULTS

Data from 1,161 participants were analyzed (92% follow-up rate). After adjustment for possible confounders, overall primary care attributes (assessed by the JPCAT total score) were associated in a dose-dependent manner with a decrease in hospitalizations (odds ratio [OR] = 0.37, 95% CI, 0.16-0.83 for the highest score quartile, compared with no usual source of care). All associations between each domain score of the JPCAT and hospitalization were statistically significant when comparing the highest quartile with no usual source of care.

CONCLUSIONS

Our study revealed that the provision of primary care, particularly high-quality primary care, was associated with decreased total hospitalization, even during a pandemic when there are many barriers to providing usual medical care. These findings support policies that seek to strengthen primary care systems during and after the COVID-19 pandemic.

Barriers to Early Presentation amongst Rural Residents Experiencing Symptoms of Colorectal Cancer: A Qualitative Interview Study

Rural cancer inequalities are evident internationally, with rural cancer patients 5% less likely to survive than their urban counterparts. There is evidence to suggest that diagnostic delays prior to entry into secondary care may be contributing to these poorer rural cancer outcomes. This study explores the symptom appraisal and help-seeking decision-making of people experiencing symptoms of colorectal cancer in rural areas of England. Patients were randomly invited from 4 rural practices, serving diverse communities. Semi-structured interviews were undertaken with 40 people who had experienced symptoms of colorectal cancer in the preceding 8 weeks. Four key themes were identified as influential in participants' willingness and timeliness of consultation: a desire to rule out cancer (facilitator of help-seeking); stoicism and self-reliance (barrier to help-seeking); time scarcity (barrier to help-seeking); and GP/patient relationship (barrier or facilitator, depending on perceived strength of the relationship). Self-employed, and "native" rural residents most commonly reported experiencing time scarcity and poor GP/patient relationships as a barrier to (re-)consultation. Targeted, active safety-netting approaches, and increased continuity of care, may be particularly beneficial to expedite timely diagnoses and minimise cancer inequalities for rural populations.

Understanding the processes behind the decisions – GPs and complex multimorbidity decision making

Complex multimorbidity, defined either as three or more chronic conditions affecting three or more different body systems or by the patients General Practitioner (GPs), is associated with various adverse outcomes. Understanding how GPs reach decisions for this complex group of patients is currently under-researched, with potential implications for health systems and service delivery. Schuttner and colleagues, through a qualitative approach, reported that internal factors of individuals (decisions tailored to patients; Primary Care Physician (PCP) consultation style; care planning towards an agreed goal of care), external factors within the environment or context of encounter (patient access to healthcare; organizational structures acting as barriers), and relationship-based factors (collaborative care planning; decisions within a dynamic patient clinician relationship) all influence care planning decisions. There are other important findings which have broader relevance to the literature such as the ongoing separation of physical and mental health which persist even within integrated care systems, GPs continue to prioritize continuity of care and that organizational barriers are reported as factors in clinician decision-making for patients. More broadly, the work has proved valuable in extending previously reported findings surrounding care coordination, and limitation of current guidelines for patients with complex multimorbidity. Work-load in general practice is increasing due to an ageing population, increasing prevalence of multimorbidity and polypharmacy, and transfer of clinical activities from secondary to primary care. The future for GPs is more complexity in the clinic room, understanding how GPs make decisions and how this can be supported is crucial for the sustainability for general practice.

Daytime contacts and general practitioner consultations, and pain as a reason for encounter in children with cerebral palsy; a Norwegian national registry linkage study

AIM

The aim of this study was to compare the prevalence of daytime contacts and consultations, and pain as a reason for encounter (RFE) with a general practitioner (GP), in children with cerebral palsy (CP) (cases) to that of the general paediatric population (controls).

METHODS

The study linked the Norwegian Directorate of Health's database for the control and reimbursement of health expenses, and the Norwegian Quality and Surveillance Registry for Cerebral Palsy, including children born from 1996 to 2012 in the period 2006 to 2018. All daytime contacts were included. International Classification for Primary Care was applied for RFE.

RESULTS

Cases accounted for 0.46% of all daytime contacts and 0.27% of all daytime consultations, the latter corresponding with the estimated national prevalence of CP. GPs registered more administrative contact and coded pain as an RFE less frequently in consultations with cases (6%) than with controls (12%).

INTERPRETATION

Children with CP did not consult GPs more than the general paediatric population did. In consultations, GPs should ask for pain even if the child with CP or parent does not address pain. The local multidisciplinary team should encourage the family to consider consulting a GP if the child is in pain.KEY MESSAGESPrevalence of GP consultations in children with CP is similar to that of children in the general population.GPs perform more administrative work for children with CP than for their other paediatric patients.GPs code pain as an RFE less frequently in consultations with children with CP than in consultations with children in the general population.

Patient experiences during the COVID-19 pandemic: a qualitative study in Dutch primary care

BACKGROUND

Changes in primary care provision during the COVID-19 pandemic could have affected patient experience of primary care both positively and negatively.

AIM

To assess the experiences of patients in primary care during the COVID-19 pandemic.

DESIGN & SETTING

A qualitative study of patients from regions with high and low COVID-19 prevalence in the Netherlands.

METHOD

A qualitative study using a phenomenological framework was performed among purposively sampled patients. Individual semi-structured interviews were performed and transcribed. Data were thematically analysed by means of an inductive approach.

RESULTS

Twenty-eight patients were interviewed (13 men and 15 women, aged 27-91 years). After thematic analysis, two main themes emerged: accessibility and continuity of primary care. Changes considered positive during the pandemic regarding accessibility and continuity of primary care included having a quieter practice, having more time for consultations, and the use of remote care for problems with low complexity. However, patients also experienced decreases in both care accessibility and continuity, such as feeling unwelcome, the GP postponing chronic care, seeing unfamiliar doctors, and care being segregated.

CONCLUSION

Despite bringing several benefits, patients indicated that the changes to primary care provision during the COVID-19 pandemic could have threatened care accessibility and continuity, which are core values of primary care. These insights can guide primary care provision not only in this and future pandemics, but also when implementing permanent changes to care provision in primary care.

Barriers to assessing vulnerability in pregnant women. A cross-sectional survey in Danish general practice

BACKGROUND

Undetected vulnerability in pregnancy contributes to inequality in maternal and perinatal health and is associated with negative birth outcomes and adverse child outcomes. Nationwide reports indicate important barriers to assessing vulnerability among Danish general practitioners.

OBJECTIVE

To explore general practitioners perceived barriers to vulnerability assessment in pregnant women and whether the barriers are associated with practice organization of antenatal care, general practitioner, and practice characteristics.

METHODS

The questionnaire was sent to all Danish general practitioners (N = 3,465). Descriptive statistics described the barriers to assessing vulnerability in pregnant women. Analytical statistics with ordered logistic regression models were used to describe the association between selected barriers to vulnerability assessment and antenatal care organization, and general practitioner and practice characteristics.

RESULTS

760 general practitioners (22%) answered. Barriers to vulnerability assessment were related to lacking routines for addressing vulnerability, lacking attention to and record-keeping on vulnerability indicators, an insufficient overview of vulnerable pregnant women, and perceived insufficient remuneration for antenatal care consultations. Not prioritizing extra time when caring for vulnerable pregnant women was associated with experiencing more barriers. Always prioritizing continuity of care was associated with experiencing fewer barriers. General practitioners of either young age, male gender, or who did not prioritize extra time to care for vulnerable pregnant women experienced more barriers.

CONCLUSION

Barriers to vulnerability assessment among pregnant women do exist in general practice and are associated with organizational characteristics such as lacking prioritization of extra time and continuity in antenatal care consultations. Also, general practitioner characteristics like male gender and relatively young age are associated with barriers to vulnerability assessment.

Healthcare utilization after mass trauma: a register-based study of consultations with primary care and mental health services in survivors of terrorism

BACKGROUND

Knowledge on healthcare utilization after mass trauma is needed to strengthen the public health preparedness to such incidents. Using register-based data, this study had a unique opportunity to investigate how young survivors' use of primary care physicians (PCP) and mental health services (MHS) changed after a terrorist attack.

METHODS

We examined register-based data on PCP and MHS consultations among 255 survivors (52% male) of the 2011 Utøya youth camp attack in Norway 3 years before and after the attack, and their reason for encounter with the PCP according to the International Classification for Primary Care (ICPC- 2).

RESULTS

The PCP and MHS consultation rates (CR) were higher in female than male survivors both acutely and at long-term. The mean yearly CRs increased from 2.25 to 4.41 for PCP and 1.77 to 13.59 for MHS the year before and after the attack in female survivors, and from 1.45 to 3.65 for PCP and 1.02 to 11.77 for MHS in male survivors. The third year post-attack CRs for PCP were 3.55 and 2.00; and CRs for MHS were 5.24 and 2.30 in female and male survivors, respectively. Among female survivors, 76% consulted PCP and 12% MHS the year preceding the attack; post-attack 93% consulted PCP and 73% MHS the first year; decreasing to 87 and 40% the third year. Among male survivors, 61% consulted PCP and 7% MHS the year preceding the attack; post-attack 86% consulted PCP and 61% MHS the first year, and 67 and 31% the third year. As for PCP consultations, there was a particular increase in psychological reasons for encounter following the attack.

CONCLUSIONS

This study indicates that it is important to anticipate an increased healthcare utilization several years following mass trauma, particularly of MHS. Both PCP and MHS practitioners played important roles in providing healthcare for psychological problems in young survivors of terrorism in a country with universal and largely publicly financed healthcare and a gatekeeping system. The healthcare utilization could be different in countries with other health systems or psychosocial care responses to mass trauma.

Personal continuity of GP care and outpatient specialist visits in people with type 2 diabetes: A cross-sectional survey

BACKGROUND

Continuity of care is particularly important for patients with chronic conditions, such as type 2 diabetes (T2D). Continuity is shown to reduce overall health service utilization among people with diabetes, however, evidence about how it relates to the utilization of outpatient specialist services in Norway is lacking. The aim of this study was to investigate continuity of GP care for people with T2D, and its association with the use of outpatient specialist health care services.

METHODS

We used e-mail questionnaire data obtained from members of The Norwegian Diabetes Association in 2018. Eligible for analyses were 494 respondents with T2D and at least one GP visit during the previous year. By descriptive statistics and logistic regressions, we studied usual provider continuity (UPC) and duration of the patient-GP relationship and associations of these measures with somatic outpatient specialist visits. Analyses were adjusted for gender, age, education, self-rated health, and diabetes duration.

RESULTS

Mean age was 62.6 years and mean UPC was 0.85 (CI 0.83-0.87). Two thirds of the sample (66.0%) had made all visits to the regular GP during the previous year (full continuity). Among these, 48.1% had made one or more specialist visits during the previous year, compared to 65.2% among those without full continuity. The probability of outpatient specialist visits was significantly lower among participants with full continuity, compared to those without full continuity (Odds Ratio 0.53, Confidence Interval 0.35-0.80). The probability of visiting outpatient specialist services was not associated with duration of the patient-GP relationship.

CONCLUSIONS

We conclude that continuity of care, as measured by Usual Provider Continuity, is high and associated with reduced use of somatic outpatient specialist services in people with T2D in Norway. Continuity and its benefits will become increasingly important as the number of older people with diabetes and other chronic diseases increases.

A named GP increases self-reported access to health care services

Background

Continuity of care strengthens health promotion and decreases mortality, although the mechanisms of these effects are still unclear. In recent decades, continuity of care and accessibility of health care services have both decreased in Finland.

Objectives

The aim of the study was to investigate whether a named and assigned GP representing continuity of care is associated with the use of primary and hospital health care services and to create knowledge on the state of continuity of care in a changing health care system in Finland.

Methods

The data are part of the Health and Social Support (HeSSup) mail survey based on a random Finnish working age population sample of 64,797 individuals drawn in 1998 and follow-up surveys in 2003 and 2012. The response rate in 1998 was 40% (n = 25,898). Continuity of care was derived from the 2003 and 2012 data sets, other variables from the 2012 survey (n = 11,924). The principal outcome variables were primary health care and hospital service use reported by participants. The association of the explanatory variables (gender, age, education, reported chronic diseases, health status, smoking, obesity, NYHA class of any functional limitation, depressive mood and continuity of care) with the outcome variables was analysed by binomial logistic regression analysis.

Results

A named and assigned GP was independently and significantly associated with more frequent use of primary and hospital care in the adjusted logistic regression analysis (ORs 1.53 (95% CI 1.35–1.72) and 1.19 (95% CI 1.08–1.32), p < 0.001).

Conclusion

A named GPs is associated with an increased use of primary care and hospital services. A named GP assures access to health care services especially to the chronically ill population. The results depict the state of continuity of care in Finland. All benefits of continuity of care are not enabled although it still assures treatment of population in the most vulnerable position.

How do general practitioners handle couple relationship problems in consultations? A focus group study

BACKGROUND

Couple relationship problems are common and associated with health problems. The aim of this study was to explore general practitioners' (GPs') experiences, expectations, and educational needs when dealing with couple relationship problems in consultations.

METHODS

We conducted an exploratory qualitative study by carrying out 3 semistructured focus group interviews with 18 GPs. We used systematic text condensation for the analyses.

RESULTS

Participants shared their experiences of handling couple relationship problems in consultations. Three main themes emerged: (i) pragmatic case-finding: golden opportunities to reveal patients' couple relationship problems; (ii) conceptual and role confusion; (iii) professional competence and personal experience. While issues in relationships could serve as an explanation for relevant clinical problems, some GPs questioned whether relationship issues are strictly medical. All participants had engaged in individual supportive therapy, but none saw themselves as therapists. The interviews revealed that an individual supportive focus might lead to a consolidation of 1 partner's view, rather than challenging their position. Long-term doctor-patient relationships made it easier to talk about these issues.

CONCLUSIONS

This study revealed several paradoxes. GPs are confident in offering individual supportive therapy for couple relationship issues but should be aware of substantial pitfalls such as side-taking and constraining change. Despite dealing with relationship problems, GPs do not see themselves as therapists. They use professional and personal experience but would benefit from increasing their skills in cognitive restructuring promoting behavioural flexibility facing relationship problems.

Improved access to and continuity of primary care after attachment to a family physician: longitudinal cohort study on centralized waiting lists for unattached patients in Quebec, Canada

Background

Having a regular family physician is associated with many benefits. Formal attachment – an administrative patient-family physician agreement – is a popular feature in primary care, intended to improve access to and continuity of care with a family physician. However, little evidence exists about its effectiveness. In Quebec, Canada, where over 20% of the population is unattached, centralized waiting lists help attach patients. This provides a unique opportunity to observe the influence of attachment in previously unattached patients. The aim was to evaluate changes in access to and continuity of primary care associated with attachment to a family physician through Quebec’s centralized waiting lists for unattached patients.

Methods

We conducted an observational longitudinal population cohort study, using medical services billing data from public health insurance in the province of Québec, Canada. We included patients attached through centralized waiting lists for unattached patients between 2012 and 2014 (n = 410,140). Our study was informed by Aday and Andersen’s framework for the study of access to health services. We compared outcomes during four 12-month periods: two periods before and two periods after attachment, with T0–2 years as the reference period. Outcome measures were number of primary care visits and Bice-Boxerman Concentration of Care Index at the physician and practice level (for patients with ≥2 visits in a given period). We included age, sex, region remoteness, medical vulnerability, and Charlson Comorbidity Index as covariates in regression models fitted with generalized estimating equations.

Results

The number of primary care visits increased by 103% in the first post attachment year and 29% in the second year (p < 0.001). The odds of having all primary care visits concentrated with a single physician increased by 53% in the first year and 22% (p < 0.001) in the second year after attachment. At the practice level, the odds of perfect concentration of care increased by 19% (p < 0.001) and 15% (p < 0.001) respectively, in first and second year after attachment.

Conclusion

Our results show an increase in patients’ number of primary care visits and concentration of care at the family physician and practice level after attachment to a family physician. This suggests that attachment may help improve access to and continuity of primary care.

Association of medical tests use with care continuity in primary care service: evidence from the Department of Veterans Affairs

BACKGROUND

Continuity of care (CoC) is an important component of health care delivery that can have cost implications and improve patient outcomes. We analysed data obtained from the Department of Veterans Affairs to examine the relationship between CoC and use of image-oriented diagnostic tests in patients with comorbid chronic conditions.

METHODS

A longitudinal, retrospective cohort study involving participants ≥18 years old, with comorbid diabetes and chronic kidney disease. We used a multivariate linear regression model to test whether greater care continuity, measured using a care continuity index (CCI), is associated with less frequent use of diagnostic tests.

RESULTS

Total of 267,442 patients and 8,142,036 tests were included. Of the diagnostic tests we chose to evaluate, the 4 most frequently ordered tests were X-ray (45.6%), electrocardiogram (EKG, 16.8%), computerized tomography (CT, 13.4%), and magnetic resonance imaging (MRI, 3.4%). Overall, greater CCI was associated with fewer use of tests (P < 0.001). A 1 standard deviation (SD, 0.27) increase in CCI was associated with 4.2% decrease (P < 0.001) in number of tests. But a mixed pattern existed. For X-ray and EKG, greater continuity was associated with less testing, 6.2% (P < 0.001) and 3.3% (P < 0.05) reductions, respectively. Whereas, for CT and MRI, greater continuity was associated with more testing, 2.3% (P < 0.001) and 1.4% increases (P < 0.01), respectively.

CONCLUSION

Overall, greater CoC was associated with fewer use of tests, representing a greater presumed efficiency of care. This has implications for designing health care delivery.

Variation in general practice referral rate to acute medicine services and association with hospital admission. A retrospective observational study

BACKGROUND

Variation in general practice (GP) referral rates to outpatient services is well described however variance in rates of referral to acute medical units is lacking.

OBJECTIVE

To investigate variance in GP referral rate for acute medical assessment and subsequent need for hospital admission.

METHODS

A retrospective cohort study of acute medical referrals from 88 GPs in Lothian, Scotland between 2017 and 2020 was performed using practice population size, age, deprivation, care home residence, and distance from hospital as explanatory variables. Patient-level analysis of demography, deprivation, comorbidity, and acuity markers was subsequently performed on referred and clinically assessed acute medical patients (n = 42,424) to examine how practice referral behaviour reflects clinical need for inpatient hospital care.

RESULTS

Variance in GP referral rates for acute medical assessment was high (2.53-fold variation 1st vs. 4th quartile) and incompletely explained by increasing age and deprivation (adjusted R2 0.67, P < 0.001) such that significant variance remained after correction for confounders (2.15-fold). Patients from the highest referring quartile were significantly less likely to require hospital admission than those from the third, second, or lowest referring quartiles (adjusted odds ratio 1.28 [1.21-1.36, P < 0.001]; 1.30 [1.23-1.37, P < 0.001]; 1.53 [1.42-1.65, P < 0.001]).

CONCLUSIONS

High variation in GP practice referral rate for acute medical assessment is incompletely explained by practice population socioeconomic factors and negatively associates with need for urgent inpatient care. Identifying modifiable factors influencing referral rate may provide opportunities to facilitate community-based care and reduce congestion on acute unscheduled care pathways.

Impact of relational continuity of primary care in aged care: a systematic review

Background

Greater continuity of care has been associated with lower hospital admissions and patient mortality. This systematic review aims to examine the impact of relational continuity between primary care professionals and older people receiving aged care services, in residential or home care settings, on health care resource use and person-centred outcomes.

Methods

Systematic review of five databases, four trial registries and three grey literature sources to October 2020. Included studies (a) aimed to increase relational continuity with a primary care professional, (b) focused on older people receiving aged care services (c) included a comparator and (d) reported outcomes of health care resource use, quality of life, activities of daily living, mortality, falls or satisfaction. Cochrane Collaboration or Joanna Briggs Institute criteria were used to assess risk of bias and GRADE criteria to rate confidence in evidence and conclusions.

Results

Heterogeneity in study cohorts, settings and outcome measurement in the five included studies (one randomised) precluded meta-analysis. None examined relational continuity exclusively with non-physician providers. Higher relational continuity with a primary care physician probably reduces hospital admissions (moderate certainty evidence; high versus low continuity hazard ratio (HR) 0.94; 95% confidence interval (CI) 0.92–0.96, n = 178,686; incidence rate ratio (IRR) 0.99, 95%CI 0.76–1.27, n = 246) and emergency department (ED) presentations (moderate certainty evidence; high versus low continuity HR 0.90, 95%CI 0.89–0.92, n = 178,686; IRR 0.91, 95%CI 0.72–1.15, n = 246) for older community-dwelling aged care recipients. The benefit of providing on-site primary care for relational continuity in residential settings is uncertain (low certainty evidence, 2 studies, n = 2,468 plus 15 care homes); whilst there are probably lower hospitalisations and may be fewer ED presentations, there may also be an increase in reported mortality and falls. The benefit of general practitioners’ visits during hospital admission is uncertain (very low certainty evidence, 1 study, n = 335).

Conclusion

Greater relational continuity with a primary care physician probably reduces hospitalisations and ED presentations for community-dwelling aged care recipients, thus policy initiatives that increase continuity may have cost offsets. Further studies of approaches to increase relational continuity of primary care within aged care, particularly in residential settings, are needed.

Review registration

CRD42021215698.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03131-2.

Finding their place - general practitioners' experiences with palliative care-a Norwegian qualitative study

BACKGROUND

Modern palliative care focuses on enabling patients to spend their remaining time at home, and dying comfortably at home, for those patients who want it. Compared to many European countries, few die at home in Norway. General practitioners' (GPs') involvement in palliative care may increase patients' time at home and achievements of home death. Norwegian GPs are perceived as missing in this work. The aim of this study is to explore GPs' experiences in palliative care regarding their involvement in this work, how they define their role, and what they think they realistically can contribute towards palliative patients.

METHODS

We performed focus group interviews with GPs, following a semi-structured interview guide. We included four focus groups with a total of 25 GPs. Interviews were recorded and transcribed verbatim. We performed qualitative analysis on these interviews, inspired by interpretative phenomenological analysis.

RESULTS

Strengths of the GP in the provision of palliative care consisted of characteristics of general practice and skills they relied on, such as general medical knowledge, being coordinator of care, and having a personal and longitudinal knowledge of the patient and a family perspective. They generally had positive attitudes but differing views about their formal role, which was described along three positions towards palliative care: the highly involved, the weakly involved, and the uninvolved GP.

CONCLUSION

GPs have evident strengths that could be important in the provision of palliative care. They rely on general medical knowledge and need specialist support. They had no consensus about their role in palliative care. Multiple factors interact in complex ways to determine how the GPs perceive their role and how involved they are in palliative care. GPs may possess skills and knowledge complementary to the specialized skills of palliative care team physicians. Specialized teams with extensive outreach activities should be aware of the potential they have for both enabling and deskilling GPs.

Optimising GPs' communication of advice to facilitate patients' self-care and prompt follow-up when the diagnosis is uncertain: a realist review of 'safety-netting' in primary care

BACKGROUND

Safety-netting has become best practice when dealing with diagnostic uncertainty in primary care. Its use, however, is highly varied and a lack of evidence-based guidance on its communication could be harming its effectiveness and putting patient safety at risk.

OBJECTIVE

To use a realist review method to produce a programme theory of safety-netting, that is, advice and support provided to patients when diagnosis or prognosis is uncertain, in primary care.

METHODS

Five electronic databases, web searches, and grey literature were searched for studies assessing outcomes related to understanding and communicating safety-netting advice or risk communication, or the ability of patients to self-care and re-consult when appropriate. Characteristics of included documents were extracted into an Excel spreadsheet, and full texts uploaded into NVivo and coded. A random 10% sample was independently double -extracted and coded. Coded data wasere synthesised and itstheir ability to contribute an explanation for the contexts, mechanisms, or outcomes of effective safety-netting communication considered. Draft context, mechanism and outcome configurations (CMOCs) were written by the authors and reviewed by an expert panel of primary care professionals and patient representatives.

RESULTS

95 documents contributed to our CMOCs and programme theory. Effective safety-netting advice should be tailored to the patient and provide practical information for self-care and reconsultation. The importance of ensuring understanding and agreement with advice was highlighted, as was consideration of factors such as previous experiences with healthcare, the patient's personal circumstances and the consultation setting. Safety-netting advice should be documented in sufficient detail to facilitate continuity of care.

CONCLUSIONS

We present 15 recommendations to enhance communication of safety-netting advice and map these onto established consultation models. Effective safety-netting communication relies on understanding the information needs of the patient, barriers to acceptance and explanation of the reasons why the advice is being given. Reduced continuity of care, increasing multimorbidity and remote consultations represent threats to safety-netting communication.

Construction and validation of a morbidity index based on the International Classification of Primary Care

OBJECTIVES

In epidemiological studies it is often necessary to describe morbidity. The aim of the present study is to construct and validate a morbidity index based on the International Classification of Primary Care (ICPC-2).

DESIGN AND SETTING

This is a cohort study based on linked data from national registries. An ICPC morbidity index was constructed based on a list of longstanding health problems in earlier published Scottish data from general practice and adapted to diagnostic ICPC-2 codes recorded in Norwegian general practice 2015 - 2017.

SUBJECTS

The index was constructed among Norwegian born people only (N = 4 509 382) and validated in a different population, foreign-born people living in Norway (N = 959 496).

MAIN OUTCOME MEASURES

Predictive ability for death in 2018 in these populations was compared with the Charlson index. Multiple logistic regression was used to identify morbidities with the highest odds ratios (OR) for death and predictive ability for different combinations of morbidities was estimated by the area under receiver operating characteristic curves (AUC).

RESULTS

An index based on 18 morbidities was found to be optimal, predicting mortality with an AUC of 0.78, slightly better than the Charlson index (AUC 0.77). External validation in a foreign-born population yielded an AUC of 0.76 for the ICPC morbidity index and 0.77 for the Charlson index.

CONCLUSIONS

The ICPC morbidity index performs equal to the Charlson index and can be recommended for use in data materials collected in primary health care.Key pointsThis is the first morbidity index based on the International Classification of Primary Care, 2^nd edition (ICPC-2)It predicted mortality equal to the Charlson index and validated acceptably in a different populationThe ICPC morbidity index can be used as an adjustment variable in epidemiological research in primary care databases.

Psychosocial care responses to terrorist attacks: a country case study of Norway, France and Belgium

Background

The international terrorism threat urges societies to invest in the planning and organization of psychosocial care. With the aim to contribute to cross-national learning, this study describes the content, target populations and providers of psychosocial care to civilians after terrorist attacks in Norway, France and Belgium.

Methods

We identified and reviewed pre- and post-attack policy documents, guidelines, reports and other relevant grey literature addressing the psychosocial care response to terrorist attacks in Oslo/Utøya, Norway on 22 July 2011; in Paris, France on 13 November 2015; and in Brussels, Belgium on 22 March 2016.

Results

In Norway, there was a primary care based approach with multidisciplinary crisis teams in the local municipalities. In response to the terrorist attacks, there were proactive follow-up programs within primary care and occupational health services with screenings of target groups throughout a year. In France, there was a national network of specialized emergency psychosocial units primarily consisting of psychiatrists, psychologists and psychiatric nurses organized by the regional health agencies. They provided psychological support the first month including guidance for long-term healthcare, but there were no systematic screening programs after the acute phase. In Belgium, there were psychosocial intervention networks in the local municipalities, yet the acute psychosocial care was coordinated at a federal level. A reception centre was organized to provide acute psychosocial care, but there were no reported public long-term psychosocial care initiatives in response to the attacks.

Conclusions

Psychosocial care responses, especially long-term follow-up activities, differed substantially between countries. Models for registration of affected individuals, monitoring of their health and continuous evaluation of countries’ psychosocial care provision incorporated in international guidelines may strengthen public health responses to mass-casualty incidents.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07691-2.

Reasons for acute referrals to hospital from general practitioners and out-of-hours doctors in Norway: a registry-based observational study

Background

General practitioners (GPs) and out-of-hours (OOH) doctors are gatekeepers to acute hospital admissions in many healthcare systems. The aim of the present study was to investigate the whole range of reasons for acute referrals to somatic hospitals from GPs and OOH doctors and referral rates for the most common reasons. We wanted to explore the relationship between some common referral diagnoses and the discharge diagnosis, and associations with patient’s gender, age, and GP or OOH doctor referral.

Methods

A registry-based study was performed by linking national data from primary care in the physicians’ claims database with hospital services data in the Norwegian Patient Registry (NPR). The referring GP or OOH doctor was defined as the physician who had sent a claim for the patient within 24 h prior to an acute hospital stay. The reason for referral was defined as the ICPC-2 diagnosis used in the claim; the discharge diagnoses (ICD-10) came from NPR.

Results

Of all 265,518 acute hospital referrals from GPs or OOH doctors in 2017, GPs accounted for 43% and OOH doctors 57%. The overall referral rate per contact was 0.01 from GPs and 0.11 from OOH doctors, with large variations by referral diagnosis. Abdominal pain (D01) (8%) and chest pain (A11) (5%) were the most frequent referral diagnoses. For abdominal pain and chest pain referrals the most frequent discharge diagnosis was the corresponding ICD-10 symptom diagnosis, whereas for pneumonia-, appendicitis-, acute myocardial infarction- and stroke referrals the corresponding disease diagnosis was most frequent. Women referred with chest pain were less likely to be discharged with ischemic heart disease than men.

Conclusions

The reasons for acute referral to somatic hospitals from GPs and OOH doctors comprise a wide range of reasons, and the referral rates vary according to the severity of the condition and the different nature between GP and OOH services. Referral rates for OOH contacts were much higher than for GP contacts. Patient age, gender and referring service influence the relationship between referral and discharge diagnosis.