The relationship between GPs and hospital consultants and the implications for patient care: a qualitative study

Informing understanding of coordination of care for patients with heart failure with preserved ejection fraction: a secondary qualitative analysis

BACKGROUND

Patients with heart failure with preserved ejection fraction (HFpEF) are a complex and underserved group. They are commonly older patients with multiple comorbidities, who rely on multiple healthcare services. Regional variation in services and resourcing has been highlighted as a problem in heart failure care, with few teams bridging the interface between the community and secondary care. These reports conflict with policy goals to improve coordination of care and dissolve boundaries between specialist services and the community.

AIM

To explore how care is coordinated for patients with HFpEF, with a focus on the interface between primary care and specialist services in England.

METHODS

We applied systems thinking methodology to examine the relationship between work-as-imagined and work-as-done for coordination of care for patients with HFpEF. We analysed clinical guidelines in conjunction with a secondary applied thematic analysis of semistructured interviews with healthcare professionals caring for patients with HFpEF including general practitioners, specialist nurses and cardiologists and patients with HFpEF themselves (n=41). Systems Thinking for Everyday Work principles provided a sensitising theoretical framework to facilitate a deeper understanding of how these data illustrate a complex health system and where opportunities for improvement interventions may lie.

RESULTS

Three themes (working with complexity, information transfer and working relationships) were identified to explain variability between work-as-imagined and work-as-done. Participants raised educational needs, challenging work conditions, issues with information transfer systems and organisational structures poorly aligned with patient needs.

CONCLUSIONS

There are multiple challenges that affect coordination of care for patients with HFpEF. Findings from this study illuminate the complexity in coordination of care practices and have implications for future interventional work.

Exploring workplace-based learning in distributed healthcare settings: a qualitative study

BACKGROUND

Distributed healthcare settings such as district hospitals, primary care, and public health facilities are becoming the real-life settings for workplace-based learning required to educate the future healthcare workforce. Therefore, a major focus should be on designing and developing workplace-based learning in these learning environments. Healthcare professionals and educational policymakers play a significant role in these settings as role models in workplace-based learning, and as leaders in integrating learning into their work environments. It is relevant to explore their beliefs, attitudes, and behaviors towards workplace-based learning in their own settings, in order to provide context-relevant recommendations that can assist in shaping workplace-based learning environments.

METHODS

We used individual interviews to understand professionals' experiences with workplace-based learning in distributed healthcare settings. We - three clinicians, an educationalist, and a philosopher - thematically analyzed transcripts of 13 interviews with healthcare professionals and educational policymakers from different healthcare settings who were involved in the clinical phase of undergraduate medical education.

RESULTS

Clustering and categorizing of the data led to the construction of five overarching themes: Identification with and attitude towards medical education, Sense of ownership, Perceived time and space, Mutual preconceptions and relations, and Curriculum for a changing profession.

CONCLUSIONS

These themes accentuate aspects relevant to the development of workplace-based learning in distributed healthcare settings on the individual, team, or organizational level. We highlight the significance of individual professionals in the development of workplace-based learning and emphasize the need for recognition and support for those occupying the 'broker' role at the intersection of education and practice. For future research and educational practice, we recommend prioritizing initiatives that build on good-practices in workplace-based learning and involve dedicated individuals in distributed healthcare settings.

General practice management of chronic post-surgical pain in patients with hip fracture: a qualitative study

Background

Hip fractures are common among elderly people and often lead to chronic post-surgical pain (CPSP). Effective CPSP management when patients transition from hospital to community settings is essential, but has not been sufficiently researched. This study examined general practitioner (GP) perspectives on managing patients with CPSP after hip fractures in Shanghai, China.

Methods

A descriptive qualitative study was performed wherein semi-structured interviews were conducted with GPs practicing in Shanghai who volunteered to participate. This study was initiated after a regional survey of general practice care for patients with CPSP following hip fracture.

Results

Six key themes emerged: (1) GPs' care priorities for patients with CPSP varied; (2) pharmacological management posed challenges in terms of selecting appropriate medications; (3) consultation time constraints hindered comprehensive management; (4) GPs desired better communication from hospitals at discharge; (5) limited access to services, such as pain specialists and allied health, obstructed optimal care delivery; and (6) patient nonadherence to CPSP treatment was an issue.

Conclusion

Multiple patient-, provider-, and system-level factors affected GP care for patients with CPSP after hip fracture. Improved interdisciplinary communication and education on evidence-based CPSP guidelines are needed to address the knowledge gaps among GPs. Barriers to healthcare access must be minimized to facilitate guideline-based care.

Impact of an email advice service on filtering and refining ophthalmology referrals in England

PURPOSE

The growing capacity-demand imbalance has necessitated the accelerated digital transformation of eye care services. The role of Oxford Eye Hospital's (OEH) email advice service has become even more relevant in the post-Covid era. We sought to evaluate its impact on referrals to secondary care.

METHODS

The consultant-led OEH email advice service primarily targets primary eye care personnel (optometrists and GPs) requiring clinical advice on patient referral. Emails received between September and November 2020 were analysed for demographic data, contents, characteristics, and outcomes. Thematic analysis was performed. A user feedback survey was conducted.

RESULTS

A total of 828 emails were received over the 3-month study period (mean 9.1/day). They were predominantly from optometrists (77.9%) and general practitioners (16.1%). Of the 81.0% (671) relating to clinical advice, over half (54.8%) included images from a variety of modalities, and following review, over half (55.5%) were deemed suitable for management in the community, while 36.5% were referred directly to appropriate subspecialty clinics. Only 8.1% required urgent assessment in eye casualty. Thematic analysis showed that this service was most useful for retinal lesions, optical coherence tomography abnormalities, and borderline abnormal optic discs. No adverse events were identified. User feedback was very positive.

CONCLUSION

A secure email advice service is a safe and low-maintenance modality that provides direct and efficient two-way communication between primary and secondary eye care professionals. It allows rapid response to clinical queries, referral filtering and refinement, and streamlining of patient referral pathways. Users (predominantly optometrists) were overwhelmingly positive about its usefulness in clinical practice.

Identifying and prioritising future interventions with stakeholders to improve paediatric urgent care pathways in Scotland, UK: a mixed-methods study

OBJECTIVES

To identify and prioritise interventions, from the perspectives of parents and health professionals, which may be alternatives to current unscheduled paediatric urgent care pathways.

DESIGN

FLAMINGO (FLow of AdMissions in chIldren and youNG peOple) is a sequential mixed-methods study, with public and patient involvement (PPI) throughout. Data linkage for urgent admissions and three referral sources: emergency department, out of hours service and general practice, was followed by qualitative interviews with parents and professionals. Findings were presented and discussed at a stakeholder intervention prioritisation event.

SETTING

National Health Service in Scotland, UK.

PARTICIPANTS

Quantitative data: children with urgent medical admission to hospital from 2015 to 2017. Qualitative interviews: parents and health professionals with experiences of urgent short stay hospital admissions of children. PPI engagement was conducted with nine parent-toddler groups and a university-based PPI advisory group. Stakeholder event: parents, health professionals and representatives from Scottish Government, academia, charities and PPI attended.

RESULTS

Data for 171 039 admissions which included 92 229 short stay admissions were analysed and 48 health professionals and 21 parents were interviewed. The stakeholder event included 7 parents, 12 health professionals and 28 other stakeholders. Analysis and synthesis of all data identified seven interventions which were prioritised at the stakeholder event: (1) addressing gaps in acute paediatric skills of health professionals working in community settings; (2) assessment and observation of acutely unwell children in community settings; (3) creation of holistic children's 'hubs'; (4) adoption of 'hospital at home' models; and three specialised care pathways for subgroups of children; (5) convulsions; (6) being aged <2 years old; and (7) wheeze/bronchiolitis. Stakeholders prioritised interventions 1, 2 and 3; these could be combined into a whole population intervention. Barriers to progressing these include resources, staffing and rurality.

CONCLUSIONS

Health professionals and families want future interventions that are patient-centred, community-based and aligned to outcomes that matter to them.

The forgotten dimension of integrated care: barriers to implementing integrated clinical care in English NHS hospitals

Multimorbid patients who enter English NHS hospitals are frequently subject to care pathways designed to assess, diagnose and treat single medical conditions. Opportunities are thereby lost to offer patients more holistic, person-centred care. Hospital organisations elsewhere are known to use in-hospital, multi-specialty, integrated clinical care (ICC) to overcome this problem. This perspective piece aims to critically discuss barriers to implementing this form of ICC in the English NHS focusing on six key areas: information technologies, the primary-secondary care interface, internal hospital processes, finance, workload, professional roles and behaviours. Integrated care programmes currently underway are largely focused on macro (system) and meso (organisational) levels. A micro (clinical) level ICC, offering highly coordinated multispecialty expertise to multimorbid hospital patients could fill an important gap in the current care pathways.

A Patient-Centered Model of Fast-Track Lung Cancer Diagnosis

INTRODUCTION

Despite the increasing importance of digital resources in modern life over the past decades, little is known about the impact of internet-based solutions on patient's health. We aimed to study the potential benefit of a digital platform helping patients to deal with abnormal chest CT scan revealing possible lung cancer.

METHODS

We set up a fast-track lung cancer diagnosis pathway through a secure online platform. Patient-generated information combined with online review of their imaging enables preplanning of further investigations ahead of clinical assessment. We compared outcomes of "self-referred" patients (patient group), who directly fill out the online questionnaire, to general practitioner-driven patients (GP group), who were referred by their GP.

RESULTS

From June 2021 to June 2022, we included 125 patients (61% males, median age 67 years, IQR 56.9-72.5): 41% in the patient group and 59% in the GP group. No difference was found between groups in terms of time from contact to first appointment (median 5 days in both groups, P = .6), percentage of pathways including prebooked tests (94% vs. 92%, P = .6), number of scheduled invasive procedures (median 1, IQR 1-2 vs. 2, IQR 1-2, P = .4) and in final cancer diagnosis (76% vs. 78%, P = .4).

CONCLUSION

A lung cancer diagnosis pathway directly accessible by patients through a secure online platform was feasible and as efficient as the usual general practitioner pathway. It demonstrated the benefit of leaning on new digital tools in order to answer to the new challenges of a patient-centered health care system.

General practice management of COPD patients following acute exacerbations: a qualitative study

BACKGROUND

Exacerbations are the strongest risk factor for future exacerbations for patients living with chronic obstructive pulmonary disease (COPD). The period immediately following exacerbation is a high-risk period for recurrence and hospital admission, and is a critical time to intervene. GPs are ideally positioned to deliver this care.

AIM

To explore perceptions of GPs regarding the care of patients following exacerbations of COPD and to identify factors affecting the provision of evidence-based care.

DESIGN AND SETTING

A descriptive qualitative study was undertaken involving semi-structured, in-depth interviews with Australian GPs who volunteered to participate following a national survey of general practice care for COPD patients following exacerbations.

METHOD

Interviews were conducted via the Zoom video conference platform, which were audio-recorded and transcribed verbatim. QSR NVivo was used to support data management, coding, and inductive thematic analysis.

RESULTS

Eighteen GPs completed interviews. Six key themes were identified: 1) GPs' perceptions and knowledge in the management of COPD patients following exacerbation and admission to hospital; 2) pharmacological management; 3) consultation time; 4) communication between healthcare professionals; 5) access to other health services; and 6) patient compliance.

CONCLUSION

Delivery of post-exacerbation care to COPD patients is affected by GPs, patients, and health service-related factors. The care of COPD patients may be further improved by supporting GPs to overcome identified barriers.

Role distribution and collaboration between specialists and rural general practitioners in long-term chronic care: a qualitative study in Switzerland

INTRODUCTION

This study explores general practitioners' (GPs') and medical specialists' perceptions of role distribution and collaboration in the care of patients with chronic conditions, exemplified by spinal cord injury.

METHODS

Semi-structured interviews with GPs and medical specialists caring for individuals with spinal cord injury in Switzerland. The physicians we interviewed were recruited as part of an intervention study. We used a hybrid framework of inductive and deductive coding to analyse the qualitative data.

RESULTS

Six GPs and six medical specialists agreed to be interviewed. GPs and specialists perceived the role of specialists similarly, namely as an expert and support role for GPs in the case of specialised questions. Specialists' expectations of GP services and what GPs provide differed. Specialists saw the GPs' role as complementary to their own responsibilities, namely as the first contact for patients and gatekeepers to specialised services. GPs saw themselves as care managers and guides with a holistic view of patients, connecting several healthcare professionals. GPs were looking for relations and recognition by getting to know specialists better. Specialists viewed collaboration as somewhat distant and focused on processes and patient pathways. Challenges in collaboration were related to unclear roles and responsibilities in patient care.

CONCLUSION

The expectations for role distribution and responsibilities differ among physicians. Different goals of GPs and specialists for collaboration may jeopardise shared care models. The role distribution should be aligned according to patients' holistic needs to improve collaboration and provide appropriate patient care.

Interaction at the primary–secondary care interface: Patients’ and physicians’ perceptions of teleconsultations

Introduction

Previous qualitative research on teleconsultations has focused on synchronous communication between a patient and a clinician. This study aims to explore physicians' and patients' perceptions of the interaction on the interface between primary care and the Cardiology service of a referral hospital through teleconsultations.

Methods

This qualitative study was embedded in an organizational case study concerning the introduction and rollout of a new service model that took place at the point of care. The patients and physicians were recruited for semi-structured interviews until thematic saturation was achieved, between September 2019 - January 2020. The interviews were audiorecorded and anonymized. The transcribed interviews were stored, coded, and analyzed in MAXQDA, following the steps for conventional content analysis.

Results

A total of 29 participants were interviewed. Patients and physicians presented clear views about the role of the GP and the cardiologist and their function in overall structure of healthcare. GPs felt their role was to bring expertise in the patient which could supplement the cardiologists' expertise on the condition. However, GPs had to renegotiate roles in the teleconsultations when they saw themselves in a new situation, together with another physician and the patient.

Conclusions

Our findings suggest that joint teleconsultations can promote continuity of care for patients in the primary/secondary care interface. Active coordination between physicians with delineation of roles throughout primary-secondary care interface is needed to manage selected patients who may benefit the most from shared care.

Designing the learning of intraprofessional collaboration among medical residents

BACKGROUND

To preserve quality and continuity of care, collaboration between primary-care and secondary-care physicians is becoming increasingly important. Therefore, learning intraprofessional collaboration (intraPC) requires explicit attention during postgraduate training. Hospital placements provide opportunities for intraPC learning, but these opportunities require interventions to support and enhance such learning. Design-Principles guide the design and development of educational activities when theory-driven Design-Principles are tailored into context-sensitive Design-Principles. The aim of this study was to develop and substantiate a set of theory-driven and context-sensitive Design-Principles for intraPC learning during hospital placements.

METHODS

Based on our earlier research, we formulated nine theory-driven Design-Principles. To enrich, refine and consolidate these principles, three focus group sessions with stakeholders were conducted using a Modified Nominal Group Technique. Next, two work conferences were conducted to test the feasibility and applicability of the Design-Principles for developing intraPC educational activities and to sharpen the principles into a final set of Design-Principles.

RESULTS

The theoretical Design-Principles were discussed and modified iteratively. Two new Design-Principles were added during focus group 1, and one more Design-Principle was added during focus group 2. The Design-Principles were categorised into three clusters: (i) Culture: building collaborative relations in a psychologically safe context where patterns or feelings of power dynamics between primary and secondary care physicians can be discussed; (ii) Connecting Contexts: making residents and supervisors mutually understand each other's work contexts and activities; and (iii) Making the Implicit Explicit: having supervising teams act as role models demonstrating intraPC and continuously pursuing improvement in intraPC to make intraPC explicit. Participants were unanimous in their view that the Design-Principles in the Culture cluster were prerequisites to facilitate intraPC learning.

CONCLUSION

This study led to the development of 12 theory-driven and context-sensitive Design-Principles that may guide the design of educational activities to support intraPC learning during hospital placements.

Improvement Strategies for the Challenging Collaboration of General Practitioners and Specialists for Patients with Complex Chronic Conditions: A Scoping Review

Introduction:

Coordination of healthcare professionals seems to be particularly important for patients with complex chronic disease, as they present a challenging interplay of conditions and symptoms. As one solution, to counteract or prevent this, improving collaboration between general practitioners (GPs) and specialists has been the aim of studies by linking or coordinating their services along the continuum of care. This scoping review summarises role distributions and components of this collaboration that have potential for improvement for the care of patients with complex chronic conditions.

Methods:

Scoping review as a knowledge synthesis for components of collaboration and role distributions between medical specialists and GPs in intervention studies. The PubMed database was searched for literature from 2010–2020.

Results:

Literature search and reference screening generated 2,174 articles. 30 articles originating from 22 unique projects were included in our synthesis. In the interventions to improve collaboration, the GP is most commonly in charge of patient management and extends the scope of practice. The specialist provides support when needed. Clear definition of roles, resources for knowledge transfer and education from specialists are commonly utilised interventions. Typically, combinations of process and system changes addressing communication and coordination issues are applied. Most interventions improve provider and patient satisfaction, health outcomes, and reduce care fragmentation.

Conclusion:

This review showed that interventions to improve collaboration between GPs and medical specialists seem promising. Further efforts should be made to test and apply the findings systematically in broad clinical practice.

Learning from the GP-consultant exchange scheme: a qualitative evaluation

Collaborative working across primary and secondary care is crucial to providing high quality patient care. There is still a lack of communication and understanding between primary and secondary care, which can impede collaborative working. The experience of observing colleagues in a different speciality can prompt insight, improve morale and promote collaborative working. The GP-Consultant Exchange Scheme aimed to improve professional understanding, foster deeper partnerships, and ignite opportunities for innovation and/or quality improvement (QI) with co-owned local solutions. This paper gives an overview of how the scheme works and sets out some of the outcomes reported by some 200 Consultants and GPs participants to date. Overall, the participants found the scheme an enjoyable way to reconnect clinicians and allowed them to learn about the challenges faced in different areas within the NHS. This low-cost intervention needs motivated individuals to drive the project forward and make it sustainable, but it can be replicated within any organisation or profession in the NHS.

Cross-sectional analysis of hospital tasks handed over to general practitioners: workload delegation or dumping?

PURPOSE OF THE STUDY

New requirements for hospital clinicians to follow up and act on hospital-initiated investigations were introduced in 2016 in the National Health Service standard contract. We aimed to evaluate the tasks handed over from hospital clinicians to general practitioners (GPs).

STUDY DESIGN

A retrospective observation of all tasks in a random sample of electronic discharge summaries at a university teaching hospital over a 1 month period was conducted. A single-best-answer questionnaire was circulated among hospital clinicians over 3 months to gain an understanding of their follow-up and referral practices.

RESULTS

The total number of tasks found on discharge summaries (n=178) were 227, of which 39% were directed at GPs and 61% at the hospital team. Of 89 tasks delegated to GPs, 33% were inappropriate. Some tasks on discharge summaries were delegated more frequently to GPs such as blood tests (73%) and endoscopy requests (67%). While others were undertaken more often by hospitals clinicians including imaging requests (88%), follow-up appointments (87%) and onward referrals (71%). Surveyed doctors (n=72) admitted to asking GPs to follow up blood tests (52%), imaging and endoscopy (16%) and make onward referrals for related conditions (14%) and unrelated conditions (70%).

CONCLUSION

The majority of outstanding tasks in the hospital setting were followed up by hospital clinicians. A considerable volume of tasks were delegated to GPs, of which a significant proportion were inappropriate. An increase in awareness and understanding among hospital clinicians of their responsibility to follow up hospital-initiated investigations is needed.

Concerns of Primary Care Clinicians Practicing in an Integrated Health System: a Qualitative Study

BACKGROUND

Clinician well-being is a major priority for healthcare organizations. However, the impact of workplace environment on clinicians' well-being is poorly understood. Integrated health systems are a particularly relevant type of practice environment to focus on, given the increasing rates of practice consolidation and integration.

OBJECTIVE

To improve understanding of the concerns of primary care clinicians (PCCs) practicing in an integrated health system.

DESIGN

We analyzed free-text comment box responses offered on a national survey about care coordination by 555 PCCs in the Veterans Health Administration, one of the largest integrated health systems in the USA.

PARTICIPANTS

A total of 555 PCCs who left free-text comments on a national survey of care coordination in the VHA (30% out of 1862 eligible respondents). Demographics and coordination scale scores were similar between respondents who left comments vs. those who did not.

APPROACH

The data were coded and analyzed in line with the grounded theory approach. Key themes were identified by team consensus and illustrative quotations were chosen to illustrate each theme.

KEY RESULTS

VHA PCCs described some pressures shared across practice environments, such as prohibitive administrative burden, but also reported several concerns particular to integrated settings, including "dumping" by specialists and moral distress related to a concern for patients. Frustrations due to several aspects of responsibility around referrals may be unique to integrated health systems with salaried clinicians and/or where specialists have the ability to reject referrals.

CONCLUSION

PCCs in integrated health systems feel many of the same pressures as their counterparts in non-integrated settings, but they are also confronted with unique stressors related to these systems' organizational features that restrict clinicians' autonomy. An understanding of these concerns can guide efforts to improve the well-being of PCCs in existing integrated health systems, as well as in practices on their way to integration.

Influenza vaccination: A qualitative study of practice level barriers from medical practitioners caring for children with special risk medical conditions

BACKGROUND

Understanding the influenza vaccination practices of general practitioners (GP) and paediatric hospital specialists caring for children with special risk medical conditions (SRMC) is imperative for designing interventions to improve uptake. This study aimed to identify the vaccination decision making, provider practices and perceived barriers and facilitators to recommending or delivering influenza vaccine for children with SRMCs at the tertiary and primary care levels.

METHODS

Nominated GPs and hospital specialists from a single tertiary hospital were interviewed to explore influenza vaccination practices and challenges for children with confirmed SRMCs. Interviews were digitally recorded, transcribed verbatim and thematic analysis was used to inductively code these data. Resulting themes were mapped across the COM-B ('capability', 'opportunity', 'motivation' and 'behaviour') theoretical framework to understanding barriers and potential interventions.

RESULTS

Twenty-six medical practitioners (21 GPs and 5 hospital specialists) completed semi-structured interviews. Barriers, and facilitators for influenza vaccine recommendation (the intended behaviour) were thematically grouped. Opportunity themes included structural barriers (e.g. limited use of systems and processes to support the identification of children with SRMCs); recommendation as standard practice; vaccination inconvenience; lack of communication and educational resources; social acceptance and normalisation; and media messaging. Capability themes included provider communication with parents; knowledge of influenza vaccine recommendations; and professional boundaries to implement the recommendation. Themes in the Motivation category included provider clinical prioritisation and responsibility towards providing a recommendation.

CONCLUSIONS

The main barriers to influenza recommendation raised by our study participants were structural. These included lack of processes to identify children with SRMCs, limited use of reminder systems and unclear delineation of role responsibility between hospital specialists and GPs. An important driver that emerged was GPs' responsibility for providing a recommendation. To increase influenza vaccine coverage for children with SRMCs, consideration should be given to addressing practice level structural barriers and improving collaboration.

Competencies to promote collaboration between primary and secondary care doctors: an integrative review

Background

In a society where ageing of the population and the increasing prevalence of long-term conditions are major issues, collaboration between primary and secondary care is essential to provide continuous, patient-centred care. Doctors play an essential role at the primary-secondary care interface in realising ‘seamless’ care. Therefore, they should possess collaborative competencies. However, knowledge about these collaborative competencies is scarce. In this review we explore what competencies doctors need to promote collaboration between doctors at the primary-secondary care interface.

Methods

We conducted an integrative literature review. After a systematic search 44 articles were included in the review. They were analysed using a thematic analysis approach.

Results

We identified six themes regarding collaborative competencies: ‘patient-centred care: a common concern’, ‘roles and responsibilities’, ‘mutual knowledge and understanding’, ‘collaborative attitude and respect’, ‘communication’ and ‘leadership’. In every theme we specified components of knowledge, skills and attitudes as found in the reviewed literature. The results show that doctors play an important role, not only in the way they collaborate in individual patient care, but also in how they help shaping organisational preconditions for collaboration.

Conclusions

This review provides an integrative view on competencies necessary for collaborative practice at the primary-secondary care interface. They are part of several domains, showing the complexity of collaboration. The information gathered in this review can support doctors to enhance and learn collaboration in daily practice and can be used in educational programmes in all stages of medical education.

Competencies for collaboration between general practitioners and medical specialists: a qualitative study of the patient perspective

OBJECTIVES

To explore the patient view of competencies essential for doctors to provide good collaboration at the primary-secondary care interface.

DESIGN

We used a qualitative research approach. Focus groups with patients were conducted to explore their opinions of doctors' competencies to provide good collaboration between primary and secondary care doctors. Transcripts were analysed using thematic analysis.

SETTING

Dutch primary-secondary care interface.

PARTICIPANTS

Sixteen participants took part in five focus groups. Patients treated in both primary and secondary care, defined as having a minimum of two contacts with their general practitioner and two contacts with a medical specialty in the last 6 months, were included. Psychiatric patients and children were excluded from this study.

RESULTS

Three groups of competencies were identified: (1) relationship building, both with patients and with other doctors; (2) transparent collaborating: be able to provide clarity on the process of collaboration and on roles and responsibilities of those involved and (3) reflective practising: to be willing to acknowledge mistakes, give and receive feedback and act as a lifelong learner.

CONCLUSIONS

This focus group study enhances our understanding of the patient perspective on doctors' collaborative competencies at the primary-secondary care interface. With this information, doctors can improve their collaborative skills to a level that would meet their patients' needs. Patients expect doctors to be able to build relationships and act as reflective practitioners. Including patients in the collaborative process by giving them a role that is appropriate to their abilities and by making collaboration more explicit could help to improve collaboration between general practitioners and medical specialists.

Reorganising dermatology care: predictors of the substitution of secondary care with primary care

Background

The substitution of healthcare is a way to control rising healthcare costs. The Primary Care Plus (PC+) intervention of the Dutch ‘Blue Care’ pioneer site aims to achieve this feat by facilitating consultations with medical specialists in the primary care setting. One of the specialties involved is dermatology. This study explores referral decisions following dermatology care in PC+ and the influence of predictive patient and consultation characteristics on this decision.

Methods

This retrospective study used clinical data of patients who received dermatology care in PC+ between January 2015 and March 2017. The referral decision following PC+, (i.e., referral back to the general practitioner (GP) or referral to outpatient hospital care) was the primary outcome. Stepwise logistic regression modelling was used to describe variations in the referral decisions following PC+, with patient age and gender, number of PC+ consultations, patient diagnosis and treatment specialist as the predicting factors.

Results

A total of 2952 patients visited PC+ for dermatology care. Of those patients with a registered referral, 80.2% (N = 2254) were referred back to the GP, and 19.8% (N = 558) were referred to outpatient hospital care. In the multivariable model, only the treating specialist and patient’s diagnosis independently influenced the referral decisions following PC+.

Conclusion

The aim of PC+ is to reduce the number of referrals to outpatient hospital care. According to the results, the treating specialist and patient diagnosis influence referral decisions. Therefore, the results of this study can be used to discuss and improve specialist and patient profiles for PC+ to further optimise the effectiveness of the initiative.

Patient's travel distance to specialised cancer diagnostics and the association with the general practitioner's diagnostic strategy and satisfaction with the access to diagnostic procedures: an observational study in Denmark

BACKGROUND

Research indicate that when general practitioners (GPs) refer their patients for specialist care, the patient often has long distance. This study had a twofold aim: in accordance to the GP's suspicion of cancer, we investigated the association between: 1) cancer patient's travel distance to the first specialised diagnostic facility and the GP's diagnostic strategy and 2) cancer patient's travel distance to the first specialised diagnostic facility and satisfaction with the waiting time and the availability of diagnostic investigations.

METHOD

This combined questionnaire- and registry-based study included incident cancer patients diagnosed in the last 6 months of 2016 where the GP had been involved in the diagnostic process of the patients prior to their diagnosis of cancer (n = 3455). The patient's travel distance to the first specialised diagnostic facility was calculated by ArcGIS Network Analyst. The diagnostic strategy, cancer suspicion and the GP's satisfaction with the waiting times and the available investigations were assessed from GP questionnaires.

RESULTS

When the GP did not suspect cancer or serious illness, an insignificant tendency was seen that longer travel distance to the first specialised diagnostic facility increased the likelihood of the GP using 'wait-and-see' approach and 'medical treatment' as diagnostic strategies. The GPs of patients with travel distance longer than 49 km to the first specialised diagnostic facility were more likely to report dissatisfaction with the waiting time for requested diagnostic investigations (PR: 1.98, 95% CI: 1.20-3.28).

CONCLUSION

A insignificant tendency to use 'wait-and-see' and 'medical treatment' were seen among GPs of patients with long travel distance to the first diagnostic facility when the GP did not suspect cancer or serious illness. Long distance was associated with higher probability of GP dissatisfaction with the waiting time for diagnostic investigations.

Perspectives of specialists and family physicians in interprofessional teams in caring for patients with multimorbidity: a qualitative study

BACKGROUND

Patients with multimorbidity often require services across different health care settings, yet team processes among settings are rarely implemented. We explored perceptions of specialists and family physicians collaborating in a telemedicine interprofessional consultation for patients with multimorbidity to better understand the value of bringing physicians together across the boundaries of health care settings.

METHODS

This was a descriptive qualitative, interview-based study. Physicians who had previously participated in the Telemedicine Interprofessional Model of Practice for Aging and Complex Treatments (Telemedicine IMPACT Plus [TIP] Program) were invited to participate and asked to describe their experience of being a member of the program. Interviews were conducted from March to May 2016. We conducted an iterative and interpretive process using both individual and team analysis to identify themes.

RESULTS

There were 15 participants, 9 specialists and 6 family physicians. Three themes emerged in the analysis: creating new perspectives on care for patients with multimorbidity by sharing knowledge, skills and attitudes; the shift from a consultant model to an interprofessional team model (allowing a window into the community, extending discussions beyond the medical model and focusing on the patient's health in context); and opportunities for learners, including learning about interprofessional collaboration and gaining exposure to a real-world model for caring for people with multimorbidity in outpatient settings.

INTERPRETATION

Family physicians and specialists participating in a TIP Program believed the program improved their knowledge and skills, while also serving as an effective care delivery strategy. The findings also support that learners require more exposure to nontraditional consultant models in order to care for patients with multimorbidity effectively.

Care coordination in two of Bogota’s public healthcare networks: A cross-sectional study among doctors

Introduction

Care coordination is a priority concern for healthcare systems. In Colombia, there is a lack of information on the topic. This study analysed how doctors of two Bogotá’s public healthcare networks perceived coordination between healthcare levels and what factors are associated with their perception.

Methods

A cross-sectional study using the COORDENA-CO questionnaire to a sample of 363 doctors (network-1 = 181; network-2 = 182) in 2015. The questionnaire asks about types and dimensions of care coordination: information and clinical management, with items in a Likert scale, as well as conditions regarding health system, organisational and doctors’ conditions. Descriptive statistics and logistic regression analysis were performed.

Results

The doctors’ perception of a high level of coordination did not exceed 25.4%. On coordination of information, limited transfer of clinical information was found. Concerning clinical management, there were limited care coherence, deficits in patient follow-up and lengthy waiting times for specialised care. A high perception of coordination were associated with being female, being over 50 years old, being a specialist, having less than one year’s working experience, working less than 20 h per week at the centre, forming part of network-1, having time available for performing coordination tasks, having job satisfaction and not identifying limitations imposed by healthcare insurers.

Discussion

There was limited perception of coordination, in its different dimensions and types with some differences between networks. The results support the importance of guaranteeing job satisfaction, ensuring sufficient time to coordination-related activities and intervening in the restrictions imposed by healthcare insurers to improve care coordination.

General practitioners referring patients to specialists in tertiary healthcare: a qualitative study

BACKGROUND

There is a large and unexplained variation in referral rates to specialists by general practitioners, which calls for investigations regarding general practitioners' perceptions and expectations during the referral process. Our objective was to describe the decision-making process underlying referral of patients to specialists by general practitioners working in a university outpatient primary care center.

METHODS

Two focus groups were conducted among general practitioners (10 residents and 8 chief residents) working in the Center for Primary Care and Public Health (Unisanté) of the University of Lausanne, in Switzerland. Focus group data were analyzed with thematic content analysis. A feedback group of general practitioners validated the results.

RESULTS

Participating general practitioners distinguished two kinds of situations regarding referral: a) "clear-cut situations", in which the decision to refer or not seems obvious and b) "complex cases", in which they hesitate to refer or not. Regarding the "complex cases", they reported various types of concerns: a) about the treatment, b) about the patient and the doctor-patient relationship and c) about themselves. General practitioners evoked numerous reasons for referring, including non-medical factors such as influencing patients' emotions, earning specialists' esteem or sharing responsibility. They also explained that they seek validation by colleagues and postpone referral so as to relieve some of the decision-related distress.

CONCLUSIONS

General practitioners' referral of patients to specialists cannot be explained in biomedical terms only. It seems necessary to take into account the fact that referral is a sensitive topic for general practitioners, involving emotionally charged interactions and relationships with patients, colleagues, specialists and supervisors. The decision to refer or not is influenced by multiple contextual, personal and clinical factors that dynamically interact and shape the decision-making process.

Does the Association Between Age and Major Illness Vary by Healthcare System Quality?

This study builds on research into global aging, by offering a multiple-indicator test of whether national healthcare system quality modifies the association between age and major illness. Recent individual-level data on morbidity among respondents aged 50 or older (16 countries; 2014 European Social Survey) are merged with nation-level healthcare indicators. Healthcare system quality is assessed using a subjective, evaluation-based approach and an objective, attributable-mortality approach. Lagged nation-level economic and health indicators are controlled to help isolate healthcare system effects. Results across subjective and objective approaches to healthcare system quality are strikingly consistent. While older individuals showed approximately a 10% reduction in probability of major illness when residing in countries with higher healthcare quality, associations between age and morbidity indices combining number and severity of illness showed greater modification by healthcare quality, with reductions around 18%. Taken together, results are suggestive of healthcare’s protective role in reducing age-related illness and disability.

Experiences of living with dystonia

PURPOSE

Dystonia is a chronic and incurable movement disorder. This qualitative study aimed to enhance understanding of the condition by exploring the experience of living with dystonia.

METHOD

Interpretative phenomenological analysis was used to analyse data gathered through semi-structured interviews. Eight participants were recruited via a UK-based dystonia charity.

RESULTS

Three superordinate themes emerged from the data: (1) dealing with ignorance and uncertainty: navigating health services with a rare, poorly understood condition; (2) the challenge of social isolation: overcoming barriers to positive social identity; and (3) fear of psychological explanations: the impact of stigmatised attitudes towards psychological explanations for dystonia symptoms.

CONCLUSION

Coping with a rare and chronic condition led to participants feeling isolated and stigmatised by health care services and their communities. Participants were able to overcome this challenge to their identities through the use of social support, particularly from other people with dystonia. Recommendations for reducing the stigmatising experiences of people with dystonia can help to ease the process of adjustment to the illness and enable people to pursue meaningful lives and positive identities. Recommendations for research are aimed at increasing knowledge about these processes.IMPLICATIONS FOR REHABILITATIONDystonia has a pervasive, negative impact on the lives of people with the condition.The struggle for diagnosis marks the beginning of a period of psychological adjustment, the difficulty of which is compounded by social isolation and stigma.Support groups and peer interaction help people to integrate dystonia into their concept of a meaningful life and identity.Health professionals should play a pivotal role in assisting patients during the process of adjustment and on-going self-management through sensitive communication and signposting to wider support services.

Specialist and family physician collaboration: Insights from primary care-based memory clinics

Given limited available geriatric specialists and complexity of dementia care, there is a need for greater collaboration between primary care and specialists to better meet the needs of persons with dementia. Meaningful family physician-specialist collaboration has the potential to improve health outcomes, timely access to care and more appropriate healthcare resource utilisation. Primary Care Collaborative Memory Clinics (PCCMCs), which include specialist support, provide a significant opportunity for studying the family physician-specialist interface. This study aimed to explore the nature of collaborative relationships between memory clinic family physicians and specialists caring for persons with memory concerns in PCCMCs across Ontario, Canada. Family physicians (N = 71) attending an education session and specialists (N = 21) completed a survey in the fall of 2017 that measured frequency and amount of collaboration, perceptions of their relationship and identified factors that enable and challenge collaboration. Descriptive statistics were generated for quantitative data and themes for responses to open-ended questions were explored using descriptive qualitative content analysis. Specialists and memory clinic family physicians valued their collaboration particularly as related to capacity building for dementia care and desired more time devoted to collaboration. Identified enablers and barriers to collaboration have implications for further integration of specialist support to potentially support improved patient care and further build capacity in primary care to manage dementia care. Opportunities exist for expanding and more intentionally supporting how family physicians and specialists interact with the creation of more formalised processes to support optimal collaboration, including a clear delineation of roles, responsibilities and expectations, more formally planned and structured relationship building and monitoring, identifying and addressing unique barriers to collaboration and use of a variety of methods of communication. Study findings have implications for how specialists and family physicians communicate and collaborate in other programmes for complex chronic conditions.

Nephrologists' perspectives on ambulatory care of patients with non-dialysis chronic kidney disease - A qualitative study

Little is known on the perspectives of nephrologists on managing non-dialysis patients with chronic kidney disease (CKD). The purpose of this qualitative study was to explore the experiences and perspectives of nephrologists regarding the interface with general practitioners (GP) and GPs' management of patients with non-dialysis CKD, so that barriers to cooperation and need for improved management can be identified. Twenty semi-structured interviews were conducted for this qualitative study. The interviews were audio-recorded and coded to be analysed. The concept of knowledge systems served as a sensitising concept. Optimising underlying diseases, medication adaptation and patient awareness of CKD were regarded as the most important treatment measures in CKD management. Differing views exist on who should be responsible for lifestyle interventions, patient education and timing of referral. Nephrologists generally preferred the referral of patients with high progression risk and co-treatment models in which daily care was performed by GP, but some preferred referral of all patients with early CKD and some nephrologists stated that patient care should be in the hands of nephrologists entirely in case of CKD. Doctor-patient communication predominantly remained within the medical-scientific knowledge system whereas patients' everyday knowledge systems were rarely considered. While stressing optimisation of laboratory values, diabetes and hypertension, patients' perspectives and shared decision-making to identify and prioritise patients' individual health goals were rarely considered by nephrologists. Instead, most nephrologists regarded educating patients and GPs as an important part of their professional role. Defining the interface between GPs and nephrologists, with specific recommendations on when to refer and which tasks each professional group should perform can lead to standardisation and improved interdisciplinary management of CKD patients. Addressing patients' everyday knowledge systems can be valuable in formulating and prioritising health goals with patients.

Professional identity in community care: The case of specialist physicians in outpatient services in Italy

Due to changes in social and health needs, the reorganisation of health systems towards community and primary care requires the redefinition of different professional identities and practices. This paper focuses on the specialists in the system: the physicians who work in outpatient services (local health authorities, hospitals, and other institutions) not as dependents but under private contract. This doctor has to balance the professional culture (in terms of autonomy and indipendence of judgment) with the bureaucratic logic that rules the organisations for which he or she works. Our research objective was to identify the identity variables characterising the specialist doctor ("ideal profile") and analyse the extent to which these differed from the doctor's actual identity ("actual profile"). From a methodological perspective, 1) we used a consensus method approach to identify the variables that define the specialist's identity, and 2) using a national web survey, we checked the distance between such characteristics and these professionals' actual identities. Involving different experts in the field of primary care, we identified 27 identity variables that appear to be at the core of specialist expertise. We then asked a representative sample of specialists to indicate how important and feasible these variables were in their work contexts and identified four main factors characterising their identities. The results demonstrate that, among experts, there is a clear perception of the need to build an identity that is linked to integration and to adopt a heuristic approach through teamwork and networking. However, this differs considerably from the logic of the specialists working in outpatient services: What emerges is the perceived difficulty of operational translation due to organisational problems or, otherwise, the constitutive elements of professional identity.

Comorbidities and the referral pathway to access joint replacement surgery: an exploratory qualitative study

Background

Variation in access to joint replacement surgery has been widely reported but less attention has been given to the impact of comorbidities on the patient journey to joint replacement surgery. There is a lack of consensus amongst healthcare professionals and commissioners about how patients with comorbidities should be referred or selected for joint replacement surgery. It is therefore important to understand the views of healthcare professionals on the management, referral and selection of patients with comorbidities for joint replacement surgery.

Methods

An exploratory qualitative study involving semi-structured interviews with 20 healthcare professionals in England across the referral pathway to joint replacement surgery. They were asked to talk about their experiences of referring and selecting patients with comorbidities for joint replacement surgery. The interviews were audio-recorded and transcribed verbatim. Data analysis followed a thematic analysis approach based on the principles of grounded theory.

Results

In general, the presence of comorbidities was not seen as a barrier to being referred or selected for joint replacement but was seen as a challenge to manage the patients’ journey across the referral pathway. Each professional group, concentrated on different aspects of the patients’ condition which appeared to affect how they managed patients with comorbidities. This implied there was a disagreement about roles and responsibilities in the management of patients with comorbidities. None of the professionals believed it was their responsibility to address comorbidities in preparation for surgery. This disagreement was identified as a reason why some patients seem to ‘get lost’ in the referral system when they were considered to be unprepared for surgery. Patients were then potentially left to manage their own comorbidities before being reconsidered for joint replacement.

Conclusions

At the clinician-level, comorbidities were not perceived as a barrier to accessing joint replacement surgery but at the pathway-level, it may create an implicit barrier such that patients with comorbidities may get ‘lost’ to the system. Further study is needed to explore the roles and responsibilities of professionals across the current orthopaedic referral pathway which may be less suitable for patients with comorbidities.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3565-0) contains supplementary material, which is available to authorized users.

A Short Weight Loss Intervention in a Neurosurgical Subspecialist Clinical Setting

Context

The relationship between back pain and obesity is well characterized; therefore, the neurosurgical consultant visit for back pain may be a key interventional opportunity for weight loss.

Aims

The aim of this project was to evaluate efficacy of an educational intervention for back pain.

Methods

A retrospective study was undertaken to evaluate effectiveness of an educational intervention (Show patient's own MRI, Explain degenerative disc disease, Relate to weight issues, Reference other weight-related comorbidities, and Encourage a plan of action for weight loss [SERRE]). This has been performed since 2014 for patients presenting to the first author's neurosurgical spine clinic with nonsurgical back pain and body mass index (BMI) over 35.

Results

The average BMI was 50.7. Fifty-five percent of patients had additional weight-related comorbidities. After SERRE intervention, 82% of patients were open to weight loss interventions. However, only 22% of patients went on to follow-up with a formal weight management program and only 9% of patients went on to have a documented weight loss. The lack of success was largely attributed to social issues and severe medical comorbidities within the specific population.

Conclusions

Incorporation of patient education regarding the relationship of weight loss to back pain and other weight-related comorbidities is well received in a rural specialist consultation setting. Improved communication with primary care physicians regarding this message and further supportive actions may improve follow-through, and therefore success of ultimate weight loss interventions.

The interplay of context factors in hypnotic and sedative prescription in primary and secondary care-a qualitative study

Purpose

Non-medical or contextual factors strongly influence physicians’ prescribing behavior and may explain why drugs, such as benzodiazepines and Z-drugs, are still frequently prescribed in spite of well-known adverse effects. This study aimed to explore which contextual factors influence the prescription of hypnotics and sedatives and to compare their role in primary and secondary care.

Methods

Understanding medical practices as games with specific rules and strategies and performed in a largely habitual, not fully conscious manner, we asked a maximum variation sample of 12 hospital doctors and 12 general practitioners (GPs) about their use of hypnotics and sedatives. The interviews were analyzed by qualitative content analysis.

Results

Hospital doctors’ and GPs’ use of hypnotics and sedatives was influenced by a variety of contextual factors, such as the demand of different patient groups, aims of management, time resources, or the role of nurses and peers. Negotiating patient demands, complying with administrative regulations, and finding acceptable solutions for patients were the main challenges, which characterized the game of drug use in primary care. Maintaining the workflow in the hospital and finding a way to satisfy both nurses and patients were the main challenges in secondary care.

Conclusions

Even if doctors try to act rationally, they cannot escape the interplay of contextual factors such as handling patient needs, complying with administrative regulations, and managing time resources. Doctors should balance these factors as if they were challenges in a complex game and reflect upon their own practices.

Electronic supplementary material

The online version of this article (10.1007/s00228-018-2555-9) contains supplementary material, which is available to authorized users.

The COPDnet integrated care model

Introduction

This research project sets out to design an integrated disease management model for patients with COPD who were referred to a secondary care setting and who qualified for pharmacological and nonpharmacological intervention options.

Theory and methods

The integrated disease management model was designed according to the guidelines of the European Pathway Association and the content founded on the Chronic Care Model, principles of integrated disease management, and knowledge of quality management systems.

Results

An integrated disease management model was created, and comprises 1) a diagnostic trajectory in a secondary care setting, 2) a nonmedical intervention program in a primary care setting, and 3) a pulmonary rehabilitation service in a tertiary care setting. The model also includes a quality management system and regional agreements about exacerbation management and palliative care.

Discussion

In the next phase of the project, the COPDnet model will be implemented in at least two different regions, in order to assess the added value of the entire model and its components, in terms of feasibility, health status benefits, and costs of care.

Conclusion

Based on scientific theories and models, a new integrated disease management model was developed for COPD patients, named COPDnet. Once the model is stable, it will be evaluated for its feasibility, health status benefits, and costs.

GPs' assessment of cooperation with other health care providers involved in cancer care-a cross-sectional study

Cancer is a complex disease requiring the involvement of several health care providers. A possible constant in the cancer care process is the general practitioner (GP). The aim of this project was to evaluate GPs' satisfaction with cooperation with other health care providers in the cancer care process of their patients and to explore which variables are associated with higher satisfaction with cooperation with other health care providers. We considered the following health care providers: outpatient oncology specialists, physicians in relatively small hospitals (≤400 beds), physicians in relatively large hospitals (>400 beds), home care services, outpatient psycho(onco)logists/psychotherapists, hospice/palliative care units and specialised palliative home care. The cross-sectional study was carried out as a postal survey all over Germany. Data were analysed descriptively and by means of logistic regression. Overall satisfaction with cooperation with other health care providers involved in cancer care was rather high. Only cooperation with outpatient psycho(onco)logists/psychotherapists was rated as not assessable/irrelevant by a majority of GPs. For all other health care providers under review, both communication and the transfer of sufficient information in good time were associated with overall satisfaction with cooperation. Little association was found between GP and practice variables and overall satisfaction with cooperation with the considered health care providers.

Improving the primary-secondary care interface in Scotland: a qualitative exploration of impact on clinicians of an educational complex intervention

OBJECTIVES

To determine the impact on clinicians and any consequent influence on patient care of taking part in the bespoke interface-focused educational intervention.

DESIGN

Qualitative design.

SETTING

Primary and secondary care centres in NHS Highland health board area, Scotland.

PARTICIPANTS

33 urban-based clinicians (18 general practitioners and 15 hospital specialists) in NHS Highland, Scotland.

INTERVENTION

An interface-focused educational intervention was carried out in primary and secondary care centres in NHS Highland health board area, Scotland. Eligible clinicians were invited to take part in the intervention which involved facilitated small group work, and use of a bespoke educational module. Subsequent one-to-one interviews explored the impact of the intervention. A standard thematic analysis was used, comprising an iterative process based on grounded theory.

RESULTS

Key themes that emerged included fresh insights (in relation to those individuals and processes across the interface), adoption of new behaviours (eg, being more empowered to directly contact a colleague, taking steps to reduce the others workload and changes in professional approach) and changes in terms of communication (including a desire to communicate more effectively, with use of different modes and methods).

CONCLUSION

The study highlighted key areas that may serve as useful outcomes for a large-scale randomised trial. Addressing issues identified in the study may help to improve interface relationships and benefit patient care.

'Doing the right thing': factors influencing GP prescribing of antidepressants and prescribed doses

BACKGROUND

Antidepressant prescribing continues to increase, with 5-16% of adults receiving antidepressants annually. Total prescribing growth is due in part to increased long-term use, greater selective serotonin re-uptake inhibitor (SSRI) use and the use of higher SSRI doses. Evidence does not support routine use of higher SSRI doses for depression treatment, and factors influencing the use of such doses are not well known. The aim of this study was to explore factors influencing GPs' use of antidepressants and their doses to treat depression.

METHODS

Semi-structured interviews with a purposive sample of 28 practising GPs; sampled by antidepressant prescribing volume, practice size and deprivation level. A topic guide drawing on past literature was used with enough flexibility to allow additional themes to emerge. Interviews were audio-recorded and transcribed verbatim. Framework analysis was employed. Constant comparison and disconfirmation were carried out across transcripts, with data collection being interspersed with analysis by three researchers. The thematic framework was then systematically applied to the data and conceptualised into an overarching explanatory model.

RESULTS

Depression treatment involved ethical and professional imperatives of 'doing the right thing' for individuals by striving to achieve the 'right care fit'. This involved medicalised and non-medicalised patient-centred approaches. Factors influencing antidepressant prescribing and doses varied over time from first presentation, to antidepressant initiation and longer-term treatment. When faced with distressed patients showing symptoms of moderate to severe depression GPs were confident prescribing SSRIs which they considered as safe and effective medicines, and ethically and professionally appropriate. Many GPs were unaware that higher doses lacked greater efficacy and onset of action occurred within 1-2 weeks, preferring to wait 8-12 weeks before increasing or switching. Ongoing pressures to maintain prescribing (e.g. fear of depression recurrence), few perceived continuation problems (e.g. lack of safety concerns) and lack of proactive medication review (e.g. patients only present in crisis), all combine to further drive antidepressant prescribing growth over time.

CONCLUSIONS

GPs strive to 'do the right thing' to help people. Antidepressants are only a single facet of depression treatment. However, increased awareness of drug limitations and regular proactive reviews may help optimise care.

Development of an interface-focused educational complex intervention

BACKGROUND

In many countries, the medical primary-secondary care interface is central to the delivery of quality patient care. There is prevailing interest in developing initiatives to improve interface working for the benefit of health care professionals and their patients.

AIM

To describe the development of an educational intervention designed to improve working at the primary-secondary care interface in NHS Scotland (United Kingdom) within the context of the Medical Research Council framework for the development and evaluation of complex interventions.

METHODS

A primary-secondary care interface focused Practice-based Small Group Learning (PBSGL) module was developed building upon qualitative synthesis and original research. A 'meeting of experts' shaped the module, which was subsequently piloted with a group of interface clinicians. Reflections on the module were sought from clinicians across NHS Scotland to provide contextual information from other areas.

FINDINGS

The PBSGL approach can be usefully applied to the development of a primary-secondary care interface-focused medical educational intervention.

Geographic Variations in Physician Relationships Over Time: Implications for Care Coordination

Care coordination may be more challenging when the specific physicians with whom primary care physicians (PCPs) are expected to coordinate care change over time. Using Medicare data on physician patient-sharing relationships and the Dartmouth Atlas, we explored the extent to which PCPs tend to share patients with other physicians over time. We found that 70.7% of ties between PCPs and other physicians that were present in 2012 persisted in 2013, and additional shared patients in 2012 increased the odds of being connected in 2013. Regions with higher persistent ties tended to have lower rates of emergency room visits, and regions where PCPs had more physician connections were more likely to have higher emergency room visits. The results point to potential opportunities and challenges faced by health care reforms that seek to improve coordination.

Preparation for practice: a novel role for general practice in pre-foundation assistantships

BACKGROUND

Hospital-based undergraduate assistantships are now widely established in medical school curricula. They are considered to improve graduates' preparedness for practice in their role as a foundation doctor. Foundation doctors play a key team role in ensuring patient safety during complex transitions across the hospital/primary care interface, and their self-reported preparedness for practice still varies considerably.

AIMS

We sought to explore what spending one week of the pre-foundation assistantship in General Practice might add.

METHODS

We solicited reflective audio diaries from final year students during a one-week pilot attachment delivered during the post-finals, pre-foundation assistantship period, and performed an iterative thematic analysis on the acquired data.

RESULTS

From this attachment in General Practice, students described diverse learning, resulting in improved preparedness for (hospital) foundation practice across several domains, impacting positively on how they might approach patients in the future. Self-confidence improved due to affirming outcomes and tutor mentorship. Students deepened their understanding of community healthcare and General Practice; and seeing the 'Patient Journey' across the interface from the patient's perspective helped them contextualise their forthcoming role as foundation doctors in managing it.

DISCUSSION

We believe that this novel intervention distinctively contributed to preparedness for practice. It aligns with published recommendations about extending the current assistantship model. We suggest it should be incorporated more widely into pre-foundation assistantship curricula.