Primary care indicators for disease burden, monitoring and surveillance of COVID-19 in 31 European countries: Eurodata Study

BACKGROUND

During the COVID-19 pandemic, the majority of patients received ambulatory treatment, highlighting the importance of primary health care (PHC). However, there is limited knowledge regarding PHC workload in Europe during this period. The utilization of COVID-19 PHC indicators could facilitate the efficient monitoring and coordination of the pandemic response. The objective of this study is to describe PHC indicators for disease surveillance and monitoring of COVID-19's impact in Europe.

METHODS

Descriptive, cross-sectional study employing data obtained through a semi-structured ad hoc questionnaire, which was collectively agreed upon by all participants. The study encompasses PHC settings in 31 European countries from March 2020 to August 2021. Key-informants from each country answered the questionnaire. Main outcome: the identification of any indicator used to describe PHC COVID-19 activity.

RESULTS

Out of the 31 countries surveyed, data on PHC information were obtained from 14. The principal indicators were: total number of cases within PHC (Belarus, Cyprus, Italy, Romania and Spain), number of follow-up cases (Croatia, Cyprus, Finland, Spain and Turkey), GP's COVID-19 tests referrals (Poland), proportion of COVID-19 cases among respiratory illnesses consultations (Norway and France), sick leaves issued by GPs (Romania and Spain) and examination and complementary tests (Cyprus). All COVID-19 cases were attended in PHC in Belarus and Italy.

CONCLUSIONS

The COVID-19 pandemic exposes a crucial deficiency in preparedness for infectious diseases in European health systems highlighting the inconsistent recording of indicators within PHC organizations. PHC standardized indicators and public data accessibility are urgently needed, conforming the foundation for an effective European-level health services response framework against future pandemics.

What would primary care practitioners do differently after a delayed cancer diagnosis? Learning lessons from their experiences

OBJECTIVE

Diagnosis of cancer is challenging in primary care due to the low incidence of cancer cases in primary care practice. A prolonged diagnostic interval may be due to doctor, patient or system factors, or may be due to the characteristics of the cancer itself. The objective of this study was to learn from Primary Care Physicians' (PCP) experiences of incidents when they had failed to think of, or act on, a cancer diagnosis.

DESIGN

A qualitative, online survey eliciting PCP narratives. Thematic analysis was used to analyse the data.

SETTING AND SUBJECTS

A primary care study, with narratives from 159 PCPs in 23 European countries.

MAIN OUTCOME MEASURES

PCPs' narratives on the question 'If you saw this patient with cancer presenting in the same way today, what would you do differently?

RESULTS

The main themes identified were: thinking broadly; improvement in communication and clinical management; use of other available resources and 'I wouldn't do anything differently'.

CONCLUSION (IMPLICATIONS)

To achieve more timely cancer diagnosis, PCPs need to provide a long-term, holistic and active approach with effective communication, and to ensure shared decision-making, follow-up and continuing re-assessment of the patients' clinical conditions.

Translation of the working alliance inventory short revised into Italian using a Delphi procedure and a forward-backward translation

Introduction

Enhancing treatment adherence, especially for chronic diseases, can be achieved through therapeutic alliance, potentially elevating the quality of care. An instrument to evaluate the therapeutic alliance could be beneficial in routine clinical settings, educational environments, and extensive research efforts at national and European levels. In this study, we translated therapist and patient versions of the Working Alliance Inventory Short Revised (WAI-SR) into Italian.

Methodology

An email-based Delphi method was employed for the English-to-Italian translation, incorporating a forward-backward process. The initial translation team comprised two Italian family physicians proficient in English, a linguist, and a psychiatrist. The forward translation was then reviewed by 18 Italian family physicians through a Delphi process and was subjected to a backward translation by two Italian English teachers. A cultural correspondence was subsequently identified to adjust translations within a national and international framework.

Results

All 18 experts fully engaged in the Delphi process, and consensus was achieved by the second Delphi round. A cultural check checked for discrepancies regarding linguistic consistency with other translations and found no difference.

Conclusion

This Italian translation of the WAI-SR is expected to support Italian family physicians aiming to enhance their clinical practice and therapeutic outcomes. It could also be a valuable tool for Italian medical students to foster therapeutic relationships and improve their communication skills.

Exploring why European primary care physicians sometimes do not think of, or act on, a possible cancer diagnosis. A qualitative study

BACKGROUND

While primary care physicians (PCPs) play a key role in cancer detection, they can find cancer diagnosis challenging, and some patients have considerable delays between presentation and onward referral.

AIM

To explore European PCPs' experiences and views on cases where they considered that they had been slow to think of, or act on, a possible cancer diagnosis.

DESIGN & SETTING

A multicentre European qualitative study, based on an online survey with open-ended questions, asking PCPs for their narratives about cases when they had missed a diagnosis of cancer.

METHOD

Using maximum variation sampling, PCPs in 23 European countries were asked to describe what happened in a case where they were slow to think of a cancer diagnosis, and for their views on why it happened. Thematic analysis was used to analyse the data.

RESULTS

A total of 158 PCPs completed the questionnaire. The main themes were as follows: patients' descriptions did not suggest cancer; distracting factors reduced PCPs' cancer suspicions; patients' hesitancy delayed the diagnosis; system factors not facilitating timely diagnosis; PCPs felt that they had acted wrongly; and problems with communicating adequately.

CONCLUSION

The study identified six overarching themes that need to be addressed. Doing so should reduce morbidity and mortality in the small proportion of patients who have a significant, avoidable delay in their cancer diagnosis. The 'Swiss cheese' model of accident causation showed how the themes related to each other.

Transitioning from face-to-face to distance education. Part 2: A qualitative study in the former Yugoslavia during COVID-19

BACKGROUND

Similar to other countries, Departments of Family Medicine in the former Yugoslavia had to transition from face-to-face to distance education during COVID-19.

OBJECTIVES

To elucidate obstacles and facilitators of the transition from face-to-face to distance education.

METHODS

A cross-sectional, multicentre, qualitative study design was used to analyse nine open-ended questions from an online survey using inductive thematic analysis. The questionnaire was distributed to 21 medical schools, inviting them to involve at least two teachers/students/trainees. Data were collected between December 2021 and March 2022.

RESULTS

In 17 medical schools, 23 students, 54 trainees and 40 teachers participated. The following themes were identified: facilitators and barriers of transition, innovations for enhancing distance education, convenience of distance education, classical teaching for better communication, the future of distance education, reaching learning outcomes and experience of online assessment. Innovations referred mainly to new online technologies for interactive education and communication. Distance education allowed for greater flexibility in scheduling and self-directed learning; however, participants felt that classical education allowed better communication and practical learning. Teachers believed knowledge-related learning outcomes could be achieved through distance education but not teaching clinical skills. Participants anticipated a future where a combination of teaching methods is used.

CONCLUSION

The transition to distance education was made possible thanks to its flexible scheduling, innovative tools and possibility of self-directed learning. However, face-to-face education was considered preferable for fostering interpersonal relations and teaching clinical skills. Educators should strive to strike a balance between innovative approaches and the preservation of personal experiences.

Transitioning from face-to-face to distance education. Part 1: A cross-sectional study in the former Yugoslavia during COVID-19

BACKGROUND

The countries of the former Yugoslavia have health and education systems with the same tradition but these have changed over the years. Little is known about how family medicine teaching transitioned from face-to-face to distance education during the COVID-19 pandemic.

OBJECTIVES

to investigate student/teacher experience in transitioning from face-to-face to distance education.

METHODS

A cross-sectional, online survey was conducted among 21 medical schools of the former Yugoslavia between December 2021 and March 2022. Under/postgraduate teachers and students who taught/studied family medicine during the academic year 2020/2021 were invited to participate. Of 31 questions for students and 35 for teachers, all but nine open questions were analysed using descriptive statistics.

RESULTS

Seventeen of 21 medical schools contributed data involving 117 participants representing all countries of the former Yugoslavia. At the beginning of the pandemic, 30%, 26% and 15% of teachers, students and trainees, respectively, received formal preparation in distance education. Of these, 92% of teachers and 58% of students/trainees felt they were not adequately prepared. Synchronous teaching was the main method used, with a third using hybrid methods. All participants were least confident about online assessment. More than 75% of respondents agreed that lectures could be kept online, not patient consultations or practical skills' classes.

CONCLUSION

Teachers used various old and new methods to provide learning opportunities despite COVID-19 constraints. Effective technology-based strategies are essential to ensure assessment integrity and enhance the learning environment.

The role of primary health care in long-term care facilities during the COVID-19 pandemic in 30 European countries: a retrospective descriptive study (Eurodata study)

BACKGROUND AND AIM

Primary health care (PHC) supported long-term care facilities (LTCFs) in attending COVID-19 patients. The aim of this study is to describe the role of PHC in LTCFs in Europe during the early phase of the pandemic.

METHODS

Retrospective descriptive study from 30 European countries using data from September 2020 collected with an ad hoc semi-structured questionnaire. Related variables are SARS-CoV-2 testing, contact tracing, follow-up, additional testing, and patient care.

RESULTS

Twenty-six out of the 30 European countries had PHC involvement in LTCFs during the COVID-19 pandemic. PHC participated in initial medical care in 22 countries, while, in 15, PHC was responsible for SARS-CoV-2 test along with other institutions. Supervision of individuals in isolation was carried out mostly by LTCF staff, but physical examination or symptom's follow-up was performed mainly by PHC.

CONCLUSION

PHC has participated in COVID-19 pandemic assistance in LTCFs in coordination with LTCF staff, public health officers, and hospitals.

Clinical pathway of COVID-19 patients in primary health care in 30 European countries: Eurodata study

BACKGROUND

Most COVID-19 patients were treated in primary health care (PHC) in Europe.

OBJECTIVES

To demonstrate the scope of PHC workflow during the COVID-19 pandemic emphasising similarities and differences of patient's clinical pathways in Europe.

METHODS

Descriptive, cross-sectional study with data acquired through a semi-structured questionnaire in PHC in 30 European countries, created ad hoc and agreed upon among all researchers who participated in the study. GPs from each country answered the approved questionnaire. Main variable: PHC COVID-19 acute clinical pathway. All variables were collected from each country as of September 2020.

RESULTS

COVID-19 clinics in PHC facilities were organised in 8/30. Case detection and testing were performed in PHC in 27/30 countries. RT-PCR and lateral flow tests were performed in PHC in 23/30, free of charge with a medical prescription. Contact tracing was performed mainly by public health authorities. Mandatory isolation ranged from 5 to 14 days. Sick leave certification was given exclusively by GPs in 21/30 countries. Patient hotels or other resources to isolate patients were available in 12/30. Follow-up to monitor the symptoms and/or new complementary tests was made mainly by phone call (27/30). Chest X-ray and phlebotomy were performed in PHC in 18/30 and 23/30 countries, respectively. Oxygen and low-molecular-weight heparin were available in PHC (21/30).

CONCLUSION

In Europe PHC participated in many steps to diagnose, treat and monitor COVID-19 patients. Differences among countries might be addressed at European level for the management of future pandemics.

Digital maturity and its determinants in General Practice: A cross-sectional study in 20 countries

Background

The extent to which digital technologies are employed to promote the delivery of high-quality healthcare is known as Digital Maturity. Individual and systemic digital maturity are both necessary to ensure a successful, scalable and sustainable digital transformation in healthcare. However, digital maturity in primary care has been scarcely evaluated.

Objectives

This study assessed the digital maturity in General Practice (GP) globally and evaluated its association with participants' demographic characteristics, practice characteristics and features of Electronic Health Records (EHRs) use.

Methods

GPs across 20 countries completed an online questionnaire between June and September 2020. Demographic data, practice characteristics, and features of EHRs use were collected. Digital maturity was evaluated through a framework based on usage, resources and abilities (divided in this study in its collective and individual components), interoperability, general evaluation methods and impact of digital technologies. Each dimension was rated as 1 or 0. The digital maturity score was calculated as the sum of the six dimensions and ranged between 0 to 6 (maximum digital maturity). Multivariable linear regression was used to model the total score, while multivariable logistic regression was used to model the probability of meeting each dimension of the score.

Results

One thousand six hundred GPs (61% female, 68% Europeans) participated. GPs had a median digital maturity of 4 (P25-P75: 3-5). Positive associations with digital maturity were found with: male gender [B = 0.18 (95% CI 0.01; 0.36)], use of EHRs for longer periods [B = 0.45 (95% CI 0.35; 0.54)] and higher frequencies of access to EHRs [B = 0.33 (95% CI 0.17; 0.48)]. Practicing in a rural setting was negatively associated with digital maturity [B = -0.25 (95%CI -0.43; -0.08)]. Usage (90%) was the most acknowledged dimension while interoperability (47%) and use of best practice general evaluation methods (28%) were the least. Shorter durations of EHRs use were negatively associated with all digital maturity dimensions (aOR from 0.09 to 0.77).

Conclusion

Our study demonstrated notable factors that impact digital maturity and exposed discrepancies in digital transformation across healthcare settings. It provides guidance for policymakers to develop more efficacious interventions to hasten the digital transformation of General Practice.

General practitioners' perceptions of using virtual primary care during the COVID-19 pandemic: An international cross-sectional survey study

With the onset of COVID-19, general practitioners (GPs) and patients worldwide swiftly transitioned from face-to-face to digital remote consultations. There is a need to evaluate how this global shift has impacted patient care, healthcare providers, patient and carer experience, and health systems. We explored GPs' perspectives on the main benefits and challenges of using digital virtual care. GPs across 20 countries completed an online questionnaire between June-September 2020. GPs' perceptions of main barriers and challenges were explored using free-text questions. Thematic analysis was used to analyse the data. A total of 1,605 respondents participated in our survey. The benefits identified included reducing COVID-19 transmission risks, guaranteeing access and continuity of care, improved efficiency, faster access to care, improved convenience and communication with patients, greater work flexibility for providers, and hastening the digital transformation of primary care and accompanying legal frameworks. Main challenges included patients' preference for face-to-face consultations, digital exclusion, lack of physical examinations, clinical uncertainty, delays in diagnosis and treatment, overuse and misuse of digital virtual care, and unsuitability for certain types of consultations. Other challenges include the lack of formal guidance, higher workloads, remuneration issues, organisational culture, technical difficulties, implementation and financial issues, and regulatory weaknesses. At the frontline of care delivery, GPs can provide important insights on what worked well, why, and how during the pandemic. Lessons learned can be used to inform the adoption of improved virtual care solutions and support the long-term development of platforms that are more technologically robust and secure.

General Practice/Family Medicine Research During the Pandemic: Showing The Links to the EGPRN Research Strategy

General Practice/Family Medicine is at the forefront of the clinical response to the COVID-19 crisis just as it is known to be a critical component of healthcare systems globally. A large number of COVID-19 related papers have been published and dedicated funding calls were available in many countries and across the European Union. However, General Practice/Family Medicine does not feature as strongly as it should in COVID-19 high impact publications or successful funding applications. In this paper, we take a look at the findings on which the recommendations of the “European General Practice Research Network (EGPRN) Research Strategy for General Practice in Europe 2021” are based and highlight how these align with the COVID-19 experience of General Practice/Family research. To elaborate on this, the issues identified and the recommendations of the EGPRN Research Strategy are grouped into three broad areas on which we need to focus – capacity, collaboration, and complexity (3-Cs). Apparent or presumed deficiencies in these 3-Cs are possibly why the General Practice/Family research impact during COVID-19 does not match its position on the ground in fighting the pandemic and supporting patients. The EGPRN Research Strategy identifies how we might work to position ourselves better in the future and gain the recognition deserved, in terms of publications, research funding, and prominence. Keywords: general practice, research, pandemics, publications, financing

Non-Medical Factors Associated with the Outcome of Treatment of Chronic Non-Malignant Pain: A Cross-Sectional Study

BACKGROUND

Chronic pain is a global public health issue with increasing prevalence. Chronic pain causes sleep disorder, reactive anxiety, and depression, impairs the quality of life; it burdens the individual and society as a whole. The aim of this study was to examine non-medical factors related to the outcome of the treatment of chronic non-malignant pain.

METHODS

A cross-sectional study with two groups of patients was conducted using a questionnaire with biological, psychological, and social characteristics of patients. Since this study was cross-sectional, it was not possible to determine whether some factors were the cause or the consequence of unsuccessful treatment outcome, which is at the same time one of the disadvantages of cross-sectional studies.

RESULTS

The poor outcome of the treatment of chronic non-malignant pain in a multivariate binary logistic regression model was statistically significantly associated with the lower quality of life (OR = 0.95 (95% CI: 0.91-0.99; p = 0.009), and higher depression level OR = 1.08 (95% CI: 1.02-1.14; p = 0.009). The outcome of the treatment was not directly related to social support measured by the multivariate binary logistic regression model (OR = 1.04, 95% CI: 0.95-1.15, p = 0.395), but solitary life (without partner) was (OR = 2.16 (95% CI: 1.03-4.53; p = 0.043).

CONCLUSION

The typical patient with a poor pain management outcome is retired, presents depressive behavior; their pain disturbs general activity and sleeping. Moreover, they have a physically disturbed quality of life and require self-treatment due to the inaccessibility of doctors and therapies. The principle of treatment of patients with chronic, non-malignant pain should take into account a biopsychosocial approach with individually adjusted procedures.

Pluralistic task shifting for a more timely cancer diagnosis. A grounded theory study from a primary care perspective

OBJECTIVE

To explore how cancer could be diagnosed in a more timely way.

DESIGN

Grounded theory analysis of primary care physicians' free text survey responses to: 'How do you think the speed of diagnosis of cancer in primary care could be improved?'. Secondary analysis of primary care physician interviews, survey responses, literature.

SETTING

Primary care in 20 European Örenäs Research Group countries.

SUBJECTS

Primary care physicians: 1352 survey respondents (2013-2016), 20 Spanish and 7 Swedish interviewees (2015-2019).

MAIN OUTCOME MEASURES

Conceptual explanation of how to improve timeliness of cancer diagnosis.

RESULTS

Pluralistic task shifting is a grounded theory of a composite strategy. It includes task sharing - among nurses, physicians, nurse assistants, secretaries, and patients - and changing tasks with cancer screening when appropriate or cancer fast-tracks to accelerate cancer case finding. A pluralistic dialogue culture of comprehensive collaboration and task redistribution is required for effective pluralistic task shifting. Pluralistic task shifting relies on cognitive task shifting, which includes learning more about slow analytic reasoning and fast automatic thinking initiated by pattern recognition; and digital task shifting, which by use of eHealth and telemedicine bridges time and place and improves power symmetry between patients, caregivers, and clinicians. Financial task shifting that involves cost tracking followed by reallocation of funds is necessary for the restructuring and retraining required for successful pluralistic task shifting. A timely diagnosis reduces expensive investigations and waiting times. Also, late-stage cancers are costlier to treat than early-stage cancers. Timing is central to cancer diagnosis: not too early to avoid overdiagnosis, and never too late.

CONCLUSIONS

We present pluralistic task shifting as a conceptual summary of strategies needed to optimise the timeliness of cancer diagnosis.Key pointsCancer diagnosis is under-researched in primary care, especially theoretically. Thus, inspired by classic grounded theory, we analysed and conceptualised the field:Pluralistic task shifting is a conceptual explanation of how the timeliness of cancer diagnosis could be improved, with data derived mostly from primary care physicians.This includes task sharing and changing tasks including screening and cancer fast-tracks to accelerate cancer case finding, and requires cognitive task shifting emphasising learning, and digital task shifting involving the use of eHealth and telemedicine.Financial task shifting with cost tracking and reallocation of funds is eventually necessary for successful pluralistic task shifting to happen.

Evaluating the Impact of COVID-19 on the Adoption of Virtual Care in General Practice in 20 Countries (inSIGHT): Protocol and Rationale Study

BACKGROUND

In recent decades, virtual care has emerged as a promising option to support primary care delivery. However, despite the potential, adoption rates remained low. With the outbreak of COVID-19, it has suddenly been pushed to the forefront of care delivery. As we progress into the second year of the COVID-19 pandemic, there is a need and opportunity to review the impact remote care had in primary care settings and reassess its potential future role.

OBJECTIVE

This study aims to explore the perspectives of general practitioners (GPs) and family doctors on the (1) use of virtual care during the COVID-19 pandemic, (2) perceived impact on quality and safety of care, and (3) essential factors for high-quality and sustainable use of virtual care in the future.

METHODS

This study used an online cross-sectional questionnaire completed by GPs distributed across 20 countries. The survey was hosted in Qualtrics and distributed using email, social media, and the researchers' personal contact networks. GPs were eligible for the survey if they were working mainly in primary care during the period of the COVID-19 pandemic. Descriptive statistical analysis will be performed for quantitative variables, and relationships between the use of virtual care and perceptions on impact on quality and safety of care and participants' characteristics may be explored. Qualitative data (free-text responses) will be analyzed using framework analysis.

RESULTS

Data collection took place from June 2020 to September 2020. As of this manuscript's submission, a total of 1605 GP respondents participated in the questionnaire. Further data analysis is currently ongoing.

CONCLUSIONS

The study will provide a comprehensive overview of the availability of virtual care technologies, perceived impact on quality and safety of care, and essential factors for high-quality future use. In addition, a description of the underlying factors that influence this adoption and perceptions, in both individual GP and family doctor characteristics and the context in which they work, will be provided. While the COVID-19 pandemic may prove the first great stress test of the capabilities, capacity, and robustness of digital systems currently in use, remote care will likely remain an increasingly common approach in the future. There is an imperative to identify the main lessons from this unexpected transformation and use them to inform policy decisions and health service design.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/30099.

Diabetes-related quality of life in six European countries measured with the DOQ-30

Background

The quantification of diabetes-related quality of life (DR-QoL) is an essential step in making Type 2 Diabetes (T2DM) self-management arrangements. The European General Practitioners Research Network (EGPRN) initiated the EUROBSTACLE study to develop a broadly conceptualised DR-QoL instrument for diverse cultural and ethnic groups; high and low-income countries. In 2016 the Diabetes Obstacles Questionnaire-30 (DOQ-30) was introduced.

Objectives

The research aimed to study obstacles a patient with diabetes (PWD) may face in everyday life. First, we assessed how descriptive and clinical characteristics and the residential country were associated with the obstacles. Secondly, we calculated the proportion of respondents who expressed obstacles.

Methods

Data were collected in 2009 in a cross-sectional survey in Belgium, France, Estonia, Serbia, Slovenia, and Turkey. Multiple linear regressions were computed to detect associations between descriptive and clinical characteristics, residential country, and obstacles. Percentages of respondents who perceived obstacles were calculated.

Results

We found that although descriptive and clinical characteristics varied to quite a great extent, they were weakly associated with the perception of obstacles. The residential country was most often associated with the existence of some obstacle. The highest percent (48%) of all respondents perceived ‘Uncertainty about Insulin Use’ as an obstacle.

Conclusion

Descriptive and clinical characteristics were weakly associated with perceived obstacles. However, the residential country plays an essential role in the decline of the QoL of PWDs. Education of both PWDs and healthcare professionals (HCPs) plays an essential role in countering the fear of insulin.

Psychosocial Factors in the Experience of Epilepsy: A Qualitative Analysis of Narratives

INTRODUCTION

Epilepsy is a complex disease. The consequences of epilepsy are varied and manifested in all aspects of people with epilepsy's (PWE) lives. The purpose of this study was to define individual experiences of epilepsy, expressed in narratives, and to find the stem of each narrative-a core event in the PWE's experience of the disease around which they structure their overall narrative.

METHOD

A qualitative, phenomenological research method was used. We conducted semistructured interviews with 22 PWE and analysed the content using a combination of inductive and deductive methods, based on which we determined the stem narratives.

RESULTS

The stem narrative of the epilepsy narrative is an important life experience of PWE. We divided the stem narratives into four groups: lifestyle changes, relationship changes, the consequences of the inciting incident, and the limitations of the disease. In our study, we found that the stem narrative was, in all but one case, a secondary (psychosocial) factor resulting from epilepsy, but not its symptom (epileptic seizure). The stem narrative, where aspects of life with epilepsy are exposed, points to a fundamental loss felt by PWE.

CONCLUSION

The narrative of the experience of epilepsy has proven to be an important source of information about the disease and life of PWE and also about the aspects at the forefront of life with epilepsy. The secondary epilepsy factors that we identified in the stem narratives were the greatest burden for PWE in all cases but one.

Primary care practitioners' diagnostic action when the patient may have cancer: an exploratory vignette study in 20 European countries

OBJECTIVES

Cancer survival rates vary widely between European countries, with differences in timeliness of diagnosis thought to be one key reason. There is little evidence on the way in which different healthcare systems influence primary care practitioners' (PCPs) referral decisions in patients who could have cancer.This study aimed to explore PCPs' diagnostic actions (whether or not they perform a key diagnostic test and/or refer to a specialist) in patients with symptoms that could be due to cancer and how they vary across European countries.

DESIGN

A primary care survey. PCPs were given vignettes describing patients with symptoms that could indicate cancer and asked how they would manage these patients. The likelihood of taking immediate diagnostic action (a diagnostic test and/or referral) in the different participating countries was analysed. Comparisons between the likelihood of taking immediate diagnostic action and physician characteristics were calculated.

SETTING

Centres in 20 European countries with widely varying cancer survival rates.

PARTICIPANTS

A total of 2086 PCPs answered the survey question, with a median of 72 PCPs per country.

RESULTS

PCPs' likelihood of immediate diagnostic action at the first consultation varied from 50% to 82% between countries. PCPs who were more experienced were more likely to take immediate diagnostic action than their peers.

CONCLUSION

When given vignettes of patients with a low but significant possibility of cancer, more than half of PCPs across Europe would take diagnostic action, most often by ordering diagnostic tests. However, there are substantial between-country variations.

Unburdening dementia - a basic social process grounded theory based on a primary care physician survey from 25 countries

OBJECTIVE

To explore dementia management from a primary care physician perspective.

DESIGN

One-page seven-item multiple choice questionnaire; free text space for every item; final narrative question of a dementia case story. Inductive explorative grounded theory analysis. Derived results in cluster analyses. Appropriateness of dementia drugs assessed by tertiary care specialist.

SETTING

Twenty-five European General Practice Research Network member countries.

SUBJECTS

Four hundred and forty-five key informant primary care physician respondents of which 106 presented 155 case stories.

MAIN OUTCOME MEASURES

Processes and typologies of dementia management. Proportion of case stories with drug treatment and treatment according to guidelines.

RESULTS

Unburdening dementia - a basic social process - explained physicians' dementia management according to a grounded theory analysis using both qualitative and quantitative data. Unburdening starts with Recognizing the dementia burden by Burden Identification and Burden Assessment followed by Burden Relief. Drugs to relieve the dementia burden were reported for 130 of 155 patients; acetylcholinesterase inhibitors or memantine treatment in 89 of 155 patients - 60% appropriate according to guidelines and 40% outside of guidelines. More Central and Northern primary care physicians were allowed to prescribe, and more were engaged in dementia management than Eastern and Mediterranean physicians according to cluster analyses. Physicians typically identified and assessed the dementia burden and then tried to relieve it, commonly by drug prescriptions, but also by community health and home help services, mentioned in more than half of the case stories.

CONCLUSIONS

Primary care physician dementia management was explained by an Unburdening process with the goal to relieve the dementia burden, mainly by drugs often prescribed outside of guideline indications. Implications: Unique data about dementia management by European primary care physicians to inform appropriate stakeholders. Key points Dementia as a syndrome of cognitive and functional decline and behavioural and psychological symptoms causes a tremendous burden on patients, their families, and society. •We found that a basic social process of Unburdening dementia explained dementia management according to case stories and survey comments from primary care physicians in 25 countries. •First, Burden Recognition by Identification and Assessment and then Burden Relief - often by drugs. •Prescribing physicians repeatedly broadened guideline indications for dementia drugs. The more physicians were allowed to prescribe dementia drugs, the more they were responsible for the dementia work-up. Our study provides unique data about dementia management in European primary care for the benefit of national and international stakeholders.

Influences of rurality on action to diagnose cancer by primary care practitioners - Results from a Europe-wide survey in 20 countries

BACKGROUND

Rural-dwellers have poorer cancer outcomes than urban counterparts, for reasons which are unclear. At healthcare institution level, poorer access to investigations and different clinical decision-making by rural primary healthcare practitioners (PCPs) could be important.

AIM

To compare access to investigations, attitudes to cancer diagnosis and clinical decision-making between rural and urban PCPs.

SETTING

A vignette-based cross-sectional survey of rural and urban PCPs in 20 European countries.

METHODS

Data on PCPs' decision-making and attitudes to cancer diagnosis were based on clinical scenarios. Comparisons were made using tests of proportion, univariable and multivariable binary logistic regression.

RESULTS

Of the 1779 PCPs completing the survey 541 30.4 %) practiced rurally. Rural PCPs had significantly less direct access to all investigative modalities: ultrasound; endoscopy; x-ray and advanced screening (all p < 0.001). Rural PCPs were as likely as urban PCPs to take diagnostic action (investigation and/or referral) at the index consultation in all four clinical vignettes ((OR, 95 % CI) for lung: 0.90, 0.72-1.12; ovarian: 0.95, 0.75-1.19; breast: 0.87, 0.69-1.09; colorectal: 0.98, 0.75-1.30). Rural PCPs were less likely to refer to a specialist at the index consultation for ovarian cancer (OR 0.71 95 % CI 0.51-0.99). Rural PCPs were significantly more likely to report that their patients faced barriers to accessing specialist care, but practitioners did not report greater difficulties making specialist referral than their urban counterparts CONCLUSIONS: European rural PCPs report poorer access to investigations but are at least as likely as urban PCPs to investigate or refer patients that might have cancer at the index consultation.

City of Hope Quality of Life-Ostomy Questionnaire Validity and Reliability Assessment on a Croatian Sample

The aim of this study was to validate City of Hope Quality of Life-Ostomy Questionnaire (CoH-QoL-OQ) for assessing the quality of life (QoL) of ostomy patients in the Republic of Croatia. The CoH-QoL-OQ is widely used, but has not been translated or validated so it can be used in the Republic of Croatia. This cross-sectional study encompassed 302 surgery patients with colostomy, ileostomy, or urostomy (182 (60.3%) male and 120 (39.7%) female), whose average age is 59 (M = 59.3, SD = 15.8). The CoH-QoL-OQ was translated into Croatian language using accepted guidelines for translation. Patients were recruited in a telephone conversation, followed by mail containing the CoH-QoL–OQ delivered to the home addresses of the patients who agreed to participate. The collected data were analyzed to verify psychometric properties of the questionnaire on the Croatian sample. All subscales showed high level of internal consistency (Cronbach α = 0.73–0.89). The test-retest reliability indicated a very satisfactory temporal stability (r = 0.99). The Confirmatory Factor Analysis (CFA), showed that the originally established model was not adequate for the data (χ² = 4237.88, p < 0.01, CFI = 0.540, NNFI = 0.481, RMSEA = 0.113). However, after modification that excluded problematic items, the data showed a better fit with the theoretical model (except for the LR chi-square test that remained statistically significant: χ² = 1144.28, p < 0.01, CFI = 0.869, NNFI = 0.855 RMSEA = 0.077). We conclude that the CoH-QoL-OQ is a valid, reliable, and reducible instrument for measuring the health-related quality of life (HRQoL) among Croatian patients with ostomy in clinical research and clinical practice.

How European primary care practitioners think the timeliness of cancer diagnosis can be improved: a thematic analysis

BACKGROUND

National European cancer survival rates vary widely. Prolonged diagnostic intervals are thought to be a key factor in explaining these variations. Primary care practitioners (PCPs) frequently play a crucial role during initial cancer diagnosis; their knowledge could be used to improve the planning of more effective approaches to earlier cancer diagnosis.

OBJECTIVES

This study sought the views of PCPs from across Europe on how they thought the timeliness of cancer diagnosis could be improved.

DESIGN

In an online survey, a final open-ended question asked PCPs how they thought the speed of diagnosis of cancer in primary care could be improved. Thematic analysis was used to analyse the data.

SETTING

A primary care study, with participating centres in 20 European countries.

PARTICIPANTS

A total of 1352 PCPs answered the final survey question, with a median of 48 per country.

RESULTS

The main themes identified were: patient-related factors, including health education; care provider-related factors, including continuing medical education; improving communication and interprofessional partnership, particularly between primary and secondary care; factors relating to health system organisation and policies, including improving access to healthcare; easier primary care access to diagnostic tests; and use of information technology. Re-allocation of funding to support timely diagnosis was seen as an issue affecting all of these.

CONCLUSIONS

To achieve more timely cancer diagnosis, health systems need to facilitate earlier patient presentation through education and better access to care, have well-educated clinicians with good access to investigations and better information technology, and adequate primary care cancer diagnostic pathway funding.

Attitudes toward professionalism in medical students and its associations with personal characteristics and values: a national multicentre study from Slovenia raising the question of the need to rethink professionalism

Background: Professionalism is becoming one of the main competencies that all medical students should develop during their education. The attitudes of medical students to professionalism in the study process can change, depending on the curriculum and methods of teaching. Factors associated with attitudes to professionalism can be divided into the characteristics of the physician and the context, eg, education about professionalism and the health system; however other student characteristics are also important. This study focused on the factors associated with attitudes toward professionalism and took into account student demographic characteristics, personality and their personal values. Methods: A convenience sampling method was employed in the academic year 2015-2016 in the fourth and final year medical students at the two Medical Faculties in Slovenia. The instrument consisted of questionnaires examining the Big Five personality traits questionairre (BFQ), the scale of personal values and demographic and family background data. The outcome measure was the validated professionalism attitude scale (PAS). Results: A total of 323 students participated, of which 101 (31.3%) were men and 222 (68.7%) were women. The samples of the two faculties did not differ in any demographic characteristics and were analyzed together. Of the personal values, partner/love, profession/work and sport activity were significantly associated with the total score of the PAS (β=0.22, p=0.033; β=0.24, p=0.003; β=0.17, p=0.040, respectively). After the adjustments for the BFQ dimensions, only profession/work kept significance (β=0.19, p=0.016). Women scored significantly higher on attitudes toward professionalism (total PAS score: M_w=93.4±5.1, M_m=89.1±9.8, p=0.001), and this significance remained in multivariate modeling (β=-0.20, p=0.001). Of the hereditary traits, only acceptability was associated with attitudes toward professionalism (β=0.25, p<0.001). Conclusions: It seems that personal characteristics and values are important in students` concept of their future professional behavior. Further research will show whether these patterns are prerequisites for enrollment in the study process.

Strategies to improve research capacity across European general practice: The views of members of EGPRN and Wonca Europe

Background: The effectiveness of any national healthcare system is highly correlated with the strength of primary care within that system. A strong research basis is essential for a firm and vibrant primary care system. General practitioners (GPs) are at the centre of most primary care systems.

Objectives: To inform on actions required to increase research capacity in general practice, particularly in low capacity countries, we collected information from the members of the European General Practice Research Network (EGPRN) and the European World Organization of Family Doctors (Wonca).

Methods: A qualitative design including eight semi-structured interviews and two discursive workshops were undertaken with members of EGPRN and Wonca Europe. Appreciative inquiry methods were utilized. Krueger’s (1994) framework analysis approach was used to analyse the data.

Results: Research performance in general practice requires improvements in the following areas: visibility of research; knowledge acquisition; mentoring and exchange; networking and research networks; collaboration with industry, authorities and other stakeholders. Research capacity building (RCB) strategies need to be both flexible and financially supported. Leadership and collaboration are crucial.

Conclusion: Members of the GP research community see the clear need for both national and international primary care research networks to facilitate appropriate RCB interventions. These interventions should be multifaceted, responding to needs at different levels and tailored to the context where they are to be implemented.

Motivators and barriers to vaccination of health professionals against seasonal influenza in primary healthcare

BACKGROUND

Over the last decade, the vaccination rates amongst the general population in Slovenia were declining. According to the World Health Organisation, the vaccination rates amongst healthcare workers are also low throughout Europe. The aim of this study was to evaluate vaccination rates for seasonal flu amongst healthcare workers on the primary care level in the Koroška region and to find motivators and barriers for vaccination.

METHODS

In a cross-sectional study, an anonymous questionnaire was distributed to all health centres, nursing homes and private contractors, who agreed to participate. Out of 334 distributed questionnaires, 250 (74.8%) were analysed. Bivariate and multivariable statistical analyses were conducted.

RESULTS

Only 12% of included health professionals were vaccinated in the 2014/15 season. The main motivators for vaccination coverage were: awareness of high risk of infection at the workplace, self-protection and protection of family members and co-workers. The main barriers for vaccination were doubt in the effectiveness of the vaccine, fear of side effects and the belief that health professionals are not at high risk of influenza infection. In the multivariable model, a positive association was found between the vaccination, older age and belief in the effectiveness against influenza, while a negative association was found between the nurses' profession and vaccination.

CONCLUSION

The trend of declining rates for seasonal influenza vaccination is continuing. Protection of the patients was not among the most important reasons for vaccination. This especially endangers clients of nursing homes. The recognized motivators, barriers and other factors that were important for vaccination coverage/hesitancy could be used for designing strategies and educational programmes for health professionals to improve the vaccination coverage rates. The strategy should include the specifics of health profession groups.

Identifying important health system factors that influence primary care practitioners' referrals for cancer suspicion: a European cross-sectional survey

OBJECTIVES

Cancer survival and stage of disease at diagnosis and treatment vary widely across Europe. These differences may be partly due to variations in access to investigations and specialists. However, evidence to explain how different national health systems influence primary care practitioners' (PCPs') referral decisions is lacking.This study analyses health system factors potentially influencing PCPs' referral decision-making when consulting with patients who may have cancer, and how these vary between European countries.

DESIGN

Based on a content-validity consensus, a list of 45 items relating to a PCP's decisions to refer patients with potential cancer symptoms for further investigation was reduced to 20 items. An online questionnaire with the 20 items was answered by PCPs on a five-point Likert scale, indicating how much each item affected their own decision-making in patients that could have cancer. An exploratory factor analysis identified the factors underlying PCPs' referral decision-making.

SETTING

A primary care study; 25 participating centres in 20 European countries.

PARTICIPANTS

1830 PCPs completed the survey. The median response rate for participating centres was 20.7%.

OUTCOME MEASURES

The factors derived from items related to PCPs' referral decision-making. Mean factor scores were produced for each country, allowing comparisons.

RESULTS

Factor analysis identified five underlying factors: PCPs' ability to refer; degree of direct patient access to secondary care; PCPs' perceptions of being under pressure; expectations of PCPs' role; and extent to which PCPs believe that quality comes before cost in their health systems. These accounted for 47.4% of the observed variance between individual responses.

CONCLUSIONS

Five healthcare system factors influencing PCPs' referral decision-making in 20 European countries were identified. The factors varied considerably between European countries. Knowledge of these factors could assist development of health service policies to produce better cancer outcomes, and inform future research to compare national cancer diagnostic pathways and outcomes.

How can we change medical students' perceptions of a career in family medicine? Marketing or substance?

Family Medicine (FM) is the care of unselected patients with undifferentiated problems in the settings where people need care in our communities. It is intellectually challenging, providing breadth and depth unparalleled in other areas of medical practice. In one survey only 19% of Israeli students reported being interested in FM. Students interested in FM had greater interest in bedside and direct long-term patient care. Students not planning FM residency training had preconceived notions that the discipline had lower academic opportunities and prestige. What can be done to increase student interest in careers in FM?

This commentary includes perspectives of family practice leaders from several countries:

The problem isn’t the students it is the scope of practice and expectations both of which can and should change if FM in Israel wants to stay viable. The scope of FM should be broadened to include more procedures and new technologies. This may also increase the earning potential of Family Practitioners (FPs). Payment policy and credentialing barriers should be change to expand scope of practice and allow FPs to practice at the full extent of their training.

FM should offer clear professional horizon with potential for many sub-specialties and areas of focus. The Israeli HMOs, the Ministry of Health and the Israeli Association of FM should invest heavily in building academic departments of FM and promoting research. This will enhance the image of FM in the eyes of the students, the profession and the public.

The clinical work environment should be improved by reducing bureaucratic assignments, such as issuing certifications, dealing with quality measurements and renewing chronic prescriptions. Much of this work can be done by nurse practitioners (NPs) working as part of an FP-led team. These NPs can also take care of patients with limited complaints to make the work of the FP more challenging and attractive.

Training must include opportunities to develop longitudinal relationships with patients and families across problems and over time. It is these relationships that add value to the process of care, improve patient outcomes and provide meaning to sustain clinical careers that meet the needs of patients and communities.

Self-care of chronic musculoskeletal pain - experiences and attitudes of patients and health care providers

BACKGROUND

Self-care is often the first choice for people with chronic musculoskeletal pain. Self-care includes the use of non-prescription medications with no doctor's supervision, as well as the use of other modern and traditional treatment methods with no consultation of the health care provider. Self-care may have positive effects on the successful outcome of a multidisciplinary approach to treatment. The aim of this study was to investigate the experiences and attitudes of patients and health care providers to the self-care of chronic musculoskeletal pain.

METHODS

Qualitative Phenomenological study, where the data were collected by the method of an audio-taped interview in 15 patients at the outpatient clinic for pain management and in 20 health care providers involved in the treatment of those patients. The interviews were transcribed verbatim and analyzed by principles of Interpretative Thematic Analysis.

RESULTS

Topics identified in patients: a) positive aspects of self-care, b) a need for pain self-care, c) social aspects of pain self-care. Topics identified in health care providers: a) aspects of self-care, b) a need for self-care c) risks of self-care. Most of patients have positive attitude to self-care and this is the first step to pain management and to care for itself. The most frequent factors influencing decision about the self-care are heavy pain, unavailability of the doctor, long awaiting time for the therapy, or ineffectiveness of methods of conventional medicine. The health care providers believe that self-care of chronic musculoskeletal pain may be a patient's contribution to clinical treatment. However, good awareness of methods used is important in this context, to avoid adverse effects of self-care.

CONCLUSION

Patients understand the self-care of musculoskeletal pain as an individually adjusted treatment and believe in its effectiveness. Health care providers support self-care as an adjunction to clinical management only, and think that self-care of musculoskeletal pain acts as a placebo, with a short-lived effect on chronic musculoskeletal pain.

Health behavior and health-related quality of life in patients with a high risk of cardiovascular disease

Background

Health-related quality of life (HRQoL) is measuring a patient’s experience of his health status and represents an outcome of medical interventions. Existing data proves that a healthy lifestyle is positively associated with HRQoL in all age groups. Patients with a high risk for cardiovascular disease typically led an unhealthy lifestyle combined with risk diseases. We aimed to analyse these characteristics and their reflection in HRQoL.

Methods

A cross-sectional study in 36 family practices, stratified by location and size. Each practice invited 30 high-risk patients from the register. Data were obtained from medical records and patient questionnaire. The EQ-5D questionnaire and the VAS scale were used for measuring the patient’s HRQoL as an independent variable.

Results

871 patients (80.6% response rate) were included in the analysis. 60.0% had 3-4 uncontrolled risk factors for CVD. The average VAS scale was 63.2 (SD 19.4). The correlation of EQ-5D was found in the number of visits in the practice (r=-0.31, p<0.001), the socioeconomic status (r=-0.25, p=0.001), age (r=-0.27, p=0.001) and healthy diet (r=0.20, p=0.006). In a multivariate model, only physical activity among lifestyle characteristics was an independent predictor of HRQoL (p=0.001, t=3.3), along with the frequency of visits (p<0.001, t=-5.3) and age (p=0.025, t=-2.2).

Conclusion

This study has been performed on a specific group of patients, not being “really sick”, but having less optimal lifestyle in many cases. Encouragement to improve or keep healthy lifestyle, especially physical activity, is important, not only to lower the risk for CVD, but also to improve HRQoL.

How the probability of presentation to a primary care clinician correlates with cancer survival rates: a European survey using vignettes

OBJECTIVE

European cancer survival rates vary widely. System factors, including whether or not primary care physicians (PCPs) are gatekeepers, may account for some of these differences. This study explores where patients who may have cancer are likely to present for medical care in different European countries, and how probability of presentation to a primary care clinician correlates with cancer survival rates.

DESIGN

Seventy-eight PCPs in a range of European countries assessed four vignettes representing patients who might have cancer, and consensus groups agreed how likely those patients were to present to different clinicians in their own countries. These data were compared with national cancer survival rates.

SETTING

A total of 14 countries.

SUBJECTS

Consensus groups of PCPs.

MAIN OUTCOME MEASURES

Probability of initial presentation to a PCP for four clinical vignettes.

RESULTS

There was no significant correlation between overall national 1-year relative cancer survival rates and the probability of initial presentation to a PCP (r  = -0.16, 95% CI -0.39 to 0.08). Within that there was large variation depending on the type of cancer, with a significantly poorer lung cancer survival in countries where patients were more likely to initially consult a PCP (lung r = -0.57, 95% CI -0.83 to -0.12; ovary: r = -0.13, 95% CI -0.57 to 0.38; breast r = 0.14, 95% CI -0.36 to 0.58; bowel: r = 0.20, 95% CI -0.31 to 0.62).

CONCLUSIONS

There were wide variations in the degree of gatekeeping between countries, with no simple binary model as to whether or not a country has a "PCP-as-gatekeeper" system. While there was case-by-case variation, there was no overall evidence of a link between a higher probability of initial consultation with a PCP and poorer cancer survival. KEY POINTS European cancer survival rates vary widely, and health system factors may account for some of these differences. The data from 14 European countries show a wide variation in the probability of initial presentation to a PCP. The degree to which PCPs act as gatekeepers varies considerably from country to country. There is no overall evidence of a link between a higher probability of initial presentation to a PCP and poorer cancer survival.

Comorbidities and characteristics of coronary heart disease patients: their impact on health-related quality of life

Background

Patients with coronary heart disease (CHD) commonly present with more than one comorbid condition, contributing to poorer health-related quality of life (HRQoL). The aim of our study was to identify the associations between HRQoL and patient characteristics, vascular comorbidities and anxiety/depression disorders.

Methods

This observational study was conducted in 36 family medicine practices selected by random stratified sampling from all regions of Slovenia. HRQoL was assessed using the European Quality of Life - 5 Dimensions (EQ-5D) questionnaire and EQ Visual Analogue Scale (EQ-VAS). The associations between HRQoL and patient characteristics stratified by demographics, vascular comorbidities, health services used, their assessment of chronic illness care, and anxiety/depression disorders were identified by ordinal logistic regression and linear regression models.

Results

The final sample included 423 CHD patients with a mean age of 68.0 ± SD 10.8 years; 35.2% were female. Mean EQ-VAS score was 58.6 ± SD 19.9 (median: 60 with interquartile range of 45–75), and mean EQ-5D index was 0.60 ± SD 0.19 (median: 0.56 with interquartile range of 0.41–0.76). The statistically significant predictors of a lower EQ-VAS score were higher family physician visit frequency, heart failure (HF) and anxiety/depression disorders (R² 0.240; F = 17.368; p < 0.001). The statistically significant predictor of better HRQoL, according to EQ-5D was higher patient education, whereas higher family physician visit frequency, HF and peripheral artery disease (PAD) were predictors of poorer HRQoL (Nagelkerke R² = 0.298; χ² = 148.151; p < 0.001).

Conclusions

Results of our study reveal that comorbid conditions (HF and PAD), family physician visit frequency and years in education are significant predictors of HRQoL in Slovenian CHD patients.

Regional coordinators: a new teaching opportunity in family medicine training

BACKGROUND

A new project on education in family medicine training was implemented last year in Slovenia by establishing regional coordinators in the specialist training programme. They are responsible for conducting regular small-group meetings with family medicine trainees. This study wanted to explore the attitudes and opinions of regional coordinators and family medicine trainees concerning this new method.

METHODS

This was a qualitative study based on focus groups. The participants were regional coordinators and family medicine specialist trainees. The data were analysed based on the principles of thematic content analysis with inductive technique.

RESULTS

The study revealed five themes which were the same for the analysis of transcripts of both regional coordinators and family medicine trainees: 1) Meetings with trainees; 2) Coordination; 3) Characteristics of regional coordinators; 4) Position of regional coordinators, and 5) Evaluation of regional coordinators.

CONCLUSION

Participants of the study have many expectations for this new programme. They expect progress in trainees' clinical knowledge through experience-based group learning and with the help of the tutorship role of regional coordinators. The role of regional coordinators represents a new possibility for solving problems in the training programme in their coordinating role. In future, they have the potential to develop into an expert body that supervises the quality of training. A close follow-up is necessary to see if the position of regional coordinators is adequate and if they meet the expectations of the trainees as well as their own goals. Administrative and financial support for the programme is necessary. The project is important also in enabling the adaptation of the training programme's needs and the regional characteristics of medical care.

Quality of care for patients with diabetes mellitus type 2 in 'model practices' in Slovenia - first results

BACKGROUND

A new organisation at the primary level, called model practices, introduces a 0.5 full-time equivalent nurse practitioner as a regular member of the team. Nurse practitioners are in charge of registers of chronic patients, and implement an active approach into medical care. Selected quality indicators define the quality of management. The majority of studies confirm the effectiveness of the extended team in the quality of care, which is similar or improved when compared to care performed by the physician alone. The aim of the study is to compare the quality of management of patients with diabetes mellitus type 2 before and after the introduction of model practices.

METHODS

A cohort retrospective study was based on medical records from three practices. Process quality indicators, such as regularity of HbA1c measurement, blood pressure measurement, foot exam, referral to eye exam, performance of yearly laboratory tests and HbA1c level before and after the introduction of model practices were compared.

RESULTS

The final sample consisted of 132 patients, whose diabetes care was exclusively performed at the primary care level. The process of care has significantly improved after the delivery of model practices. The most outstanding is the increase of foot exam and HbA1c testing. We could not prove better glycaemic control (p>0.1). Nevertheless, the proposed benchmark for the suggested quality process and outcome indicators were mostly exceeded in this cohort.

CONCLUSION

The introduction of a nurse into the team improves the process quality of care. Benchmarks for quality indicators are obtainable. Better outcomes of care need further confirmation.

Work-family balance by women GP specialist trainees in Slovenia: a qualitative study

BACKGROUND

Women physicians face many challenges while balancing their many roles: doctor, specialist trainee, mother and partner. The most opportune biological time for a woman to start a family coincides with a great deal of demands and requirements at work. In this study we explored the options and capabilities of women GP specialist trainees in coordinating their family and career.

METHODS

This is a phenomenological qualitative research. Ten GP specialist trainees from urban and rural areas were chosen by the purposive sampling technique, and semi-structured in-depth interviews were conducted, recorded, transcribed and analysed by using thematic analysis process. Open coding and the book of codes were formed. Finally, we performed the process of code reduction by identifying the themes, which were compared, interpreted and organised in the highest analytical units--categories.

RESULTS

One hundred fifty-five codes were identified in the analysis, which were grouped together into eleven themes. The identified themes are: types, causes and consequences of burdens, work as pleasure and positive attitude toward self, priorities, planning and help, and understanding of superiors, disburdening and changing in specialisation. The themes were grouped into four large categories: burdens, empowerment, coordination and needs for improvement.

CONCLUSION

Women specialist trainees encounter intense burdens at work and home due to numerous demands and requirements during their specialisation training. In addition, there is also the issue of the work-family conflict. There are many consequences regarding burden and strain; however, burnout stands out the most. In contrast, reconciliation of work and family life and needs can be successful. The key element is empowerment of women doctors. The foremost necessary systemic solution is the reinforcement of general practitioners in primary health care and their understanding of the specialisation training scheme with more flexible possibilities for time adaptations of specialist training.

Development and validation of the short version of the diabetes obstacles questionnaire (DOQ-30) in six European countries

BACKGROUND

Patients with type 2 diabetes reveal different obstacles in living with the disease. The EGPRN initiated a qualitative research EUROBSTACLE to create a broadly conceptualized diabetes-related quality of life (DR-QoL) instrument. It led to the development of the diabetes obstacle questionnaire (DOQ), a five-point Likert-scaled measure, consisting of 78 items in eight scales.

OBJECTIVES

To develop and validate a short, easy-to-use version of the DOQ.

METHODS

A cross-sectional study with the DOQ was carried out. Participants answered the DOQ and GPs added some clinical data from their medical records. Data of 853 patients from Belgium, France, Estonia, Serbia, Slovenia, and Turkey were included in the analysis. The selection of items for the short version of the DOQ was achieved with exploratory factor analysis (EFA). Construct validity was proved with EFA and Pearson correlations between the DOQ and the new DOQ-30. Internal reliability was established with Cronbach's alpha.

RESULTS

DOQ-30 resulted in 30 items in nine subscales. It explained 49.8% of items' variance. It shows a considerable good internal reliability and construct validity.

CONCLUSION

The DOQ-30 is a five-point Likert-scaled broadly conceptualized measure of DR-QoL. It addresses a variety of obstacles, such as social, psychological, cognitive and behavioural. The DOQ-30 is ready for implementation in general practice and research in Europe as a valuable instrument to assess DR-QoL.

Screening and Registering Patients with Asthma and Copd in Slovenian Primary Care: First Results

AIM

This study aimed to evaluate a new project of the Slovene Ministry of Health - the Family Medicine Model Practices (MPs) Project in Slovenia, and to show its effectiveness in the management of asthma and COPD by family medicine practice teams, consisting of a family physician, a nurse practitioner and a practice nurse.

METHODS

A total of 107 family practices with 203122 patients joined the project during the first year of its initiation. The effectiveness of the program in disease management was analysed in two phases according to the registration of family practices. The number of patients registered and the number of asthma and COPD patients (existing and newly detected) by model practice teams were being reported. Descriptive analyses were used to describe the study populations. Prevalence by diseases and phases was established after the initial round of data collection. Chi square (χ(2)) test was used to analyse the difference between the phases.

RESULTS

The frequency of asthma was 2.12%, while the frequency of COPD was 1.15% throughout the study period. For both diseases, more than 30% of patients were newly diagnosed.

CONCLUSIONS

The project of implementing Family Medicine MPs in the area of COPD has given first positive results and the project is still ongoing to its full implementation.

Validation of the Slovenian version of patient assessment of chronic illness care (PACIC) in patients with coronary heart disease

The Chronic Care Model (CCM) is a conceptual framework that supports the evidence-based proactive and planned care of chronic diseases. Our aim was to validate a Slovenian translation of Patient Assessment of Chronic Illness Care (PACIC)--a self-reported instrument designed to measure the extent to which patients with chronic illnesses receive care congruent with CCM--on a sample of patients with coronary heart disease. Secondary analysis of patients' evaluation of general practice care (EPA Cardio study) was done in patients with coronary heart disease in Slovenia. Patients completed a written questionnaire, which included the instrument for assessing chronic illness care (PACIC), the EUROPEP questionnaire and demographical data. Internal consistency was expressed in terms of Cronbach's alpha. Reliability was expressed as the intra class correlation coefficient (ICC). Correlation between PACIC and EUROPEP was considered as a measure of construct validity. Factor analysis was done to identify number and types of domains in the instrument. Questionnaires of 843 patients were analysed. The mean age was 68.2 (SD 11.1) years, 34.6% of participants were female. 32.7% of PACIC questionnaires were not completely fulfilled. The internal consistency of the entire questionnaire assessed by Cronbach's alpha was 0.953 and reliability was 0.937. Construct validity was confirmed with important and significant correlation between PACIC and EUROPEP questionnaire (Spearman's correlation coefficient = 0.60, p < 0.001). Principal component factor analysis identifies two major factors which we labeled according to the PACIC domains as "Patient activation, decision support and problem solving" and "Goal settings and coordination". A translated and validated Slovenian version of PACIC questionnaire is now available. Further research on its validity in other groups of chronically ill patients and the use of instrument for monitoring changes of chronic care over time is recommended.

Do family physicians advise younger people on cardiovascular disease prevention? A cross-sectional study from Slovenia

Background

One of the main family practice interventions in the younger healthy population is advice on how to keep or develop a healthy lifestyle. In this study we explored the level of counselling regarding healthy lifestyle by family physicians and the factors associated with it.

Methods

A cross-sectional study with a random sample of 36 family practices, stratified by size and location. Each practice included up to 40 people aged 18–45 with low/medium risk for cardiovascular disease (CVD). Data were obtained by patient and practice questionnaires and semi-structured interviews. Several predictors on the patient and practice level for received advice in seven areas of CVD prevention were applied in corresponding models using a two-level logistic regression analysis.

Results

Less than half of the eligible people received advice for the presented risk factors and the majority of them found it useful. Practices with medium patient list-sizes showed consistently higher level of advice in all areas of CVD prevention. Independent predictors for receiving advice on cholesterol management were patients’ higher weight (regression coefficient 0.04, p=0.03), urban location of practice (regression coefficient 0.92, p=0.04), organisation of education by the practice (regression coefficient 0.47, p=0.01) and practice list size (regression coefficient 6.04, p=0.04). Patients who self-assessed their health poorly more frequently received advice on smoking (regression coefficient −0.26, p=0.03). Hypertensive patients received written information more often (regression coefficient 0.66, p=0.04). People with increased weight more often received advice for children’s lifestyle (regression coefficient 0.06, p=0.03). We did not find associations with patient or practice characteristics and advice regarding weight and physical activity. We did not find a common pattern of predictors for advice.

Conclusions

Counselling for risk diseases such as increased cholesterol is more frequently provided than basic lifestyle counselling. We found some doctors and practice factors associated with counselling behaviour, but the majority has to be explained by further studies.

Which practice characteristics are associated with the quality of cardiovascular disease prevention in European primary care?

BACKGROUND

Prevention of cardiovascular diseases (CVD) is a major health issue worldwide. Primary care plays an important role in cardiovascular risk management (CVRM). Guidelines and quality of care measures to assess CVRM in primary care practices are available. In this study, we assessed the relationship between structural and organisational practice characteristics and the quality of care provided in individuals at high risk for developing CVD in European primary care.

METHODS

An observational study was conducted in 267 general practices from 9 European countries. Previously developed quality indicators were abstracted from medical records of randomly sampled patients to create a composite quality measure. Practice characteristics were collected by a practice questionnaire and face to face interviews. Data were aggregated using factor analysis to four practice scores representing structural and organisational practice features. A hierarchical multilevel analysis was performed to examine the impact of practice characteristics on quality of CVRM.

RESULTS

The final sample included 4223 individuals at high risk for developing CVD (28% female) with a mean age of 66.5 years (SD 9.1). Mean indicator achievement was 59.9% with a greater variation between practices than between countries. Predictors at the patient level (age, gender) had no influence on the outcome. At the practice level, the score 'Preventive Services' (13 items) was positively associated with clinical performance (r = 1.92; p = 0.0058). Sensitivity analyses resulted in a 5-item score (PrevServ_5) that was also positively associated with the outcome (r = 4.28; p < 0.0001).

CONCLUSIONS

There was a positive association between the quality of CVRM in individuals at high risk for developing CVD and the availability of preventive services related to risk assessment and lifestyle management supported by information technology.

Self-rated health and its relationship to health/ life problems and coping strategies in members of the professional Slovenian armed forces

The aim of this study was to test the association between self-rated health status (i.e. psychological and interpersonal welfare, physical health, coping mechanisms) and absence from work due to illness in the Slovenian armed forces. 390 military personnel were included in the study. Two groups of soldiers, healthy (G1-H) and sick/less healthy (G2-S), were created according to the median value of their annual sick leave. A third group consisted of soldiers on a mission (G3-M). A background questionnaire (demographic data, lifestyle habits, a list of life problems and a list of health problems in the last three years), a Self-Rated Health Scale and the Folkman-Lazarus Ways of Coping Questionnaire were administered. Self-rated physical health was best in group G1-H and worst in G2-S, with differences between the groups being statistically significant. No gender differences were found either between the groups or in the whole sample. The most common coping strategies amongst all the soldiers were found to be problem solving, positive re-evaluation of the situation and self-control. The groups differed only in their use of the distancing strategy. The self-rated health of all the participants was found to be in strong negative correlation with the escape/avoidance coping strategy. In group G2-S, more soldiers assessed their health as poor; the differences between the groups were statistically significant. Strong positive correlations between self-rated health and satisfaction with interpersonal relationships were found. Self-rated health was found to be significantly associated with the quality of interpersonal relationships and the socio-economic and psycho-physical conditions of the soldiers.

Cardiovascular risk management in patients with coronary heart disease in primary care: variation across countries and practices. An observational study based on quality indicators

Background

Primary care has an important role in cardiovascular risk management (CVRM) and a minimum size of scale of primary care practices may be needed for efficient delivery of CVRM . We examined CVRM in patients with coronary heart disease (CHD) in primary care and explored the impact of practice size.

Methods

In an observational study in 8 countries we sampled CHD patients in primary care practices and collected data from electronic patient records. Practice samples were stratified according to practice size and urbanisation; patients were selected using coded diagnoses when available. CVRM was measured on the basis of internationally validated quality indicators. In the analyses practice size was defined in terms of number of patients registered of visiting the practice. We performed multilevel regression analyses controlling for patient age and sex.

Results

We included 181 practices (63% of the number targeted). Two countries included a convenience sample of practices. Data from 2960 CHD patients were available. Some countries used methods supplemental to coded diagnoses or other inclusion methods introducing potential inclusion bias. We found substantial variation on all CVRM indicators across practices and countries. We computed aggregated practice scores as percentage of patients with a positive outcome. Rates of risk factor recording varied from 55% for physical activity as the mean practice score across all practices (sd 32%) to 94% (sd 10%) for blood pressure. Rates for reaching treatment targets for systolic blood pressure, diastolic blood pressure and LDL cholesterol were 46% (sd 21%), 86% (sd 12%) and 48% (sd 22%) respectively. Rates for providing recommended cholesterol lowering and antiplatelet drugs were around 80%, and 70% received influenza vaccination. Practice size was not associated to indicator scores with one exception: in Slovenia larger practices performed better. Variation was more related to differences between practices than between countries.

Conclusions

CVRM measured by quality indicators showed wide variation within and between countries and possibly leaves room for improvement in all countries involved. Few associations of performance scores with practice size were found.

Predictors of the quality of cardiovascular prevention--a multilevel cross-sectional study

AIM

To attempt to develop a model of predictors for quality of the process of cardiovascular prevention in patients at high risk of cardiovascular disease (CVD).

METHODS

We formed a random sample of patients from a stratified sample of 36 family practice registers of patients at high risk of CVD without diabetes and without established CVD. Data were gathered by chart audit and questionnaires about patient and practice characteristics. We defined the process of care as a dependent variable by principle component analysis and tested the relationship of the process with several independent variables (family physicians', patients', and practice characteristics). To study the effects of independent variables (predictors) on the process of care we carried out multilevel regression analysis with the patients constituting the lower level and nested within the family physician/practice (the second level).

RESULTS

Multilevel regression analysis included 645 patients from 36 practices (74.1% from the final sample). Patients' characteristics that predicted the higher-quality process of CVD prevention were younger age (t=-4.94, 95% confidence interval [CI] -0.018 to -0.008) and lower socioeconomic status (t=-2.18, 95%CI -0.195 to -0.010). Practice characteristics that predicted the higher-quality process of CVD prevention were smaller practice size (t=2.83, 95% CI 0.063 to 1.166), a good information system for CVD prevention (t=3.15, 95% CI 0.030 to 0.282), and the organization of education on CVD prevention (t=3.19, 95%CI 0.043 to 0.380).

CONCLUSION

This study shows that the quality of cardiovascular prevention could be measured as a composite outcome and future studies should further develop this approach and test the impact of several practice/patient characteristics on the quality of CVD prevention with the international data.