[Reasons for General Practitioner Shortage – a Comparison Between France and Switzerland]

How time consuming are general practitioners' home visits? Insights from a cross-sectional study in Switzerland

BACKGROUND

Worldwide, the number of home visits has been decreasing over past decades. Lack of time and long journeys have been reported to hinder general practitioners (GPs) from conducting home visits. In Switzerland also, home visits have declined. Time constraints in a busy GP practice could be one reason. Therefore, the aim of this study was to analyse the time requirements of home visits in Switzerland.

METHODS

A one-year cross-sectional study involving GPs from the Swiss Sentinel Surveillance System (Sentinella) was conducted in 2019. GPs provided basic information on all home visits performed throughout the year and additionally detailed reports of up to 20 consecutive home visits. Univariable and multivariable logistic regression analyses were run to identify factors affecting journey and consultation duration.

RESULTS

In total, 95 GPs conducted 8489 home visits in Switzerland, 1139 of which have been characterised in detail. On average, GPs made 3.4 home visits per week. Average journey and consultation duration were 11.8 and 23.9 minutes, respectively. Prolonged consultations were provided by GPs working part-time (25.1 minutes), in group practice (24.9 minutes) or in urban regions (24.7 minutes). Rural environments and short journey to patient's home were both found to lower the odds of performing a long consultation compared to a short consultation (odds ratio [OR] 0.27, 95% confidence interval [CI] 0.16-0.44 and OR 0.60, 95% CI 0.46-0.77, respectively). Emergency visits (OR 2.20, 95% CI 1.21-4.01), out-of-hours appointments (OR 3.06, 95% CI 2.36-3.97) and day care involvement (OR 2.78, 95% CI 2.13-3.62) increased the odds of having a long consultation. Finally, patients in their 60s had markedly higher odds of receiving long consultations than patients in their 90s (OR 4.13, 95% CI 2.27-7.62), whereas lack of chronic conditions lowered the odds of a long consultation (OR 0.09, 95% CI 0.00-0.43).

CONCLUSION

GPs perform rather few but long home visits, especially for multimorbid patients. GPs working part-time, in group practice or in urban regions devote more time to home visits.

[The contribution of advanced practice nurses in Swiss family practices: Multiple case study design]

The contribution of advanced practice nurses in Swiss family practices: Multiple case study design Abstract. Background: The increase in chronic diseases, multimorbidity and shortage of health professionals make it essential to adapt primary health care. New models of care are needed which are oriented towards patient needs and thus ensure comprehensive care for chronically ill people. In this context, there is great potential for the use of advanced practice nurses in Swiss family practices. Aims: In this study we investigated the contribution of advanced practice nurses in the interprofessional context in two family practices. Methods: We conducted a multiple case study design. We investigated two advanced practice nurses, located in family practices in rural and in mountainous regions. We used qualitative and quantitative methods. As an intermediate step, within-case analyses were performed and we summarized data inductively to create case vignettes. Results: The cases showed that advanced practice nurses contribute to self-management, prevention and health promotion in complex, stable and unstable patients. These areas have not been covered adequately by other health professionals in family practices. They strengthened interface management through hybrid employment and flexible, addressee-appropriate communication. Conclusions: Similarities and differences between family practices with and without new professional roles should be elicited to specifically identify gaps in care for the chronically ill.

Medical students' attitudes towards and views of general practice careers in Singapore: a cross-sectional survey and qualitative analysis

BACKGROUND

Like many other countries, Singapore needs to support its ageing population by attracting more doctors into general practice (GP) and family medicine (FM). To achieve this requires a better understanding of what attracts or deters medical students. We conducted a cross-sectional survey among medical students in Singapore.

METHODS

An online survey was distributed to students from all three medical schools to understand their likelihood of choosing primary care careers, what they valued in their careers, their attitude towards different aspects of general practice and family medicine relative to other medical fields, and the positive and negative perceptions of primary care held by themselves, their lecturers, and clinical mentors. They were able to elaborate the negativity encountered in the open-ended questions. Quantitative data was analyzed with descriptive statistics, principal component analysis, and linear regression; qualitative data was analyzed thematically.

RESULTS

The survey was completed by 391 students. Slightly over half indicated a likelihood of choosing a career in primary care. For their own careers, the students valued job satisfaction and career development opportunities the most. They perceived careers in primary care as being most likely to offer reasonable hours and close patient relationships, but least likely to offer career advancement potential relative to other medical fields. Their likelihood of choosing primary care careers was significantly predicted by what they value in their own career and their attitudes toward GP/FM relative to other medical fields, but not by the perceptions of GP/FM by others. Free-text responses illustrated how students encounter derogatory comments about GP/FM: the work being "mundane and repetitive", the careers non-competitive, and the doctors poor in clinical competence.

CONCLUSION

While the shortage of primary care doctors is a global issue, our findings highlight the value of situating inquiries in localized contexts. Medical curriculum should emphasize the critical role of primary care in the healthcare system and primary care doctors should be given due recognition to build a strong and motivated primary care workforce to serve the future healthcare needs of the population.

Collaboration amongst general practitioners and gynaecologists working in primary health care in Germany: a cross-sectional study

AIM

This cross-sectional study is the first one to explore the collaboration of the influencing factors thereof amongst general practitioners (GPs) and gynaecologists (Gyns) working in primary care in urban and rural settings in Germany.

BACKGROUND

The number of women aged ≥ 50 years is predicted to increase in the next years in Germany. This coincides with the ageing of primary care specialists providing outpatient care. Whereas delegation of tasks to nurses as a form of interprofessional collaboration has been the target of recent studies, there is no data regarding collaboration amongst physicians in different specialisations working in primary care. We explored collaboration amongst GPs and Gyn regarding the healthcare provision to women aged ≥ 50 years.

METHODS

A quantitative postal survey was administered to GPs and Gyns in three federal states in Germany, focusing on care provision to women aged ≥ 50 years. A total of 4545 physicians, comprising 3514 GPs (67% of the total GP population) randomly selected, and all 1031 Gyns practicing in these states received the postal survey in March 2018. A single reminder was sent in April 2018 with data collection ending in June 2018. Multiple logistic regressions were performed for collaboration, adjusted by age and sex, alongside descriptive methods.

FINDINGS

The overall response rate was 31% (1389 respondents): 861 GPs (25%) and 528 Gyns (51%), with the mean respondent age being 54.4 years. Seventy-two per cent were female. Key competencies of collaboration are associated with working in rural federal states and with network participation. Physicians from rural states [odds ratio (OR) = 1.5, 95% confidence interval (CI) = 1.2, 1.9] and physicians in networks (OR = 3.0, CI = 2.3, 3.9) were more satisfied with collaboration. Collaboration to deliver services for women aged ≥ 50 years is more systematic amongst GPs and Gyns who are members of a network; increased networking could improve collaboration, and ultimately, outcomes too.

Nurse Practitioners in Swiss Family Practices as Potentially Autonomous Providers of Home Visits: An Exploratory Study of Two Cases

In Swiss primary care, general practitioner (GP) home visits have decreased due to impending GP shortages particularly in rural areas. Nurse practitioners (NP) are newly introduced in family practices and could potentially offer home visits to the increasing number of multimorbid elderly. We analysed consultation data from two pilot projects (Practice A and Practice B) with the goal to measure the frequency and patient characteristics of NP consultations both in the practice and on home visits, and to determine the NPs’ autonomy based on the required GP supervision. In Practice A, 17% of all NP consultations were home visits, in Practice B 51%. In both practices, the NPs saw older patients and reported higher autonomy on home visits compared to consultations in the practice. In Practice A, the NP encountered a higher share of multimorbid patients on home visits than in the practice, and the NP’s proportion of autonomously conducted consultations increased from 0% in the first month to 19% after 13 months of GP supervision. In Practice B, the NP was autonomous in about three-quarters of consultations after 2 years on the job. These first cases provide some evidence that NPs could reach a relatively high degree of autonomy and might pose a potential solution for the decreasing numbers of GP home visits to multimorbid elderly in Swiss primary care.

Medical students' perceptions of a career in family medicine

Background

In Israel, there is a shortage of family medicine (FM) specialists that is occasioned by a shortage of students pursuing a FM career.

Methods

A questionnaire, based on methods adapted from marketing research, was used to provide insight into the medical specialty selection process. It was distributed to 6^th-year medical students from two Israeli medical schools.

Results

A response rate of 66% resulted in collecting 218 completed questionnaires. Nineteen of the students reported that they were interested in FM, 68% of them were women. When compared to students not interested in FM, the selection criteria of students interested in FM reflected greater interest in a bedside specialty which provides direct long-term patient care. These latter students were also more interested in a controllable lifestyle that allowed time to be with family and children and working outside the hospital especially during the daytime. These selection criteria aligned with their perceptions of FM, which they perceived as providing them with a controllable lifestyle, allowing them to work limited hours with time for family and having a reasonable income to lifestyle ratio. The students not interested in FM, agreed with those interested in FM, that the specialty affords a controllable lifestyle and the ability to work limited hours Yet, students not interested in FM more often perceived FM as being a boring specialty and less often perceived it as providing a reasonable income to lifestyle ratio. Additionally, students not interested in FM rated the selection criteria, academic opportunities and a prestigious specialty, more highly than did students interested in FM. However, they perceived FM as neither being prestigious nor as affording academic opportunities

Conclusion

This study enriches our understanding of the younger generation's attitudes towards FM and thus provides administrators, department chairs and residency program directors with objective information regarding selection criteria and the students’ perceptions of FM. We identified the disconnect between the selection criteria profiles and the perceptions of FM of students not inclined to pursue a residency in FM. This allowed for recommendations on how to possibly make FM more attractive to some of these students.

mHealth Technologies for Palliative Care Patients at the Interface of In-Patient to Outpatient Care: Protocol of Feasibility Study Aiming to Early Predict Deterioration of Patient's Health Status

Background

Palliative care patients are a particularly vulnerable population and one of the critical phases in patients’ trajectories is discharge from specialized in-patient palliative care into outpatient care, where availability of a palliative care infrastructure is highly variable. A relevant number of potentially avoidable readmissions and emergency visits of palliative patients is observed due to rapid exacerbation of symptoms indicating the need for a closer patient monitoring. In the last years, different mHealth technology applications have been evaluated in many different patient groups.

Objective

The aim of our study is to test feasibility of a remote physical and social tracking system in palliative care patients.

Methods

A feasibility study with explorative, descriptive study design, comprised of 3 work packages. From the wards of the Clinic of Radiation-Oncology at the University Hospital Zurich, including the specialized palliative care ward, 30 patients will be recruited and will receive a mobile phone and a tracking bracelet before discharge. The aim of work package A is to evaluate if severely ill patients accept to be equipped with a tracking bracelet and a mobile phone (by semiquantitative questionnaires and guideline interviews). Work package B evaluates the technical feasibility and quality of the acquired electronic health data. Work package C will demonstrate whether physical activity parameters, such as step count, sleep duration, social activity patterns like making calls, and vital signs (eg, heart rate) do correlate with subjective health data and can serve as indicator to early detect and predict changes in patients’ health status. Activity parameters will be extracted from the mobile phone’s and wristband’s sensor data using signal processing methods. Subjective health data is captured via electronic version of visual analog scale and Distress Thermometer as well as the European Organization for Research and Treatment of Cancer – Quality of Life Questionnaire C30 in paper version.

Results

Enrollment began in February 2017. First study results will be reported in the middle of 2018.

Conclusions

Our project will deliver relevant data on patients’ acceptance of activity and social tracking and test the correlation between subjective symptom assessment and objective activity in the vulnerable population of palliative care patients. The proposed study is meant to be preparatory work for an intervention study to test the effect of wireless monitoring of palliative care patients on symptom control and quality of life.