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

Does proactive care in care homes improve survival? A quality improvement project

BACKGROUND

NHS England's 'Enhanced Health in Care Homes' specification aims to make the healthcare of care home residents more proactive. Primary care networks (PCNs) are contracted to provide this, but approaches vary widely: challenges include frailty identification, multidisciplinary team (MDT) capability/capacity and how the process is structured and delivered.

AIM

To determine whether a proactive healthcare model could improve healthcare outcomes for care home residents.

DESIGN AND SETTING

Quality improvement project involving 429 residents in 40 care homes in a non-randomised crossover cohort design. The headline outcome was 2-year survival.

METHOD

All care home residents had healthcare coordinated by the PCN's Older Peoples' Hub. A daily MDT managed the urgent healthcare needs of residents. Proactive healthcare, comprising information technology-assisted comprehensive geriatric assessment (i-CGA) and advanced care planning (ACP), were completed by residents, with prioritisation based on clinical needs.Time-dependent Cox regression analysis was used with patients divided into two groups:Control group: received routine and urgent (reactive) care only.Intervention group: additional proactive i-CGA and ACP.

RESULTS

By 2 years, control group survival was 8.6% (n=108), compared with 48.1% in the intervention group (n=321), p<0.001. This represented a 39.6% absolute risk reduction in mortality, 70.2% relative risk reduction and the number needed to treat of 2.5, with little changes when adjusting for confounding variables.

CONCLUSION

A PCN with an MDT-hub offering additional proactive care (with an i-CGA and ACP) in addition to routine and urgent/reactive care may improve the 2-year survival in older people compared with urgent/reactive care alone.

Dutch GP healthcare consumption in COVID-19 heterogeneous regions: an interregional time-series approach in 2020-2021

BACKGROUND

Many countries observed a sharp decline in the use of general practice services after the outbreak of the COVID-19 pandemic. However, research has not yet considered how changes in healthcare consumption varied among regions with the same restrictive measures but different COVID-19 prevalence.

AIM

To investigate how the COVID-19 pandemic affected healthcare consumption in Dutch general practice during 2020 and 2021, among regions with known heterogeneity in COVID-19 prevalence, from a pre-pandemic baseline in 2019.

DESIGN & SETTING

Population-based cohort study using electronic health records. The study was undertaken in Dutch general practices involved in regional research networks.

METHOD

An interrupted time-series analysis of changes in healthcare consumption from before to during the pandemic was performed. Descriptive statistics were used on the number of potential COVID-19-related contacts, reason for contact, and type of contact.

RESULTS

The study covered 3 595 802 contacts (425 639 patients), 3 506 637 contacts (433 340 patients), and 4 105 413 contacts (434 872 patients) in 2019, 2020, and 2021, respectively. Time-series analysis revealed a significant decrease in healthcare consumption after the outbreak of the pandemic. Despite interregional heterogeneity in COVID-19 prevalence, healthcare consumption decreased comparably over time in the three regions, before rebounding to a level significantly higher than baseline in 2021. Physical consultations transitioned to phone or digital over time.

CONCLUSION

Healthcare consumption decreased irrespective of the regional prevalence of COVID-19 from the start of the pandemic, with the Delta variant triggering a further decrease. Overall, changes in care consumption appeared to reflect contextual factors and societal restrictions rather than infection rates.

General practitioner workforce sustainability to maximise effective and equitable patient care: a realist review protocol

INTRODUCTION

There are not enough general practitioners (GPs) in the UK National Health Service. This problem is worse in areas of the country where poverty and underinvestment in health and social care mean patients experience poorer health compared with wealthier regions. Encouraging more doctors to choose and continue in a GP career is a government priority. This review will examine which aspects of the healthcare system affect GP workforce sustainability, how, why and for whom.

METHODS AND ANALYSIS

A realist review is a theory-driven interpretive approach to evidence synthesis, that brings together qualitative, quantitative, mixed-methods research and grey literature. We will use a realist approach to synthesise data from the available published literature to refine an evidence-based programme theory that will identify the important contextual factors and underlying mechanisms that underpin observed outcomes relating to GP workforce sustainability. Our review will follow Pawson's five iterative stages: (1) finding existing theories, (2) searching for evidence, (3) article selection, (4) data extraction and (5) synthesising evidence and drawing conclusions. We will work closely with key stakeholders and embed patient and public involvement throughout the review process to refine the focus of the review and enhance the impact and relevance of our research.

ETHICS AND DISSEMINATION

This review does not require formal ethical approval as it draws on secondary data from published articles and grey literature. Findings will be disseminated through multiple channels, including publication in peer-reviewed journals, at national and international conferences, and other digital scholarly communication tools such as video summaries, X and blog posts.

PROSPERO REGISTRATION NUMBER

CRD42023395583.

HbA1c changes in a deprived population who followed or not a diabetes self-management programme, organised in a multi-professional primary care practice: a historical cohort study on 207 patients between 2017 and 2019

BACKGROUND

Diabetes self-management (DSM) helps people with diabetes to become actors in their disease. Deprived populations are particularly affected by diabetes and are less likely to have access to these programmes. DSM implementation in primary care, particularly in a multi-professional primary care practice (MPCP), is a valuable strategy to promote care access for these populations. In Rennes (Western France), a DSM programme was designed by a MPCP in a socio-economically deprived area. The study objective was to compare diabetes control in people who followed or not this DSM programme.

METHOD

The historical cohort of patients who participated in the DSM programme at the MPCP between 2017 and 2019 (n = 69) was compared with patients who did not participate in the programme, matched on sex, age, diabetes type and place of the general practitioner's practice (n = 138). The primary outcome was glycated haemoglobin (HbA1c) change between 12 months before and 12 months after the DSM programme. Secondary outcomes included modifications in diabetes treatment, body mass index, blood pressure, dyslipidaemia, presence of microalbuminuria, and diabetes retinopathy screening participation.

RESULTS

HbA1c was significantly improved in the exposed group after the programme (p < 0.01). The analysis did not find any significant between-group difference in socio-demographic data, medical history, comorbidities, and treatment adaptation.

CONCLUSIONS

These results, consistent with the international literature, promote the development of DSM programmes in primary care settings in deprived areas. The results of this real-life study need to be confirmed on the long-term and in different contexts (rural area, healthcare organisation).

Theoretical Perspectives Underpinning Research on the Physician-Patient Relationship in a Digital Health Practice: Scoping Review

BACKGROUND

The advent of digital health technologies has transformed the landscape of health care, influencing the dynamics of the physician-patient relationship. Although these technologies offer potential benefits, they also introduce challenges and complexities that require ethical consideration.

OBJECTIVE

This scoping review aims to investigate the effects of digital health technologies, such as digital messaging, telemedicine, and electronic health records, on the physician-patient relationship. To understand the complex consequences of these tools within health care, it contrasts the findings of studies that use various theoretical frameworks and concepts with studies grounded in relational ethics.

METHODS

Using the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) guidelines, we conducted a scoping review. Data were retrieved through keyword searches on MEDLINE/PubMed, Embase, IEEE Xplore, and Cochrane. We screened 427 original peer-reviewed research papers published in English-language journals between 2010 and 2021. A total of 73 papers were assessed for eligibility, and 10 of these were included in the review. The data were summarized through a narrative synthesis of the findings.

RESULTS

Digital health technologies enhance communication, improve health care delivery efficiency, and empower patients, leading to shifts in power dynamics in the physician-patient relationship. They also potentially reinforce inequities in health care access due to variations in technology literacy among patients and lead to decreases in patient satisfaction due to the impersonal nature of digital interactions. Studies applying a relational ethics framework have revealed the nuanced impacts of digital health technologies on the physician-patient relationship, highlighting shifts toward more collaborative and reciprocal care. These studies have also explored transitions from traditional hierarchical relationships to mutual engagement, capturing the complexities of power dynamics and vulnerabilities. Other theoretical frameworks, such as patient-centered care, and concepts, such as patient empowerment, were also valuable for understanding these interactions in the context of digital health.

CONCLUSIONS

The shift from hierarchical to collaborative models in the physician-patient relationship not only underscores the empowering potential of digital tools but also presents new challenges and reinforces existing ones. Along with applications for various theoretical frameworks and concepts, this review highlights the unique comprehensiveness of a relational ethics perspective, which could provide a more nuanced understanding of trust, empathy, and power dynamics in the context of digital health. The adoption of relational ethics in empirical research may offer richer insights into the real-life complexities of the physician-patient relationship, as mediated by digital technologies.

"I do not know the advantages of having a general practitioner" - a qualitative study exploring the views of low-acuity emergency patients without a regular general practitioner toward primary care

BACKGROUND

Emergency departments (ED) worldwide have to cope with rising patient numbers. Low-acuity consulters who could receive a more suitable treatment in primary care (PC) increase caseloads, and lack of PC attachment has been discussed as a determinant. This qualitative study explores factors that contribute to non-utilization of general practitioner (GP) care among patients with no current attachment to a GP.

METHOD

Qualitative semi-structured telephone interviews were conducted with 32 low-acuity ED consulters with no self-reported attachment to a GP. Participants were recruited from three EDs in the city center of Berlin, Germany. Data were analyzed by qualitative content analysis.

RESULTS

Interviewed patients reported heterogeneous factors contributing to their PC utilization behavior and underlying views and experiences. Participants most prominently voiced a rare need for medical services, a distinct mobility behavior, and a lack of knowledge about the role of a GP and health care options. Views about and experiences with GP care that contribute to non-utilization were predominantly related to little confidence in GP care, preference for directly consulting medical specialists, and negative experiences with GP care in the past. Contrasting their reported utilization behavior, many interviewees still recognized the advantages of GP care continuity.

CONCLUSION

Understanding reasons of low-acuity ED patients for GP non-utilization can play an important role in the design and implementation of patient-centered care interventions for PC integration. Increasing GP utilization, continuity of care and health literacy might have positive effects on patient decision-making in acute situations and in turn decrease ED burden.

TRIAL REGISTRATION

German Clinical Trials Register: DRKS00023480; date: 2020/11/27.

Primary care transformation in Scotland: a qualitative evaluation of the views of patients

BACKGROUND

The new Scottish GP contract introduced in April 2018 aims to improve quality of care through expansion of the multidisciplinary team (MDT) to enable GPs to spend more time as expert medical generalists with patients with complex needs.

AIM

To explore patients' views on the changes in general practice in Scotland since the inception of the new contract.

DESIGN AND SETTING

Qualitative study with 30 patients (10 living in urban deprived areas, 10 living in urban affluent/mixed urban areas, and 10 living in remote and rural areas).

METHOD

In-depth semi-structured interviews with thematic analysis.

RESULTS

Patients were generally unaware of the new GP contract, attributing recent changes in general practice to the COVID-19 pandemic. Ongoing concerns included access to GP consultations (especially face-to-face ones), short consultation length with GPs, and damage to continuity of care and the GP-patient relationship. Most patients spoke positively about consultations with MDT staff but still wanted to see a known GP for health concerns that they considered potentially serious. These issues were especially concerning for patients with multiple complex problems, particularly those from deprived areas.

CONCLUSION

Following the introduction of the new Scottish GP contract, patients in this study's sample were accepting of first contact care from the MDT but still wanted continuity of care and longer face-to-face consultations with GPs. These findings suggest that the expert generalist role of the GP is not being adequately supported by the new contract, especially in deprived areas, though further quantitative research is required to confirm this.

Continuity and breaches in GP care and their associations with mortality for patients with chronic disease: an observational study using Norwegian registry data

BACKGROUND

Despite many benefits of continuity of care with a named regular GP (RGP), continuity is deteriorating in many countries.

AIM

To investigate the association between RGP continuity and mortality, in a personal list system, in addition to examining how breaches in continuity affect this association for patients with chronic diseases.

DESIGN AND SETTING

A registry-based observational study using Norwegian primary care consultation data for patients with asthma, chronic obstructive pulmonary disease (COPD), diabetes mellitus, or heart failure.

METHOD

The Usual Provider of Care (UPC, value 0-1) Index was used to measure both disease-related (UPCdisease) and overall (UPCall) continuity with the RGP at the time of consultation. In most analyses, patients who changed RGP during the study period were excluded. In the combined group of all four chronic conditions, the proportion of consultations with other GPs and out-of-hours services was calculated. Cox regression models calculated the associations between continuity during 2013-2016 and mortality in 2017-2018.

RESULTS

Patients with COPD with UPCdisease <0.25 had 47% increased risk of dying within 2 years (hazard ratio 1.47, 95% confidence interval = 1.22 to 1.64) compared with those with UPCdisease ≥0.75. Mortality also increased with decreasing UPCdisease for patients with heart failure and decreasing UPCall for those with diabetes. In the combined group of chronic conditions, mortality increased with decreasing UPCall. This latter association was also found for patients who had changed RGP.

CONCLUSION

Higher disease-related and overall RGP UPC are both associated with lower mortality. However, changing RGP did not significantly affect mortality, indicating a compensatory benefit of informational and management continuity in a patient list system.

Extended access to general practice services during weekends in the first wave of the COVID-19 pandemic

OBJECTIVE

The incidence, symptoms, and trajectories of COVID-19 in the community were unknown in the early phase of the pandemic. Consequently, organizing a primary health care response was challenging. The aim of this study was to investigate whether reorganizing general practice services with extended weekend access for patients was feasible, and to assess the extent to which patients used this service.

DESIGN

Observational study with registration after a simple intervention.

SETTING

General practice services in the second half of March 2020 when the first wave of the COVID-19 pandemic hit Bergen, the second largest city in Norway.

SUBJECTS

All general practices in Bergen were asked to be available during weekends for their patients with respiratory tract infections (RTIs), by telephone, video-, or e-consultation.

MAIN OUTCOME MEASURES

Number of practices participating, patients connected to these practices, and consultations for RTIs and suspected COVID-19.

RESULTS

During the first weekend, 33 of 71 practices (45%) covering 51% of the population participated. The following weekend this increased to 39 practices (53%) covering 64% of the population. The first weekend 25 practices reported a total of 336 consultations for RTIs, eight of which were for confirmed and 113 were for suspected COVID-19. The corresponding numbers reported from 23 practices the second weekend were 158 RTI consultations, four for confirmed and 41 for suspected COVID-19.

CONCLUSIONS

On short notice about half the practices in Bergen were made accessible during weekends for their patients with RTIs. The number of consultations per practice was small, but combined this amounted to a substantial improvement in the emergency services.

[Family and community medicine: The most chosen specialty in the MIR]

Family and Community Medicine is the most offered and chosen specialty in the MIR (Spanish medical residency examination), however, every year its attractiveness is questioned due to not all offered positions being filled and a certain number of resident doctors deciding not to continue in this specialty once started. In this context, some of the proposals to address the problem focus on increasing the supply when the facts show that the challenge lies in addressing the demand by making the specialty and its professional scope more attractive. The problem and its determinants are analyzed in this context by focusing on four elements that may be influencing it: the vocational aspects of medical graduates who pursue specialization, the characteristics of the specialty program and the teaching units where training is carried out, the presence of family medicine in the university as a key element for knowledge and affinity to this specialty from undergraduate studies, and finally, the situation of primary care as the space where training is materialized and the priority setting for the professional practice of future specialists.

Developing a prediction model to identify people with severe mental illness without regular contact to their GP - a study based on data from the Danish national registers

INTRODUCTION

People with severe mental illness (SMI) face a higher risk of premature mortality due to physical morbidity compared to the general population. Establishing regular contact with a general practitioner (GP) can mitigate this risk, yet barriers to healthcare access persist. Population initiatives to overcome these barriers require efficient identification of those persons in need.

OBJECTIVE

To develop a predictive model to identify persons with SMI not attending a GP regularly.

METHOD

For individuals with psychotic disorder, bipolar disorder, or severe depression between 2011 and 2016 (n = 48,804), GP contacts from 2016 to 2018 were retrieved. Two logistic regression models using demographic and clinical data from Danish national registers predicted severe mental illness without GP contact. Model 1 retained significant main effect variables, while Model 2 included significant bivariate interactions. Goodness-of-fit and discriminating ability were evaluated using Hosmer-Lemeshow (HL) test and area under the receiver operating characteristic curve (AUC), respectively, via cross-validation.

RESULTS

The simple model retained 11 main effects, while the expanded model included 13 main effects and 10 bivariate interactions after backward elimination. HL tests were non-significant for both models (p = 0.50 for the simple model and p = 0.68 for the extended model). Their respective AUC values were 0.789 and 0.790.

CONCLUSION

Leveraging Danish national register data, we developed two predictive models to identify SMI individuals without GP contact. The extended model had slightly better model performance than the simple model. Our study may help to identify persons with SMI not engaging with primary care which could enhance health and treatment outcomes in this group.

Associations between outpatient care and later hospital admissions for patients with chronic obstructive pulmonary disease - a registry study from Norway

BACKGROUND

Although chronic obstructive pulmonary disease (COPD) admissions put a substantial burden on hospitals, most of the patients' contacts with health services are in outpatient care. Traditionally, outpatient care has been difficult to capture in population-based samples. In this study we describe outpatient service use in COPD patients and assess associations between outpatient care (contact frequency and specific factors) and next-year COPD hospital admissions or 90-day readmissions.

METHODS

Patients over 40 years of age residing in Oslo or Trondheim at the time of contact in the period 2009-2018 were identified from the Norwegian Patient Registry (in- and outpatient hospital contacts, rehabilitation) and the KUHR registry (contacts with GPs, contract specialists and physiotherapists). These were linked to the Regular General Practitioner registry (characteristics of the GP practice), long-term care data (home and institutional care, need for assistance), socioeconomic and-demographic data from Statistics Norway and the Cause of Death registry. Negative binomial models were applied to study associations between combinations of outpatient care, specific care factors and next-year COPD hospital admissions and 90-day readmissions. The sample consisted of 24,074 individuals.

RESULTS

A large variation in the frequency and combination of outpatient service use for respiratory diagnoses (GP, emergency room, physiotherapy, contract specialist and outpatient hospital contacts) was apparent. GP and outpatient hospital contact frequency were strongly associated to an increased number of next-year hospital admissions (1.2-3.2 times higher by increasing GP frequency when no outpatient hospital contacts, 2.4-5 times higher in combination with outpatient hospital contacts). Adjusted for healthcare use, comorbidities and sociodemographics, outpatient care factors associated with lower numbers of next-year hospitalisations were fees indicating interaction between providers (7% reduction), spirometry with GP or specialist (7%), continuity of care with GP (15%), and GP follow-up (8%) or rehabilitation (18%) within 30 days vs. later following any current year hospitalisations. For 90-day readmissions results were less evident, and most variables were non-significant.

CONCLUSION

As increased use of outpatient care was strongly associated with future hospitalisations, this further stresses the need for good communication between providers when coordinating care for COPD patients. The results indicated possible benefits of care continuity within and interaction between providers.

The transition of general practice into an academic discipline: tracing the origins through the first four professors in general practice/family medicine

Being the 'mother' of most clinical specialties, general practice is as old as medicine itself. However, as a recognized academic discipline within medical schools, general practice has a relatively short life span. A decisive step forward was taken in 1956 when the University of Edinburgh established its Department of General Practice, and appointed the world's inaugural professor in the field in 1963. During the 1960s, the pioneering move in Edinburgh was followed by universities in the Netherlands (University of Utrecht), Canada (Western University, Ontario), and Norway (University of Oslo), marking the beginning of global academic recognition for general practice/family medicine. Despite its critical role in healthcare, the academic evolution of general practice has been sparingly documented, with a notable absence of comprehensive accounts detailing its integration into medical schools as an independent discipline with university departments and academic professors. Last year (2023) marked the 60th anniversary of Dr. Richard Scott's historic appointment as the first professor of General Practice/Family Medicine. Through the lens of the first four professors appointed between 1963 and 1969, we explore the 'birth' of general practice to become an academic discipline. In most western countries of today, general practice has become a recognized medical discipline and an important part of the medical education. But many places, this development is lagging behind. The global shaping of general practice into an academic discipline is therefore definitively not completed.

The French ecology of medical care. A nationwide population-based cross sectional study

PURPOSE

Studies in the United States, Canada, Belgium, and Switzerland showed that the majority of health problems are managed within primary health care; however, the ecology of French medical care has not yet been described.

METHODS

Nationwide, population-based, cross sectional study. In 2018, we included data from 576,125 beneficiaries from the General Sample of Beneficiaries database. We analysed the reimbursement of consultations with (i) a general practitioner (GP), (ii) an outpatient doctor other than a GP, (iii) a doctor from a university or non-university hospital; and the reimbursement of (iv) hospitalization in a private establishment, (v) general hospital, and (vi) university hospital. For each criterion, we calculated the average monthly number of reimbursements reported on 1,000 beneficiaries. For categorical variables, we used the χ2 test, and to compare means we used the z test. All tests were 2-tailed with a P-value < 5% considered significant.

RESULTS

Each month, on average, 454 (out of 1,000) beneficiaries received at least 1 reimbursement, 235 consulted a GP, 74 consulted other outpatient doctors in ambulatory care and 24 in a hospital, 13 were hospitalized in a public non-university hospital and 10 in the private sector, and 5 were admitted to a university hospital. Independently of age, people consulted GPs twice as much as other specialists. The 13-25-year-old group consulted the least. Women consulted more than men. Individuals covered by complementary universal health insurance had more care.

CONCLUSIONS

Our study on reimbursement data confirmed that, like in other countries, in France the majority of health problems are managed within primary health care.

Midwife continuity of care models versus other models of care for childbearing women

BACKGROUND

Midwives are primary providers of care for childbearing women globally and there is a need to establish whether there are differences in effectiveness between midwife continuity of care models and other models of care. This is an update of a review published in 2016.

OBJECTIVES

To compare the effects of midwife continuity of care models with other models of care for childbearing women and their infants.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Trials Register, ClinicalTrials.gov, and the WHO International Clinical Trials Registry Platform (ICTRP) (17 August 2022), as well as the reference lists of retrieved studies.

SELECTION CRITERIA

All published and unpublished trials in which pregnant women are randomly allocated to midwife continuity of care models or other models of care during pregnancy and birth.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed studies for inclusion criteria, scientific integrity, and risk of bias, and carried out data extraction and entry. Primary outcomes were spontaneous vaginal birth, caesarean section, regional anaesthesia, intact perineum, fetal loss after 24 weeks gestation, preterm birth, and neonatal death. We used GRADE to rate the certainty of evidence.

MAIN RESULTS

We included 17 studies involving 18,533 randomised women. We assessed all studies as being at low risk of scientific integrity/trustworthiness concerns. Studies were conducted in Australia, Canada, China, Ireland, and the United Kingdom. The majority of the included studies did not include women at high risk of complications. There are three ongoing studies targeting disadvantaged women. Primary outcomes Based on control group risks observed in the studies, midwife continuity of care models, as compared to other models of care, likely increase spontaneous vaginal birth from 66% to 70% (risk ratio (RR) 1.05, 95% confidence interval (CI) 1.03 to 1.07; 15 studies, 17,864 participants; moderate-certainty evidence), likelyreduce caesarean sections from 16% to 15% (RR 0.91, 95% CI 0.84 to 0.99; 16 studies, 18,037 participants; moderate-certainty evidence), and likely result in little to no difference in intact perineum (29% in other care models and 31% in midwife continuity of care models, average RR 1.05, 95% CI 0.98 to 1.12; 12 studies, 14,268 participants; moderate-certainty evidence). There may belittle or no difference in preterm birth (< 37 weeks) (6% under both care models, average RR 0.95, 95% CI 0.78 to 1.16; 10 studies, 13,850 participants; low-certainty evidence). We arevery uncertain about the effect of midwife continuity of care models on regional analgesia (average RR 0.85, 95% CI 0.79 to 0.92; 15 studies, 17,754 participants, very low-certainty evidence), fetal loss at or after 24 weeks gestation (average RR 1.24, 95% CI 0.73 to 2.13; 12 studies, 16,122 participants; very low-certainty evidence), and neonatal death (average RR 0.85, 95% CI 0.43 to 1.71; 10 studies, 14,718 participants; very low-certainty evidence). Secondary outcomes When compared to other models of care, midwife continuity of care models likely reduce instrumental vaginal birth (forceps/vacuum) from 14% to 13% (average RR 0.89, 95% CI 0.83 to 0.96; 14 studies, 17,769 participants; moderate-certainty evidence), and may reduceepisiotomy 23% to 19% (average RR 0.83, 95% CI 0.77 to 0.91; 15 studies, 17,839 participants; low-certainty evidence). When compared to other models of care, midwife continuity of care models likelyresult in little to no difference inpostpartum haemorrhage (average RR 0.92, 95% CI 0.82 to 1.03; 11 studies, 14,407 participants; moderate-certainty evidence) and admission to special care nursery/neonatal intensive care unit (average RR 0.89, 95% CI 0.77 to 1.03; 13 studies, 16,260 participants; moderate-certainty evidence). There may be little or no difference in induction of labour (average RR 0.92, 95% CI 0.85 to 1.00; 14 studies, 17,666 participants; low-certainty evidence), breastfeeding initiation (average RR 1.06, 95% CI 1.00 to 1.12; 8 studies, 8575 participants; low-certainty evidence), and birth weight less than 2500 g (average RR 0.92, 95% CI 0.79 to 1.08; 9 studies, 12,420 participants; low-certainty evidence). We are very uncertain about the effect of midwife continuity of care models compared to other models of care onthird or fourth-degree tear (average RR 1.10, 95% CI 0.81 to 1.49; 7 studies, 9437 participants; very low-certainty evidence), maternal readmission within 28 days (average RR 1.52, 95% CI 0.78 to 2.96; 1 study, 1195 participants; very low-certainty evidence), attendance at birth by a known midwife (average RR 9.13, 95% CI 5.87 to 14.21; 11 studies, 9273 participants; very low-certainty evidence), Apgar score less than or equal to seven at five minutes (average RR 0.95, 95% CI 0.72 to 1.24; 13 studies, 12,806 participants; very low-certainty evidence) andfetal loss before 24 weeks gestation (average RR 0.82, 95% CI 0.67 to 1.01; 12 studies, 15,913 participants; very low-certainty evidence). No maternal deaths were reported across three studies. Although the observed risk of adverse events was similar between midwifery continuity of care models and other models, our confidence in the findings was limited. Our confidence in the findings was lowered by possible risks of bias, inconsistency, and imprecision of some estimates. There were no available data for the outcomes: maternal health status, neonatal readmission within 28 days, infant health status, and birth weight of 4000 g or more. Maternal experiences and cost implications are described narratively. Women receiving care from midwife continuity of care models, as opposed to other care models, generally reported more positive experiences during pregnancy, labour, and postpartum. Cost savings were noted in the antenatal and intrapartum periods in midwife continuity of care models.

AUTHORS' CONCLUSIONS

Women receiving midwife continuity of care models were less likely to experience a caesarean section and instrumental birth, and may be less likely to experience episiotomy. They were more likely to experience spontaneous vaginal birth and report a positive experience. The certainty of some findings varies due to possible risks of bias, inconsistencies, and imprecision of some estimates. Future research should focus on the impact on women with social risk factors, and those at higher risk of complications, and implementation and scaling up of midwife continuity of care models, with emphasis on low- and middle-income countries.

Primary care gatekeeping during the COVID-19 pandemic: a survey of 1234 Norwegian regular GPs

BACKGROUND

In the Nordic healthcare systems, GPs regulate access to secondary health services as gatekeepers. Limited knowledge exists about the gatekeeper role of GPs during public health crises seen from the perspective of GPs.

AIM

To document GPs' gatekeeper role and organisational changes during the initial COVID-19 lockdown in Norway.

DESIGN & SETTING

A cross-sectional online survey was addressed to all regular Norwegian GPs (n = 4858) during pandemic lockdown in spring 2020.

METHOD

Each GP documented how patients with potential COVID-19 disease were triaged and handled during a full regular workday. The survey also covered workload, organisational changes, and views on advice given by the authorities.

RESULTS

A total of 1234 (25.4%) of Norway's GPs participated. Together, they documented nearly 18 000 consultations, of which 65% were performed digitally (video, text, and telephone). Suspected COVID-19 symptoms were reported in 11% of the consultations. Nearly all these patients were managed in primary care, either in regular GP offices (55.7%) or GP-run municipal respiratory clinics (40.7%), while 3.7% (n = 73) were admitted to hospitals. The GPs proactively contacted an average of 0.8 at-risk patients per day. While 84% were satisfied with the information provided by the medical authorities, only 20% were able to reorganise their practice in accordance with national recommendations.

CONCLUSION

During the early stage of the COVID-19 pandemic in Norway, the vast majority of patients with COVID-19-suspected symptoms were handled in primary care. This is likely to have protected secondary health services from potentially detrimental exposure to contagion and breakdown of capacity limits.

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.

Importance of continuity of care from a patient perspective - a cross-sectional study in Swedish health care

OBJECTIVE

The primary objective of this study was to evaluate the patients' view on continuity of care (CoC), including preference for a certain general practitioner (GP) and importance and access to a regular general practitioner (RGP).

DESIGN

Cross-sectional study.

SETTING

Primary care center in Halland County, in the western part of Sweden.

SUBJECTS

Patients ≥18 years old and having at least one appointment at the primary care center during October-December 2022.

MAIN OUTCOME MEASURES

Preference for a certain GP and importance of and accessibility for an RGP.

RESULTS

The study included 404 patients. Importance of having an RGP was considered by 86% of the patients. Preference for a certain GP was thought by 73% of the patients, and when asked as a bivariate question, 69% considered having an RGP. Both the importance of an RGP and preference for a certain GP were more often considered by patients ≥65 years (p < .0001). Regarding accessibility, 67% of the patients reported having access to their RGP 'always/most of the time or a lot of the time' and 62% reported seeing their RGP at last visit.

CONCLUSIONS

In conclusion, this study showed that the majority of patients value CoC in terms of importance of having an RGP. Older patients were more likely to have a preference for a certain GP. Two-third of the patients succeeded in seeing their RGP always or a lot of the time. The results in this study provide evidence that CoC is important for most patients, regardless of age and gender.Key pointsPrevious studies have showed that continuity of care (CoC) is important regarding mortality and morbidity. In primary care, there is a current debate regarding CoC, accessibility and the strive for CoC. This study showed that the majority of patients, regardless of age and gender, value CoC and consider it being important. However, there was a statistically significant difference regarding age, where patients above 65 years old thought it was more important to have a regular general practitioner and more often had a preference for a certain GP.

Insulin initiation in patients with type 2 diabetes is often delayed, but access to a diabetes nurse may help-insights from Norwegian general practice

Objective: We opted to study how support staff operational capacity and diabetes competences may impact the timeliness of basal insulin-initiation in general practice patients with type 2 diabetes (T2D).Design/Setting/Outcomes: This was an observational and retrospective study on Norwegian primary care patients with T2D included from the ROSA4-dataset. Exposures were (1) support staff size, (2) staff size relative to number of GPs, (3) clinic access to a diabetes nurse and (4) share of staff with diabetes course (1 and 2 both relate to staff operational capacity, whereas 3 and 4 are both indicatory of staff diabetes competences). Outcomes were 'timely basal insulin-initiation' (primary) and 'attainment of HbA1c<7%' after insulin start-up (secondary). Associations were analyzed using multiple linear regression, and directed acyclic graphs guided statistical adjustments.Subjects: Insulin naïve patients with 'timely' (N = 294), 'postponed' (N = 219) or 'no need of' (N = 3,781) basal insulin-initiation, respectively.Results: HbA1c [median (IQR)] increased to 8.8% (IQR, 8.0, 10.2) prior to basal insulin-initiation, which reduced HbA1c to 7.3 (6.8-8.1) % by which only 35% of the subjects reached HbA1c <7%. Adjusted risk of 'timely basal insulin-initiation' was more than twofold higher if access to a diabetes nurse (OR = 2.40, [95%CI, 1.68, 3.43]), but related only vaguely to staff size (OR = 1.01, [95%CI, 1.00, 1.03]). No other staff factors related significantly to neither the primary nor the secondary outcome.Conclusion: In Norwegian general practice, insulin initiation in people with T2D may be affected by therapeutic inertia but access to a diabetes nurse may help facilitating more timely insulin start-up.

Incidence of short-term community hospital stays and clinical profiles of patients: the Finnish Community Hospital Cohort Study

OBJECTIVE

A community hospital system covers the entire population of Finland. Yet there is little research on the system beyond routine statistics. More knowledge is needed on the incidence of hospital stays and patient profiles. We investigated the incidence of short-term community hospital stays and the features of care and patients.

DESIGN

Prospective observational study.

SETTING

Community hospitals in the catchment area of Kuopio University Hospital in Finland.

SUBJECTS

Short-term (up to one month) community hospital stays of adult residents.

MAIN OUTCOME MEASURES

The outcome was the incidence rate of short-term community hospital stays according to age, sex and the first underlying diagnoses.

RESULTS

A number of 13,482 short-term community hospital stays were analyzed. The patients' mean age was 77 years. The incidence rate of short-term hospital stays was 28.6 stays per 1000 person-years among residents aged <75 years and 419.0 among residents aged ≥75 years. In men aged <75 years, the hospital stay incidence was about 40% higher than in women of the same age but in residents aged ≥75 years incidences did not differ between sexes. The most common diagnostic categories were vascular and respiratory diseases, injuries and mental illnesses.

CONCLUSIONS

The incidence rate of short-term community hospital stays increased sharply with age and was highest among women aged ≥75 years. Care was required for acute and chronic conditions common in older adults.

IMPLICATIONS

Community hospitals have a substantial role in hospital care of older adults.

Family practice research in the African region 2020-2022

BACKGROUND

 The African region produces a small proportion of all health research, including primary health care research. The SCOPUS database only lists the African Journal of Primary Health Care Family Medicine (PHCFM) and the South African Family Practice Journal (SAFP) in the field of family practice.

AIM

 To review the nature of all original research (2020-2022) published in PHCFM and SAFP.

SETTING

 African region.

METHOD

 All 327 articles were included. Data were extracted into REDCap, using a standardised tool and exported to the Statistical Package for Social Sciences.

RESULTS

 The median number of authors was 3 (interquartile range [IQR]: 2-4) and institutions and disciplines 1 (IQR: 1-2). Most authors were from South Africa (79.8%) and family medicine (45.3%) or public health (34.2%). Research focused on integrated health services (76.1%) and was mostly clinical (66.1%) or service delivery (37.9%). Clinical research addressed infectious diseases (23.4%), non-communicable diseases (24.6%) and maternal and women's health (19.4%). Service delivery research addressed the core functions of primary care (35.8%), particularly person-centredness and comprehensiveness. Research targeted adults and older adults (77.0%) as well as health promotion or disease prevention (38.5%) and treatment (30.9%). Almost all research was descriptive (73.7%), mostly surveys.

CONCLUSION

 Future research should include community empowerment and multisectoral action. Within integrated health services, some areas need more attention, for example, children, palliative and rehabilitative care, continuity and coordination. Capacity building and support should enable larger, less-descriptive and more collaborative interdisciplinary studies with authors outside of South Africa.Contribution: The results highlight the strengths and weaknesses of family practice research in Africa.

Patients' experiences with receiving sick leave certificates via remote consultations in Norway during the COVID-19 pandemic: a nationwide online survey

OBJECTIVES

To explore patients' experiences with receiving sick leave certificates via remote consultations during the COVID-19 pandemic and investigate whether there were differences among the types of remote consultation (telephone, video or text).

DESIGN

A nationwide online patient survey consisting of quantitative data supplemented by qualitative opinions conducted in Norway.

SETTING

Primary care.

PARTICIPANTS

Patients who received a sick leave certificate via remote consultation in the period from 16 November to 15 December 2020.

RESULTS

Of the 5429 respondents, 3233 (59.6%) received a sick leave certificate via telephone consultation, 657 (12.1%) via video consultation and 1539 (28.3%) via text-based e-consultation. Most respondents (76.8%) were satisfied. Only 10% of the respondents thought that the doctor would have obtained more information through an office appointment. The majority of the respondents (59.6%) found that they had as much time to explain the problem as at an office appointment. Some patients also thought that it was easier to formulate the problem via a remote consultation (18.2%) and agree with the doctor on the sick leave (10.3%).The users of text-based e-consultations were the most satisfied (79.3%, p<0.001) compared with those using telephone or video consultations. Among users of text-based e-consultations, there was a higher proportion of patients who thought that they had more time to explain the problem compared with an office appointment (p<0.001), it was easier to explain the problem (p<0.001) and agree with the doctor (p<0.001). Most respondents would use the same type of remote consultation if they were to contact the general practitioner (GP) for the same problem, with the highest proportion among the users of video consultations (62.1%, p<0.001).

CONCLUSIONS

Patients were satisfied with communicating and receiving sick leave certificates via remote consultations. Future studies should investigate patients' and GPs' use and experiences in a postpandemic setting.

Core values of employed general practitioners in Germany - a qualitative study

BACKGROUND

"Core values" help to guide practice of health care delivery. The core values of general practice are described in the European definition of general practice by WONCA, e.g. a holistic, comprehensive and continuous care. They may be associated with the idea that the general practitioner is the owner of the practice rather than an employee.

OBJECTIVES

The objective was to examine the core values of employed GPs in their professional setting and their practical manifestation.

METHODS

From April to May 2021, we conducted 17 semi-structured telephone-interviews with employed GPs in two districts in Baden-Wuerttemberg, Germany. The data were analysed using qualitative content analysis.

RESULTS

We identified twelve core values, including values relevant to patient care and values relevant to the lives of employed GPs. Values with high relevance were job satisfaction, the professional distance from patients, collaboration and collegial exchange, comprehensive care, adequate consultation time and availability to patients. Values with heterogeneous relevance were continuity of care, waiting times and medical autonomy. The value "availability" of employed GPs to patients was associated with both patient care and personal life. The limited availability of employed GPs was accompanied by tensions between these two trends and other values.

CONCLUSION

The values of employed GPs are partly consistent with the current WONCA definition of general practice. There were also indications of new values. The increase in the proportion of employed GPs implies a need to reflect on the core values of general practice, taking into account factors on the part of employed GPs, patients, and practice organisation.

Continuity of care and mortality for patients with chronic disease: an observational study using Norwegian registry data

BACKGROUND

Research on continuity of care (CoC) is mainly conducted in primary care and has received little acknowledgment in other levels of care. This study sought to investigate CoC across care levels for patients with selected chronic diseases, along with its association with mortality.

METHODS

In a registry-based cohort study, patients with ≥1 consultation in primary or specialist healthcare or hospital admission with asthma, chronic obstructive pulmonary disease (COPD), diabetes mellitus, or heart failure in 2012 were linked to disease-related consultation data in 2013-2016. CoC was measured by Usual Provider of Care index (UPC) and Bice-Boxermann continuity of care score (COCI). Values equal to one were categorized into one group and the rest into three equal groups (tertiles). The association with mortality was determined by Cox regression models.

RESULTS

The highest mean UPCtotal was measured for patients with diabetes mellitus (0.58) and the lowest for those with asthma (0.46). The population with heart failure had the highest death rate (26.5). In adjusted Cox regression analyses for COPD, mortality was 2.6 times higher (95% CI 2.25-3.04) for patients in the lowest tertile of continuity compared to those with UPCtotal = 1. Patients with diabetes mellitus and heart failure showed similar results.

CONCLUSION

CoC was moderate to high for disease-related contacts across care levels. A higher mortality associated with lower CoC was observed for patients with COPD, diabetes mellitus, and heart failure. A similar, but not statistically significant trend was found for patients with asthma. This study suggests that higher CoC across levels of care can decrease mortality.

Continuity and discontinuity of care among older patients in Danish general practice: a retrospective cohort study

BACKGROUND

Continuity of care (COC) for older adults has been associated with lower use of healthcare services, decreased risk of hospitalisation, and lower mortality. However, research on COC in older adults is limited by short time periods and small sample sizes. Long-term COC can only develop if the patient stays with the general practice for ≥10 years. Therefore, research that focuses on long duration and broader populations is needed.

AIM

To measure the extent of longitudinal site-level COC in general practice and listing duration of the patient-general practice relation for all older Danish citizens.

DESIGN & SETTING

Retrospective cohort study of all patients aged ≥65 years on 31 December 2021 listed with a Danish general practice (N = 1 144 941 persons).

METHOD

Individual-level register data were used on start and end dates for listing with a general practice to analyse site-level COC by number of changes and listing duration of the patient-general practice relation from January 2007-December 2021.

RESULTS

During the 15 years, 39.3% of older adults did not change general practice. Among the remaining 60.7%, who experienced discontinuity of care, 34.0% changed once, 16.3% changed twice, and 6.3% changed three times. Overall, <5% changed general practice >3 times. The duration of the patient-general practice relations were on average 9.5 years. Overall, 27.5% lasted 0-4 years, 33.7% lasted 5-9 years, and 38.8% lasted ≥10 years.

CONCLUSION

Danish general practice provides high levels of site-level COC for their older patients. On average, patients aged ≥65 years changed general practice once and had a patient-general practice relation length of 9.5 years.

Expanding general practice with interprofessional teams: a mixed-methods patient perspective study

BACKGROUND

Across healthcare systems, current health policies promote interprofessional teamwork. Compared to single-profession general practitioner care, interprofessional primary healthcare teams are expected to possess added capacity to care for an increasingly complex patient population. This study aims to explore patients' experiences when their usual primary healthcare encounter with general practice shifts from single-profession general practitioner care to interprofessional team-based care.

METHODS

Qualitative and quantitative data were collected through interviews and a survey among Norwegian patients. The interviews included ten patients (five women and five men) aged between 28 and 89, and four next of kin (all women). The qualitative analysis was carried out using thematic analysis and a continuity framework. The survey included 287 respondents, comprising 58 per cent female and 42 per cent male participants, aged 18 years and above. The respondents exhibited multiple diagnoses and often a lengthy history of illness. All participants experienced the transition to interprofessional teamwork at their general practitioner surgery as part of a primary healthcare team pilot.

RESULTS

The interviewees described team-based care as more fitting and better coordinated, including more time and more learning than with single-profession general practitioner care. Most survey respondents experienced improvements in understanding and mastering their health problems. Multi-morbid elderly interviewees and interviewees with mental illness shared experiences of improved information continuity. They found that important concerns they had raised with the nurse were known to the general practitioner and vice versa. None of the interviewees expressed dissatisfaction with the inclusion of a nurse in their general practitioner relationship. Several interviewees noted improved access to care. The nurse was seen as a strengthening link to the general practitioner. The survey respondents expressed strong agreement with being followed up by a nurse. The interviewees trusted that it was their general practitioner who controlled what happened to them in the general practitioner surgery.

CONCLUSION

From the patients' perspective, interprofessional teamwork in general practice can strengthen management, informational, and relational continuity. However, a prerequisite seems to be a clear general practitioner presence in the team.

Primary care utilisation, adherence to guideline-based pharmacotherapy and continuity of care in primary care patients with chronic diseases and multimorbidity - a cross-sectional study

BACKGROUND

To understand how to improve care for patients with chronic diseases and multimorbidity we wanted to describe the prevalence of different chronic diseases and the pattern of multimorbidity and to analyse the associations between occurrence of diseases and primary care utilization, adherence to guideline-based pharmacotherapy, and continuity of care.

METHODS

Retrospective cross-sectional study of routine care data of the general population in region Jönköping in Sweden (345 916 inhabitants using primary care services) covering 4.3 years.

PARTICIPANTS

Patients fulfilling the inclusion criteria of having ≥ 1 of 10 common chronic diseases and ≥ 3 visits to primary care between 2011 and 2015.

PRIMARY OUTCOME MEASURES

In order to determine diseases and multimorbidity, primary care utilisation, adherence to guideline-based pharmacotherapy, frequencies and percentages, interval and ratio scaled variables were described using means, standard deviations, and various percentiles in the population. Two continuity indices were used (MMCI, COC) to describe continuity.

RESULTS

Of the general population, 25 829 patients fulfilled the inclusion criteria (7.5% of the population). Number of diseases increased with increasing age, and multimorbidity was much more common than single diseases (mean 2.0 per patient). There was a slight positive correlation (0.29) between number of diseases and visits, but visits did not increase proportionally to the number of diseases. Patients with physical diseases combined with anxiety and/or depression made more visits than others. The number of diseases per patient was negatively associated with the adherence to pharmacotherapy guidelines. There was no association between continuity and healthcare utilisation or adherence to pharmacotherapy guidelines.

CONCLUSIONS

Multimorbid patients are common in primary care and for many chronic diseases it is more common to have other simultaneous diseases than having only one disease. This can make adherence to pharmacotherapy guidelines a questionable measure for aged multimorbid patients. Existing continuity indices also revealed limitations. Holistic and patient-centred measures should be used for quality assessment of care for multimorbid patients in primary care.

First contact with the health system: a survey study in northern Portugal

OBJECTIVE

The objective of this study is to characterise the self-reported first contact with the health system and the reasons stated for each choice, testing associations with population characteristics.

DESIGN

Cross-sectional survey.

SETTING

Primary care department of a local health unit in northern Portugal.

PARTICIPANTS

Random sample of 4286 persons, retrieved from all registered adults.

OUTCOMES

Participants who stated they usually see the same doctor when a health problem arises were considered to adopt first-contact care and were asked to identify their regular doctor. Participants were asked why they adopt first-contact care or why they choose to do otherwise. Associations between personal characteristics and the adoption of first-contact care were tested using logistic regression.

RESULTS

There were 808 valid questionnaires received (19% response rate). The mean age of respondents was 53 years, 58% were women and 60% had a high school or higher degree. Most (71%) stated always seeing the same doctor when facing a health problem. This was a general practitioner (GP) in 84%. The main reasons were previous knowledge and trust in the doctor. When this doctor was not a GP, the main reason was the need to obtain an appointment quickly. Participants who chose first-contact care were less likely to have university degrees than those who did not (OR 0.31; 95% CI 0.13 to 0.76). Being registered with the same GP for over 1 year increased the odds of adopting first-contact care: twice as likely for those registered for 1-4 years with the same GP (2.07; 95% CI 1.04 to 4.11), and three times more likely for those registered for over 10 years (3.21; 95% CI 1.70 to 6.08).

CONCLUSIONS

The high adoption of first-contact care and the reasons given for this suggest a strong belief in primary care in this population. The longer patients experience continuity, the more they adopt first-contact care. The preferences of higher-educated patients regarding first-contact care deserve reflection.

Models of working in general practice: personal perspectives

Four general practioners share perspectives on their career pathways, which span different models in both partnered and salaried GP work, and reflect on the challenges and benefits of each model.

Primary care in the world of integrated care systems: education and training for general practice

Here, we discuss the required education and training for the emergent and evolving roles of GPs and other healthcare professionals within Integrated Care Systems (ICSs). We underscore the importance of collaborative skills for all medical specialties, and the need for interprofessional education and leadership development in undergraduate and postgraduate medical training. We also argue for a paradigm shift in medical education, away from traditional siloed approaches and toward comprehensive training that prepares practitioners to excel in integrated and multidisciplinary healthcare environments, within which expert generalists (GPs) and specialists collaborate in individual patient care and concurrently co-develop innovative system pathways for chronic medical conditions, including complexity and frailty. We highlight the need to align workforce development with evolving healthcare systems and the existing obstacles hindering this alignment.

Challenges in reaching patients with severe mental illness for trials in general practice-a convergent mixed methods study based on the SOFIA pilot trial

BACKGROUND

Patients with severe mental illness (SMI) die prematurely due to undetected and inadequate treatment of somatic illnesses. The SOFIA pilot study was initiated to mend this gap in health inequity. However, reaching patients with SMI for intervention research has previously proven difficult. This study aimed to investigate the recruitment of patients with SMI for the SOFIA pilot study in 2021.

METHODS

We used a mixed-method convergent design. The qualitative material comprised 20 interviews with general practitioners (GPs) and staff, during patient recruitment. The quantitative data consisted of process data on baseline characteristics, GPs reported reasons for excluding a patient, reported reasons for patients declining participation, and registered data from a Danish population of patients with SMI. We used thematic analysis in the qualitative analysis and descriptive statistics for the quantitative analysis. Pillar integration was used for integrating the material.

RESULTS

Our findings show that selection bias occurred in the pilot study. We describe four main themes based on the integrated analysis that highlights selection issues: (1) poor data quality and inconsistency in defining severity definitions troubled identification and verification, (2) protecting the patient and maintaining practice efficiency, (3) being familiar with the patient was important for a successful recruitment, and (4) in hindsight, the GPs questioned whether the target population was reached.

CONCLUSIONS

In the light of theories of professions and street-level bureaucracy, we find that the main drivers of the patient selection bias occurring in the SOFIA pilot study were that 1) GPs and staff mended eligibility criteria to protect certain patients and/or to minimize workload and maintain efficiency in the practice 2) the data from the GP record systems and the digital assessment tool to assist recruitment was not optimal. Interventions targeting this patient group should carefully consider the recruitment strategy with a particular focus on professionals' discretionary practices and information technology pitfalls.

TRIAL REGISTRATION

The pilot trial protocol was registered on the 5th of November 2020. The registration number is NCT04618250 .

A named General Practitioner (GP) is associated with an increase of hospital days in a single predictor analysis: a follow-up of 15 years

BACKGROUND

Continuity of care constitutes the basis of primary health care services and is associated with decreased hospitalization. In Finland, accessibility to primary care and increased use of hospital services are recognized challenges for the health care system.

OBJECTIVES

The aim of the study was to determine whether having a named GP is associated with hospital service use.

METHODS

The data are part of the Health and Social Support study (HeSSup) based on a random Finnish working-age population sample. The cohort of the study comprised participants of postal surveys in 1998 (n = 25,898) who returned follow-up questionnaires both in 2003 and 2012 (n = 11,924). Background characteristics were inquired in the questionnaires, and hospitalization was derived from national registries (Hilmo-register).

RESULTS

A named GP was reported both in 2003 and 2012 only by 34.3% of the participants. The association between hospital days and a named GP was linearly rising and statistically significant in a single predictor model. The strongest associations with hospital use were with health-related factors, and the association with a named GP was no longer significant in multinomial analysis.

CONCLUSION

A named GP is associated with an increased use of hospital days, but in a multinomial analysis the association disappeared. Health related factors showed the strongest association with hospital days. From the perspective of the on-going Finnish health and social services reform, continuity of care should be emphasized.

Frequent attenders in primary health care: a mixed-methods study of patient and staff perspectives

AIMS AND OBJECTIVE

To understand the frequent attendance phenomenon from the perspective of patients and healthcare professionals and how it can be reduced.

BACKGROUND

Frequent attenders (FAs) are characterised by the consumption of a disproportionate number of medical consultations and a high number of visits per year to primary care physicians (PCP). Although FAs constitute about 10% of all primary clinic attendees, they are responsible for ~40-50% of clinic visits, affecting the efficiency, accessibility and quality of health services provided to other patients.

DESIGN

Mixed methods (STROBE Statement: Data S1; COREQ checklist: Data S2).

METHODS

Eighteen FAs were interviewed in a qualitative approach. PCPs and nurses (n = 184) completed a cross-sectional survey.

RESULTS

FAs are driven by their personal, emotional and mental state. FAs viewed clinics as a source for information and resolving medical problems. They perceived PCPs as authoritative and knowledgeable, and nurses as treatment managers and mediators between PCPs and patients. In contrast, FAs evoked more negative emotions than positive ones among medical staff. PCPs and nurses attributed frequent visits to FAs' personal and emotional states. A model based on the findings was constructed to provide a framework for grasping frequent attendance from a sociological perspective and for planning and managing it.

CONCLUSIONS

The accessibility and availability of health services at primary clinics, and collaboration and trust in medical staff facilitate the frequent attendance phenomenon.

RELEVANCE TO CLINICAL PRACTICE

The frequent attendance phenomenon should be proactively prevented, even before patients become FA, using the model constructed, which serves as a foundation for introducing an intervention program to identify and prevent frequent attendance. PCPs and nurses working in primary care clinics should be made aware of the FA phenomenon and should be educated and given tools to deal with it within the clinic. The process should be facilitated by organisational support.

PATIENT OR PUBLIC CONTRIBUTION

There was no patient or public contribution to the design or conduct of the study, analysis or interpretation of the data, or in the preparation of the manuscript.

Experience of Lifetime Health Maintenance Program: An Observational Study of a 30-Year Period of Outpatient Primary Care in a Tertiary Hospital

BACKGROUND

This study aimed to identify the clinical content of patients registered with the Lifetime Health Maintenance Program (LHMP) under the care of a single family physician who introduced and operated the program in Korea at a tertiary hospital for over 30 years.

METHODS

We analyzed the electronic medical records of 745 patients who had registered for more than 3 times with the LHMP under the care of a single family physician between January 1, 2010 and December 31, 2019. We reviewed medical records from June 1989, when the hospital was established, to February 2022. The participants' age at the time of LHMP enrollment, sex, initial consultation date, final consultation date, and consultation content were evaluated.

RESULTS

Patients visited the LHMP for various reasons, including acute symptom management, chronic disease management, psychiatric consultation, counseling on health behaviors, health checkups, and vaccination. The top five diagnoses for acute symptom management were upper respiratory infection, abdominal pain, dizziness/vertigo, headache, and lower back pain, whereas those for chronic disease management were dyslipidemia, hypertension, osteoarthritis, osteoporosis/osteopenia, and diabetes. More than one in five patients received psychiatric consultation and counseling on health behaviors. As the duration of the program enrollment increased, the proportion of patients visiting the LHMP for acute symptoms, vaccinations, and health checkups also increased. Furthermore, the number of categories of consultation content increased for each patient.

CONCLUSION

The LHMP emphasized the need to systematize regular primary care physicians in Korea. Policy changes are necessary to strengthen primary care, and the LHMP serves as an intermediate step in organizing regular primary care physicians in Korea.

Use of emergency primary care among pregnant undocumented migrants over ten years: an observational study from Oslo, Norway

OBJECTIVE

To compare consultations with pregnant undocumented migrants at emergency primary health care to consultations with pregnant residents of Norway.

DESIGN

A cross-sectional study of consultations at several time points.

SETTING

The study was conducted at the Oslo Accident and Emergency Outpatient Clinic (OAEOC), the main emergency primary care service in Oslo, Norway.

SUBJECTS

Consultations with pregnant patients without a Norwegian identity number seeking care at the Department of Emergency General Practice at the OAEOC were identified through a manual search of registration lists from 2009 to 2019. The consultations were categorized by women's residency status as 'probably documented migrant', 'uncertain migrant status', or 'probably undocumented migrant'. We also extracted aggregated data for women with a Norwegian identity number (i.e. residents) presenting in consultations with pregnancy-related (ICPC-2 chapter W) conditions.

MAIN OUTCOME MEASURES

Manchester Triage System urgency level at presentation, and hospitalization.

RESULTS

Among 829 consultations with female patients categorized as probably undocumented migrants, we found 27.1% (225/829) with pregnant women. About half of the pregnant women (54.6% (123/225)) presented with a pregnancy-related condition. Pregnant women that were probably undocumented migrants had an increased risk of being triaged with a high level of urgency at presentation (relative risk (RR) 1.86, 95% CI 1.14-3.04) and being hospitalized (RR 1.68, 95% CI 1.21-2.34), compared to pregnant residents.

CONCLUSION

Pregnant undocumented migrants were more severely sick when presenting to emergency primary care services than pregnant residents. Increased access to primary care and emergency primary care services for pregnant undocumented migrants is urgently needed.

Characteristics of collaborative care networks in functional disorders: A systematic review

OBJECTIVE

Functional disorders (FD) are complex conditions, for which multidisciplinary involvement is often recommended. Collaborative care networks (CCN) may unlock the potential of the multidisciplinary team (MDT) in FD care. To understand what characteristics should be part of CCNs in FD, we studied the composition and characteristics of existing CCNs in FD.

METHODS

We performed a systematic review following PRISMA guidelines. A search of PubMed, WebofScience, PsycInfo, SocINDEX, AMED and CINAHL was undertaken to select studies describing CCNs in FD. Two reviewers extracted characteristics of the different CCNs. Characteristics were classified as relating to structure and processes of networks.

RESULTS

A total of 62 studies were identified representing 39 CCNs across 11 countries. Regarding structural characteristics, we found that most networks are outpatient, secondary-care based, with teams of between two and 19 members. Medical specialists were most commonly involved and the typical team leads as well as main patient contacts were general practitioners (GPs) or nurses. Regarding processes, collaboration was demonstrated mostly during assessment, management and patient education, less often during rehabilitation and follow-up, mostly using MDT meetings. CCNs provided a wide range of treatment modalities, reflecting a biopsychosocial approach, including psychological therapies, physiotherapy and social and occupational therapy.

CONCLUSION

CCNs for FD are heterogeneous, showing a wide variety of structures as well as processes. The heterogeneity of results provides a broad framework, demonstrating considerable variation in how this framework is applied in different contexts. Better development of network evaluation, as well as professional collaboration and education processes is needed.

Healthcare fragmentation, multimorbidity, potentially inappropriate medication, and mortality: a Danish nationwide cohort study

BACKGROUND

Patients with multimorbidity are frequent users of healthcare, but fragmented care may lead to suboptimal treatment. Yet, this has never been examined across healthcare sectors on a national scale. We aimed to quantify care fragmentation using various measures and to analyze the associations with patient outcomes.

METHODS

We conducted a register-based nationwide cohort study with 4.7 million Danish adult citizens. All healthcare contacts to primary care and hospitals during 2018 were recorded. Clinical fragmentation indicators included number of healthcare contacts, involved providers, provider transitions, and hospital trajectories. Formal fragmentation indices assessed care concentration, dispersion, and contact sequence. The patient outcomes were potentially inappropriate medication and all-cause mortality adjusted for demographics, socioeconomic factors, and morbidity level.

RESULTS

The number of involved healthcare providers, provider transitions, and hospital trajectories rose with increasing morbidity levels. Patients with 3 versus 6 conditions had a mean of 4.0 versus 6.9 involved providers and 6.6 versus 13.7 provider transitions. The proportion of contacts to the patient's own general practice remained stable across morbidity levels. High levels of care fragmentation were associated with higher rates of potentially inappropriate medication and increased mortality on all fragmentation measures after adjusting for demographic characteristics, socioeconomic factors, and morbidity. The strongest associations with potentially inappropriate medication and mortality were found for ≥ 20 contacts versus none (incidence rate ratio 2.83, 95% CI 2.77-2.90) and ≥ 20 hospital trajectories versus none (hazard ratio 10.8, 95% CI 9.48-12.4), respectively. Having less than 25% of contacts with your usual provider was associated with an incidence rate ratio of potentially inappropriate medication of 1.49 (95% CI 1.40-1.58) and a mortality hazard ratio of 2.59 (95% CI 2.36-2.84) compared with full continuity. For the associations between fragmentation measures and patient outcomes, there were no clear interactions with number of conditions.

CONCLUSIONS

Several clinical indicators of care fragmentation were associated with morbidity level. Care fragmentation was associated with higher rates of potentially inappropriate medication and increased mortality even when adjusting for the most important confounders. Frequent contact to the usual provider, fewer transitions, and better coordination were associated with better patient outcomes regardless of morbidity level.

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSION

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