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2.  A nurse-led clinic for patients consulting with osteoarthritis in general practice: development and impact of training in a cluster randomised controlled trial 
BMC Family Practice  2016;17:173.
Background
Despite a lack of service provision for people with osteoarthritis (OA), each year 1 in 5 of the general population consults a GP about a musculoskeletal condition such as OA. Consequently this may provide an opportunity for practice nurses to take an active role in helping patients manage their condition. A nurse led clinic for supporting patients with OA was developed for the MOSAICS study investigating how to implement the NICE 2014 OA Guideline core recommendations. This paper has two main objectives, firstly to provide an overview of the nurse-led OA clinic, and secondly to describe the development, key learning objectives, content and impact of the training to support its delivery.
Methods
A training programme was developed and delivered to provide practice nurses with the knowledge and skill set needed to run the nurse-led OA clinic. The impact of the training programme on knowledge, confidence and OA management was evaluated using case report forms and pre and post training questionnaires.
Results
The pre-training questionnaire identified a gap between what practice nurses feel they can do and what they should be doing in line with NICE OA guidelines. Evaluation of the training suggests that it enabled practice nurses to feel more knowledgeable and confident in supporting patients to manage their OA and this was reflected in the clinical management patients received in the nurse-led OA clinics.
Conclusions
A significant gap between what is recommended and what practice nurses feel they can currently provide in terms of OA management was evident. The development of a nurse training programme goes some way to develop a system in primary care for delivering the core recommendations by NICE.
Trial registration
The cluster trial linked to this training was conducted from May 2012 through February 2014 by the Arthritis Research UK Primary Care Centre, Keele University, UK (Trial registration number ISRCTN06984617).
Electronic supplementary material
The online version of this article (doi:10.1186/s12875-016-0568-y) contains supplementary material, which is available to authorized users.
doi:10.1186/s12875-016-0568-y
PMCID: PMC5178095  PMID: 28003026
Osteoarthritis; Practice nurses; Training; Primary care; Implementation; Evaluation
3.  What influences general practitioners’ use of exercise for patients with chronic knee pain? Results from a national survey 
BMC Family Practice  2016;17:172.
Background
Exercise is a recommended ‘core’ treatment for chronic knee pain (CKP), however it appears to be underused by general practitioners (GPs). While behavioural theories suggest that attitudes and beliefs influence behaviours, no single theory reliably predicts GPs’ behaviours. A theoretical analysis framework, developed from sociocognitive theories, was used to underpin investigation of the key influences associated with GPs’ use of exercise for patients with CKP, to inform future interventions to optimise GPs’ use of exercise.
Methods
A cross-sectional postal questionnaire survey investigated UK GPs’ reported use of exercise based on a patient case vignette. Factors influencing GPs’ exercise use (behaviour) were examined using attitude statements, free-text questions and multiple response option questions related to factors within the analysis framework. Unadjusted logistic regression analyses explored the associations between GPs’ attitudes/beliefs and behaviour.
Results
From a total sample of 5000 GPs, 835 (17%) returned a questionnaire. Most respondents (n = 729, 87%) reported that they would use exercise. Factors significantly associated with exercise use (OR (95% CI)) included GPs’ beliefs about their role (belief that GPs should give information on type, duration and frequency of exercise (30.71 (5.02,188.01)), beliefs about consequences (agreement that knee problems are improved by local (3.23 (1.94,5.39)) and general exercise (2.63 (1.38,5.02))), moral norm (agreement that GPs should prescribe all patients local (3.08 (1.96,4.83)) and general exercise (2.63 (1.45,4.76))), and GP-related beliefs about capabilities (prior experience of insufficient expertise to give detailed exercise information (0.50 (0.33,0.76)). Whilst perceived time limitations were not associated with exercise use (1.00 (0.33,3.01)), GPs who disagreed that they experienced time limitations were more likely to suggest general (2.17 (1.04,4.55)), or demonstrate local (2.16 (1.06,4.42)), exercises.
Conclusion
GPs’ attitudes and beliefs are associated with their use of exercise for patients with CKP, particularly beliefs about role, responsibilities and skills in initiating exercise, and about the efficacy of exercise. Although the low response risks response bias, these results can inform future interventions to optimise GPs’ behaviour. The role of GP uncertainty and influences on clinical decision-making need further exploration, thus an amended analysis framework is suggested, which should be tested in future research.
Electronic supplementary material
The online version of this article (doi:10.1186/s12875-016-0570-4) contains supplementary material, which is available to authorized users.
doi:10.1186/s12875-016-0570-4
PMCID: PMC5168590  PMID: 27993126
General practitioner; Attitude; Belief; Behaviour; Exercise; Chronic knee pain; Knee osteoarthritis; Questionnaire survey
4.  Disenrollment from general practitioners among chronic patients: a register-based longitudinal study of Norwegian claims data 
BMC Family Practice  2016;17:170.
Background
Norwegian general practitioners (GPs) consult on a variety of conditions with a mix of patient types. Patients with chronic diseases benefit from appropriate continuity of care and generally visit their GPs more often than the average patient. Our aim was to study disenrollment patterns among patients with chronic diseases in Norway, because such patterns could indicate otherwise unobserved GP quality. For instance, higher quality GPs could have both a greater share of patients with chronic diseases and lower disenrollment rates.
Methods
Data on 384,947 chronic patients and 3,974 GPs for the years 2009–2011 were obtained from national registers, including patient and GP characteristics, disenrollment data, and patient list composition. The birth cohorts from 1940 and 1970 (146,906 patients) were included for comparison. Patient and GP characteristics, comorbidity, and patient list composition were analyzed using descriptive statistics. Patients’ voluntary disenrollment was analyzed using logistic regression models.
Results
The GPs’ proportion of patients with a given chronic disease varied more than expected when the allocation was purely random. The proportions of patients with different chronic diseases were positively correlated, partly due to comorbidity. Patients tended to have lower disenrollment rates from GPs who had higher shares of patients with the same chronic disease. Disenrollment rates were generally lower from GPs with higher shares of patients with arthritis or depression, and higher from GPs who had higher shares of patients with diabetes type 1 and schizophrenia. This was the same in the comparison group.
Conclusion
Patients with a chronic disease appeared to prefer GPs who have higher shares of patients with the same disease. High shares of patients with some diseases were also negatively associated with disenrollment for all patient groups, while other diseases were positively associated. These findings may reflect the GPs’ general quality, but could alternatively result from the GPs’ specialization in particular diseases. The supportive findings for the comparison group make it more plausible that high shares of chronic patients could indicate GP quality.
doi:10.1186/s12875-016-0571-3
PMCID: PMC5159957  PMID: 27978811
Chronic patients; Switching; Primary health care; Schizophrenia; Epilepsy; Diabetes type 1; Diabetes type 2; Asthma; Arthritis; Depression
5.  The clinically excellent primary care physician: examples from the published literature 
BMC Family Practice  2016;17:169.
Clinical excellence is the ultimate goal in patient care. Exactly what the clinically excellent primary care physician (PCP) looks like and her characteristics have not been explicitly described. This manuscript serves to illustrate clinical excellence in primary care, using primarily case reports exemplifying physicians delivering holistic and patient-centred care to their patients. With an ever increasing demand for accessible and accountable health care, an understanding of the qualities desirable in primary care providers is now especially relevant.
A literature review was conducted to identify compelling stories showing how excellent PCPs care for their patients. In the 2397 published works reviewed, we were able to find case reports and studies that exemplified every domain of the description of clinical excellence proposed and published by the Miller Coulson Academy of Clinical Excellence (MCACE). After reviewing these reports, the authors felt that the domains of excellence, as described by the MCACE, are practically applicable and relevant for primary care physicians. It is our hope that this paper prompts readers to reflect on clinical excellence in primary care.
doi:10.1186/s12875-016-0569-x
PMCID: PMC5153856  PMID: 27964709
Clinical excellence; Primary care
6.  Relations between task delegation and job satisfaction in general practice: a systematic literature review 
BMC Family Practice  2016;17:168.
Background
It has for years been discussed whether practice staff should be involved in patient care in general practice to a higher extent. The research concerning task delegation within general practice is generally increasing, but the literature focusing on its influence on general practitioners' and their staff’s job satisfaction appears to be sparse even though job satisfaction is acknowledged as an important factor associated with both patient satisfaction and medical quality of care. Therefore, the overall aim of this study was 1) to review the current research on the relation between task delegation and general practitioners' and their staff’s job satisfaction and, additionally, 2) to review the evidence of possible explanations for this relation.
Methods
A systematic literature review. We searched the four databases PubMed, Cinahl, Embase, and Scopus systematically. The immediate relevance of the retrieved articles was evaluated by title and abstract by the first author, and papers that seemed to meet the aim of the review were then fully read by first author and last author independently judging the eligibility of content.
Results
We included four studies in the review. They explored views and attitudes of the staff, encompassing nurses as well as practice managers. Only one of the included studies also explored general practitioners' views and attitudes, hence making it impossible to establish any syntheses on this relation. According to the studies, the staff’s overall attitude towards task delegation was positive and led to increased job satisfaction, probably because task delegation comprised a high degree of work autonomy.
Conclusions
The few studies included in our review suggest that task delegation within general practice may be seen by the staff as an overall positive issue contributing to their job satisfaction, primarily due to perceived autonomy in the work. However, because of the small sample size comprising only qualitative studies, and due to the heterogeneity of these studies, we cannot draw unambiguous conclusions although we point towards tendencies.
doi:10.1186/s12875-016-0565-1
PMCID: PMC5129662  PMID: 27899090
Task delegation; Job satisfaction; General practice; Nurse’s role; Systematic review
7.  Long term condition morbidity in English general practice: a cross-sectional study using three composite morbidity measures 
BMC Family Practice  2016;17:166.
Background
The burden of morbidity represented by patients with long term conditions (LTCs) varies substantially between general practices. This study aimed to determine the characteristics of general practices with high morbidity burden.
Method
Retrospective cross-sectional study; general practices in England, 2014/15. Three composite morbidity measures (MMs) were constructed to quantify LTC morbidity at practice level: a count of LTCs derived from the 20 LTCs included in the UK Quality and Outcomes Framework (QOF) disease registers, expressed as ‘number of QOF LTCs per 100 registered patients’; the % of patients with one or more QOF LTCs; the % of patients with one or more of 15 broadly defined LTCs included in the GP Patient Survey (GPPS). Determinants of MM scores were analysed using multi-level regression models. Analysis was based on a national dataset of English general practices (n = 7779 practices); GPPS responses (n = 903,357); general practice characteristics (e.g. list size, list size per full time GP); patient demographic characteristics (age, deprivation status); secondary care utilisation (out-patient, emergency department, emergency admission rates).
Results
Mean MM scores (95% CIs) were: 57.7 (±22.3) QOF LTCs per 100 registered patients; 22.8% (±8.2) patients with a QOF LTC; 63.5% (±11.7) patients with a GPPS LTC. The proportion of elderly patients and social deprivation scores were the strongest predictors of each MM score; scores were largely independent of practice characteristics. MM scores were positive predictors of secondary care utilization and negative predictors’ access, continuity of care and overall satisfaction.
Conclusions
Wide variation in LTC morbidity burden was observed across English general practice. Variation was determined by demographic factors rather than practice characteristics. Higher rates of secondary care utilisation in practices with higher morbidity burden have implications for resource allocation and commissioning budgets; lower reported satisfaction in these practices suggests that practices may struggle with increased workload. There is a need for a readily available metric to define the burden of morbidity and multimorbidity in general practice.
doi:10.1186/s12875-016-0563-3
PMCID: PMC5127084  PMID: 27894265
Primary care; Long term conditions; Multimorbidity; Patient experience; Secondary care utilisation
8.  Having a usual source of care and its associated factors in Korean adults: a cross-sectional study of the 2012 Korea Health Panel Survey 
BMC Family Practice  2016;17:167.
Background
Usual source of care (USC) is one of the hallmarks of primary care. We aimed to examine the status of having a USC and its patient-related sociodemographic factors among Korean adults.
Methods
Data were obtained from the 2012 Korea Health Panel survey. Panel participants were selected for the study who were aged 18 years or older and who replied to questionnaire items on having a USC (n = 11,935).
Results
Of the participants, 21.5% had a usual place and 13.9% had a usual physician. Reasons for not having a USC were seldom being ill (66.1%), the preference to visit multiple medical institutions (27.9%), and others. The private community clinic was the most common type of usual place (57.0%). In patient-reported attributes of care provided by a usual physician, the percentages of positive responses for comprehensiveness and coordination were 67.2% and 34.5%, respectively. By institution type, primary care clinics showed the lowest percentage (32.8%) of positive responses for coordination. Adjusted odds ratios of having a usual physician were 3.77 (95% confidence interval, CI: 3.75–3.79) for those aged 65 years or older (vs. aged 18–34 years), 1.31 (CI: 1.30–1.31) for females (vs. males), 0.72 (CI: 0.72–0.73) for unmarried people (vs. married), 1.16 (CI: 1.16–1.16) for college graduates or higher (vs. elementary school graduate or less), 0.64 for the fifth quintile (vs. the first quintile) by household income, 1.53 (CI: 1.52–1.54) for Medical Aid (vs. employee health insurance) for type of health insurance, and 4.09 (CI: 4.08–4.10) for presence (vs. absence) of a chronic diseases.
Conclusions
The proportion of Korean adults who have a USC is extremely low, the most influential factor of having a USC is having a chronic disease or not, and Korean patients experience much poorer health care coordination than do patients in other industrialized countries. The findings of this study will give insight to researchers and policy makers regarding the potential facilitators of and barriers to promoting having a USC in the general Korean public.
doi:10.1186/s12875-016-0555-3
PMCID: PMC5129206  PMID: 27899071
Primary health care; Surveys and questionnaires; Health policy; Korea
9.  Impact of financial incentives on alcohol intervention delivery in primary care: a mixed-methods study 
BMC Family Practice  2016;17:165.
Background
Local and national financial incentives were introduced in England between 2008 and 2015 to encourage screening and brief alcohol intervention delivery in primary care. We used routine Read Code data and interviews with General Practitioners (GPs) to assess their impact.
Methods
A sequential explanatory mixed-methods study was conducted in 16 general practices representing 106,700 patients and 99 GPs across two areas in Northern England. Data were extracted on screening and brief alcohol intervention delivery for 2010-11 and rates were calculated by practice incentive status. Semi-structured interviews with 14 GPs explored which factors influence intervention delivery and recording in routine consultations.
Results
Screening and brief alcohol intervention rates were higher in financially incentivised compared to non-incentivised practices. However absolute rates were low across all practices. Rates of short screening test administration ranged from 0.05% (95% CI: 0.03-0.08) in non-incentivised practices to 3.92% (95% CI: 3.70-4.14) in nationally incentivised practices. For the full AUDIT, rates were also highest in nationally incentivised practices (3.68%, 95% CI: 3.47-3.90) and lowest in non-incentivised practices (0.17%, 95% CI: 0.13-0.22). Delivery of alcohol interventions was highest in practices signed up to the national incentive scheme (9.23%, 95% CI: 8.91-9.57) and lowest in non-incentivised practices (4.73%, 95% CI: 4.50-4.96). GP Interviews highlighted a range of influences on alcohol intervention delivery and subsequent recording including: the hierarchy of different financial incentive schemes; mixed belief in the efficacy of alcohol interventions; the difficulty of codifying complex conditions; and GPs’ beliefs about patient-centred practice.
Conclusions
Financial incentives have had some success in encouraging screening and brief alcohol interventions in England, but levels of recorded activity remain low. To improve performance, future policies must prioritise alcohol prevention work within the quality and outcomes framework, and address the values, attitudes and beliefs that shape how GPs’ provide care.
Electronic supplementary material
The online version of this article (doi:10.1186/s12875-016-0561-5) contains supplementary material, which is available to authorized users.
doi:10.1186/s12875-016-0561-5
PMCID: PMC5124277  PMID: 27887577
Alcohol drinking; Screening; Brief intervention; Pay for performance; Primary health care; Mixed methods
10.  Do primary care professionals agree about progress with implementation of primary care teams: results from a cross sectional study 
BMC Family Practice  2016;17:163.
Background
Primary care is the cornerstone of healthcare reform with policies across jurisdictions promoting interdisciplinary team working. The effective implementation of such health policies requires understanding the perspectives of all actors. However, there is a lack of research about health professionals’ views of this process. This study compares Primary Healthcare Professionals’ perceptions of the effectiveness of the Primary Care Strategy and Primary Care Team (PCT) implementation in Ireland.
Methods
Design and Setting: e-survey of (1) General Practitioners (GPs) associated with a Graduate Medical School (N = 100) and (2) Primary Care Professionals in 3 of 4 Health Service Executive (HSE) regions (N = 2309). After piloting, snowball sampling was used to administer the survey. Descriptive analysis was carried out using SPSS. Ratings across groups were compared using non-parametric tests.
Results
There were 569 responses. Response rates varied across disciplines (71 % for GPs, 22 % for other Primary Healthcare Professionals (PCPs). Respondents across all disciplines viewed interdisciplinary working as important. Respondents agreed on lack of progress of implementation of formal PCTs (median rating of 2, where 1 is no progress at all and 5 is complete implementation). GPs were more negative about the effectiveness of the Strategy to promote different disciplines to work together (median rating of 2 compared to 3 for clinical therapists and 3.5 for nurses, P = 0.001). Respondents identified resources and GP participation as most important for effective team working. Protected time for meetings and capacity to manage workload for meetings were rated as very important factors for effective team working by GPs, clinical therapists and nurses. A building for co-location of teams was rated as an important factor by nurses and clinical therapists though GPs rated it as less important. Payment to attend meetings and contractual arrangements were considered important factors by GPs but not by nurses or clinical therapists.
Conclusion
PCPs and GPs agree there is limited PCT implementation. GPs are most negative about this implementation. There is some disagreement about which resources are most important for effective PCT working. These findings provide valuable data for clinicians and policy makers about implementation of interdisciplinary teams in primary care.
Electronic supplementary material
The online version of this article (doi:10.1186/s12875-016-0541-9) contains supplementary material, which is available to authorized users.
doi:10.1186/s12875-016-0541-9
PMCID: PMC5120534  PMID: 27875994
Policy implementation, Health care surveys, Primary health care; Patient care team, General practice, Interdisciplinary teams, Health policy
11.  Lesbian womens’ access to healthcare, experiences with and expectations towards GPs in German primary care 
BMC Family Practice  2016;17:162.
Background
Lesbian women have higher rates of physical and psychiatric disorders associated with experiences of discrimination, homophobia and difficulties with coming out. Therefore, easy access to specialized healthcare in an open atmosphere is needed. We aimed to describe women’s access to and experiences with healthcare in Germany, and to assess the responsibility of the general practitioner (GP) compared to other specialities providing primary health care.
Methods
A questionnaire study was conducted via internet and paper-based sampling. Using current literature, we designed a questionnaire consisting of sociodemographic data, sexual orientation, access to care and reasons for encounter, disclosure of sexual orientation, experience with the German health system (discrimination, homophobia), and psychological burden. Depression was assessed using the depression screening from the Patient Health Questionnaire (PHQ-2).
Results
We obtained responses from 766 lesbian women. Although 89% had a primary care physician, only 40% had revealed their sexual orientation to their doctor. The main medical contacts were GPs (66%), gynaecologists (10%) or psychiatrists (6%). Twenty-three percent claimed they were unable to find a primary care physician. Another 12.4% had experienced discrimination. Younger lesbian women with higher education levels and who were less likely to be out to other physicians were more likely to disclose their sexual orientation to their primary care physician. GPs play an important role in healthcare for lesbian women, even in a non-gatekeeping healthcare system like Germany. Study participants suggested improvements regarding gender neutral language, flyers on homosexuality in waiting areas, involvement of partners, training of physicians, directories of homosexual physicians and labelling as a lesbian-friendly practice.
Conclusions
GPs should create an open atmosphere and acquire the respective knowledge to provide adequate treatment. Caring for marginal groups should be incorporated in medical training and further education. Ideally, physicians address patients’ sexual orientation pro-actively in order to address individual needs accordingly.
Electronic supplementary material
The online version of this article (doi:10.1186/s12875-016-0562-4) contains supplementary material, which is available to authorized users.
doi:10.1186/s12875-016-0562-4
PMCID: PMC5117504  PMID: 27871239
Female homosexuality; Health surveys; Internet; Questionnaires; Primary health care
12.  The need to scale up HIV indicator condition-guided testing for early case-finding: a case-control study in primary care 
BMC Family Practice  2016;17:161.
Background
European guidelines recommend offering an HIV test to individuals who display HIV indicator conditions (ICs). We aimed to investigate the incidence of ICs in primary care reported in medical records prior to HIV diagnosis.
Methods
We did a cross-sectional search in an electronic general practice database using a matched case-control design to identify which predefined ICs registered by Dutch GPs were most associated with an HIV-positive status prior to the time of diagnosis.
Results
We included 224 HIV cases diagnosed from 2009 to 2013, which were matched with 2,193 controls. Almost two thirds (n = 136, 60.7%) of cases were diagnosed with one or more ICs in the period up to five years prior to the index date compared to 18.7% (n = 411) of controls. Cases were more likely to have an IC than controls: in the one year prior to the index date, the odds ratio (OR) for at least one condition was 11.7 (95% CI: 8.3 to 16.4). No significant differences were seen in the strength of the association between HIV diagnosis and ICs when comparing genders, age groups or urbanisation levels. There is no indication that subgroups require a different testing strategy.
Conclusions
Our study shows that there are opportunities for IC-guided testing in primary care. We recommend that IC-guided testing be more integrated in GPs’ future guidelines and that education strategies be used to facilitate its implementation in daily practice.
Electronic supplementary material
The online version of this article (doi:10.1186/s12875-016-0556-2) contains supplementary material, which is available to authorized users.
doi:10.1186/s12875-016-0556-2
PMCID: PMC5114759  PMID: 27855639
Case-control studies; General practice; HIV infections/prevention & control; HIV infections/epidemiology; Primary healthcare
13.  Non-coronary chest pain does not affect long-term mortality: a prospective, observational study using a matched population control 
BMC Family Practice  2016;17:159.
Background
Chest pain assumed to be of non-coronary origin (NCCP) may be linked to enhanced mortality due to coronary heart disease (CHD). The aim of this study was to follow NCCP patients, as defined in primary care, with respect to mortality and long-term morbidity of CHD. We further examined if NCCP associates with risk factors for CHD.
Methods
Patients consulting general practitioners (GPs) in 1998–2000 in three primary care centers in the southeast Sweden for chest pain regarded as NCCP were compared with controls matched for age, gender and residential area. Causes of death were gathered from registry data and death certificates. In 2005 a postal questionnaire was distributed to the survivors to collect demographic and clinical data. If participants had CHD diagnosed by a physician prior to inclusion they were excluded.
Results
Patients with NCCP (n = 382) and population controls (n = 746) did not differ with respect to mortality and incidence of CHD. The NCCP group reported more ongoing chest pain (OR 3.34 95 % CI 2.41–4.62), they more often had elevated blood pressure (OR 1.86 95 % CI 1.32–2.60), consumed more β-blockers (p < 0.001), aspirin (p = 0.013), thiazides (p = 0.004) and long-acting nitrates (p = 0.002). They further had more remedies for acid-related disorders (p = 0.014) and obstructive pulmonary disease (p < 0.001).
Conclusions
The study suggests that individuals with chest pain judged by GPs to be NCCP do not develop CHD more frequently than population controls. It is evident that NCCP often lasts for many years and that the condition associates with hypertension.
doi:10.1186/s12875-016-0559-z
PMCID: PMC5112656  PMID: 27852221
Coronary heart disease; Hypertension; Mortality; Non-coronary chest pain; Primary health care
14.  Identification of priorities for improvement of medication safety in primary care: a PRIORITIZE study 
BMC Family Practice  2016;17:160.
Background
Medication error is a frequent, harmful and costly patient safety incident. Research to date has mostly focused on medication errors in hospitals. In this study, we aimed to identify the main causes of, and solutions to, medication error in primary care.
Methods
We used a novel priority-setting method for identifying and ranking patient safety problems and solutions called PRIORITIZE. We invited 500 North West London primary care clinicians to complete an open-ended questionnaire to identify three main problems and solutions relating to medication error in primary care. 113 clinicians submitted responses, which we thematically synthesized into a composite list of 48 distinct problems and 45 solutions. A group of 57 clinicians randomly selected from the initial cohort scored these and an overall ranking was derived. The agreement between the clinicians’ scores was presented using the average expert agreement (AEA). The study was conducted between September 2013 and November 2014.
Results
The top three problems were incomplete reconciliation of medication during patient ‘hand-overs’, inadequate patient education about their medication use and poor discharge summaries. The highest ranked solutions included development of a standardized discharge summary template, reduction of unnecessary prescribing, and minimisation of polypharmacy. Overall, better communication between the healthcare provider and patient, quality assurance approaches during medication prescribing and monitoring, and patient education on how to use their medication were considered the top priorities. The highest ranked suggestions received the strongest agreement among the clinicians, i.e. the highest AEA score.
Conclusions
Clinicians identified a range of suggestions for better medication management, quality assurance procedures and patient education. According to clinicians, medication errors can be largely prevented with feasible and affordable interventions. PRIORITIZE is a new, convenient, systematic, and replicable method, and merits further exploration with a view to becoming a part of a routine preventative patient safety monitoring mechanism.
Electronic supplementary material
The online version of this article (doi:10.1186/s12875-016-0552-6) contains supplementary material, which is available to authorized users.
doi:10.1186/s12875-016-0552-6
PMCID: PMC5112691  PMID: 27852240
Medication error; Patient safety; Priority-setting; Crowd-sourcing; Primary care; Clinicians
15.  Developing cultural competence in general practitioners: an integrative review of the literature 
BMC Family Practice  2016;17:158.
Background
Cultural competence is a broad concept with multiple theoretical underpinnings and conflicting opinions on how it should be materialized. While it is recognized that cultural competence should be an integral part of General Practice, literature in the context of General Practice is limited.
The aim of this article is to provide a comprehensive summary of the current literature with respect to the following: the elements of cultural competency that need to be fostered and developed in GPs and GP registrars; how is cultural competence being developed in General Practice currently; and who facilitates the development of cultural competence in General Practice.
Methods
We conducted an integrative review comprising a systematic literature search followed by a synthesis of the results using a narrative synthesis technique.
Results
Fifty articles were included in the final analysis. Cultural competence was conceptualized as requiring elements of knowledge, awareness/attitudes and skills/behaviours by most articles. The ways in which elements of cultural competence were developed in General Practice appeared to be highly varied and rigorous evaluation was generally lacking, particularly with respect to improvement in patient outcomes. Formal cultural competence training in General Practice appeared to be underdeveloped despite GP registrars generally desiring more training. The development of most aspects of cultural competence relied on informal learning and in-practice exposure but this required proper guidance and facilitation by supervisors and educators. Levels of critical and cultural self-reflection amongst General Practitioners and GP registrars varied and were potentially underdeveloped. Most standalone training workshops were led by trained medical educators however the value of cultural mentors was recognised by patients, educators and GP registrars across many studies.
Conclusions
Cultural competency development of GP registrars should receive more focus, particularly training in non-conscious bias, anti-racism training and critical self-reflectiveness. There is a need for further exploration of how cultural competence training is delivered within the GP training model, including clarifying the supervisor’s role.
It is hoped this discussion will inform future research and training practices in order to achieve quality and respectful care to patients across cultures, and to remove health inequities that exist between cultural groups.
doi:10.1186/s12875-016-0560-6
PMCID: PMC5111200  PMID: 27846805
Cultural competency; Cultural competency education; Graduate medical education; General practice
16.  Effectiveness of the EMPOWER-PAR Intervention in Improving Clinical Outcomes of Type 2 Diabetes Mellitus in Primary Care: A Pragmatic Cluster Randomised Controlled Trial 
BMC Family Practice  2016;17:157.
Background
The chronic care model was proven effective in improving clinical outcomes of diabetes in developed countries. However, evidence in developing countries is scarce. The objective of this study was to evaluate the effectiveness of EMPOWER-PAR intervention (based on the chronic care model) in improving clinical outcomes for type 2 diabetes mellitus using readily available resources in the Malaysian public primary care setting.
Methods
This was a pragmatic, cluster-randomised, parallel, matched pair, controlled trial using participatory action research approach, conducted in 10 public primary care clinics in Malaysia. Five clinics were randomly selected to provide the EMPOWER-PAR intervention for 1 year and another five clinics continued with usual care. Patients who fulfilled the criteria were recruited over a 2-week period by each clinic. The obligatory intervention components were designed based on four elements of the chronic care model i.e. healthcare organisation, delivery system design, self-management support and decision support. The primary outcome was the change in the proportion of patients achieving HbA1c < 6.5%. Secondary outcomes were the change in proportion of patients achieving targets for blood pressure, lipid profile, body mass index and waist circumference. Intention to treat analysis was performed for all outcome measures. A generalised estimating equation method was used to account for baseline differences and clustering effect.
Results
A total of 888 type 2 diabetes mellitus patients were recruited at baseline (intervention: 471 vs. control: 417). At 1-year, 96.6 and 97.8% of patients in the intervention and control groups completed the study, respectively. The baseline demographic and clinical characteristics of both groups were comparable. The change in the proportion of patients achieving HbA1c target was significantly higher in the intervention compared to the control group (intervention: 3.0% vs. control: −4.1%, P < 0.002). Patients who received the EMPOWER-PAR intervention were twice more likely to achieve HbA1c target compared to those in the control group (adjusted OR 2.16, 95% CI 1.34–3.50, P < 0.002). However, there was no significant improvement found in the secondary outcomes.
Conclusions
This study demonstrates that the EMPOWER-PAR intervention was effective in improving the primary outcome for type 2 diabetes in the Malaysian public primary care setting.
Trial registration
Registered with: ClinicalTrials.gov.: NCT01545401. Date of registration: 1st March 2012. 
Electronic supplementary material
The online version of this article (doi:10.1186/s12875-016-0557-1) contains supplementary material, which is available to authorized users.
doi:10.1186/s12875-016-0557-1
PMCID: PMC5109682  PMID: 27842495
Type 2 diabetes mellitus; Chronic disease management; Chronic care model; Multifaceted intervention; Clinical outcomes; Primary care; Family medicine
17.  More primary care patients regret health decisions if they experienced decisional conflict in the consultation: a secondary analysis of a multicenter descriptive study 
BMC Family Practice  2016;17:156.
Background
We sought to estimate the extent of decision regret among primary care patients and identify risk factors associated with regret.
Methods
Secondary analysis of an observational descriptive study conducted in two Canadian provinces. Unique patient-physician dyads were recruited from 17 primary care clinics and data on patient, physician and consultation characteristics were collected before, during and immediately after consultations, as well as two weeks post-consultation, when patients completed the Decision Regret Scale (DRS). We examined the DRS score distribution and performed ordinal logistic regression analysis to identify predictors of regret.
Results
Among 258 unique patient-physicians dyads, mean ± standard deviation of decision regret scores was 11.7 ± 15.1 out of 100. Overall, 43 % of patients reported no regret, 45 % reported mild regret and 12 % reported moderate to strong regret. In multivariate analyses, higher decision regret was strongly associated with increased decisional conflict and less significantly associated with patient age and education, as well with male (vs. female) physicians and residents (vs. teachers).
Conclusion
After consulting family physicians, most primary care patients experience little decision regret, but some experience more regret if there is decisional conflict. Strategies for reducing decisional conflict in primary care, such as shared decision-making with decision aids, seem warranted.
doi:10.1186/s12875-016-0558-0
PMCID: PMC5103443  PMID: 27832752
Decision regret; Decisional conflict; Shared decision-making; Primary care; Dyads; Risk factors
18.  Ill and substance-abusing parents: how can the general practitioner help their children? A qualitative study 
BMC Family Practice  2016;17:154.
Background
Severe illness among parents may interfere with their parenting. Children having ill or substance-abusing parents are at risk of own health problems and psychosocial difficulties. The health care system should identify families in need of help and provide the help needed. For ill parents, it can be difficult to seek help and advices for their parenting. The aim of this study was to identify important factors for the general practitioner (GP) to bear in mind during encounters with ill and substance-abusing parents, to enable the GP to provide appropriate support for the children.
Method
A qualitative approach was chosen and the data material was semi-structured individual interviews with 12 parents with mental illness, substance abuse or severe somatic illness. The participants were recruited through GPs in Norway, and the interviews were performed in 2014. We used systematic text condensation for analysis.
Results
It was important for the participants that the GP was oriented about their family and children’s situation. They wanted to be regarded as competent parents in ordinary families; however, they were aware that their illness affected their parenting. They expressed a need for advice about how to inform the children of their illness and talk to them about their challenges, and, if necessary, utilize helpers who could inform the children and talk to them directly. There were often many agencies involved, and it was important that the helpers cooperated and shared information. In addition, the parents were in need of information about support services.
Conclusion
Ill parents in this study conveyed a double message to their helpers. They wanted to be considered as responsible and well-intended parents who wished the best for their children. At the same time they needed support in parenting. The GP should take the time to listen to the parents’ first spontaneous description about an ordinary daily life (while realising that it may not necessarily be an accurate report), then explore their worries and needs of support.
doi:10.1186/s12875-016-0553-5
PMCID: PMC5100102  PMID: 27821069
General Practice; Family health; Parenting; Child of impaired parent; Qualitative research
19.  A screening protocol for child abuse at out-of-hours primary care locations: a descriptive study 
BMC Family Practice  2016;17:155.
Background
Child abuse is often unrecognized at out-of-hours primary care (OOH-PC) services. The aim of our study was to evaluate the clinical outcome of the screening instrument SPUTOVAMO-R2 for child abuse (checklist), followed by a structured approach (reporting code), at OOH-PC services. The reporting code with five steps should ensure consistent action in case of a suspicion.
Methods
All children attending one of the five participating OOH-PC services in the region of Utrecht, the Netherlands, in a year time, were included. The checklist is an obligatory field in the electronic patient file and was filled in for all children. In case of a positive checklist, the steps in the reporting code were followed. Additionally, the case was evaluated in a multidisciplinary team to determine the probability of child abuse.
Results
The checklist was filled in for 50671 children; 108 (0.2 %) were positive. The multidisciplinary team diagnosed child abuse in 24 (22 %) of the 108 positive checklists, and no child abuse in 36 (33 %). Emotional neglect was the most frequent type of abuse diagnosed. For all abused children, care was implemented according to the protocol. The most frequent care given was a referral to the hospital (N = 7) or contact with child’s own general practitioner (N = 6).
Conclusion
A checklist followed by a reporting code guarantees consistent actions and care for children with a suspicion of child abuse. The percentage of positive checklists is lower than expected. Validity of the checklist should be assessed in a diagnostic study.
Electronic supplementary material
The online version of this article (doi:10.1186/s12875-016-0554-4) contains supplementary material, which is available to authorized users.
doi:10.1186/s12875-016-0554-4
PMCID: PMC5101665  PMID: 27825297
Child abuse; Mass screening; Primary health care
20.  Factors influencing deprescribing for residents in Advanced Care Facilities: insights from General Practitioners in Australia and Sweden 
BMC Family Practice  2016;17:152.
Background
General Practitioners (GPs) are responsible for primary prescribing decisions in most settings. Elderly patients living in Advanced Care Facilities (ACFs) often have significant co-morbidities to consider when selecting an appropriate drug therapy. Careful assessment is required when considering appropriate medication use in frail older patients as they have multiple diseases and thus multiple medication. Many physicians seem reluctant to discontinue other physicians’ prescriptions, resulting in further polypharmacy. Therefore it is relevant to ascertain and synthesise the GP views from multiple settings to understand the processes that might promote appropriate deprescribing medications in the elderly.
The aims of this study were to 1) compare and contrast behavioural factors influencing the deprescribing practices of GPs providing care for ACF residents in two separate countries, 2) review health policy and ACF systems in each setting for their potential impact on the prescribing of medications for an older person in residential care of the elderly, and 3) based on these findings, provide recommendations for future ACF deprescribing initiatives.
Methods
A review and critical synthesis of qualitative data from two interview studies of knowledge, attitudes, and behavioural practices held by GPs towards medication management and deprescribing for residents of ACFs in Australia and Sweden was conducted.
A review of policies and health care infrastructure was also carried out to describe the system of residential aged care in the both countries.
Results
Our study has identified that deprescribing by GPs in ACFs is a complex process and that there are numerous barriers to medication reduction for aged care residents in both countries, both with similarities and differences. The factors affecting deprescribing behaviour were identified and divided into: intentions, skills and abilities and environmental factors.
Conclusions
In this study we show that the GPs’ behaviour of deprescribing in two different countries is much dependent on the larger health care system. There is a need for more education to both GPs and ACF staff as well as better cooperation between the different health care systems and appropriate monetary incentives for elderly care to achieve better conditions for deprescribing practice.
doi:10.1186/s12875-016-0551-7
PMCID: PMC5097406  PMID: 27814691
Deprescribing practice; General Practitioners; Polypharmacy; Ageing; Advanced Care Facilities; Nursing homes
21.  Feasibility of alcohol screening among patients receiving opioid treatment in primary care 
BMC Family Practice  2016;17:153.
Background
Identifying and treating problem alcohol use among people who also use illicit drugs is a challenge. Primary care is well placed to address this challenge but there are several barriers which may prevent this occurring. The objective of this study was to determine if a complex intervention designed to support screening and brief intervention for problem alcohol use among people receiving opioid agonist treatment is feasible and acceptable to healthcare providers and their patients in a primary care setting.
Methods
A randomised, controlled, pre-and-post design measured feasibility and acceptability of alcohol screening based on recruitment and retention rates among patients and practices. Efficacy was measured by screening and brief intervention rates and the proportion of patients with problem alcohol use.
Results
Of 149 practices that were invited, 19 (12.8 %) agreed to participate. At follow up, 13 (81.3 %) practices with 81 (62.8 %) patients were retained. Alcohol screening rates in the intervention group were higher at follow up than in the control group (53 % versus 26 %) as were brief intervention rates (47 % versus 19 %). Four (18 %) people reduced their problem drinking (measured by AUDIT-C), compared to two (7 %) in the control group.
Conclusions
Alcohol screening among people receiving opioid agonist treatment in primary care seems feasible. A definitive trial is needed. Such a trial would require over sampling and greater support for participating practices to allow for challenges in recruitment of patients and practices.
Electronic supplementary material
The online version of this article (doi:10.1186/s12875-016-0548-2) contains supplementary material, which is available to authorized users.
doi:10.1186/s12875-016-0548-2
PMCID: PMC5097838  PMID: 27816057
Alcohol; Primary care; Screening; Agonist treatment; Methadone; General practice; Implementation; Feasibility; Brief intervention; SBIRT
22.  Quality of primary health care in Poland from the perspective of the physicians providing it 
BMC Family Practice  2016;17:151.
Background
Primary care (PC) allows patients to address most of their health needs and is essential for high quality healthcare systems. The aim of the study was to analyze the insight of nine core dimensions of Polish PC system: “Economic conditions”, “Workforce”, “Accessibility”, “Comprehensiveness”, “Continuity”, “Coordination”, “Quality of care”, “Efficiency” and “Equity” and to identify the characteristics of the providing physicians that influence their perception of the quality of care.
Methods
A cross-sectional study was conducted as part of an international QUALICOPC project. In Poland a nationally representative sample of 220 PC physicians was selected from the database of Polish National Health Fund by a stratified random sampling procedure. The research tool was a standardized 64-item questionnaire. Each of the respondents’ answers were assigned a numerical value ranging from−1 (extremely negative) to +1 (extremely positive). The quality indicators were calculated as an arithmetic mean of variables representing particular PC dimensions.
Results
The mean scores for the majority of the dimensions had negative values. Accessibility of care was perceived as the best dimension, while the economic conditions were evaluated most negatively. Only a small part of variation in quality evaluation could be explained by physicians’ characteristics.
Conclusions
The negative evaluation of primary care reflects the growing crisis in the health care system in Poland. There is an urgent need to apply complex recovery measures to improve the quality of primary care.
Electronic supplementary material
The online version of this article (doi:10.1186/s12875-016-0550-8) contains supplementary material, which is available to authorized users.
doi:10.1186/s12875-016-0550-8
PMCID: PMC5096289  PMID: 27809809
Primary care; General practice; Quality of care; Health policy; Health services research
23.  Exploring the barriers and facilitators to use of point of care tests in family medicine clinics in the United States 
BMC Family Practice  2016;17:149.
Background
Point-of-care tests (POCTs) are increasingly used in family medicine clinics in the United States. While the diagnostics industry predicts significant growth in the number and scope of POCTs deployed, little is known about clinic-level attitudes towards implementation of these tests. We aimed to explore attitudes of primary care providers, laboratory and clinic administrative/support staff to identify barriers and facilitators to use of POCTs in family medicine.
Methods
Seven focus groups and four semi-structured interviews were conducted with a total of 52 clinic staff from three family medicine clinics in two US states. Qualitative data from this exploratory study was analyzed using the constant comparison method.
Results
Five themes were identified which included the impact of POCTs on clinical decision-making; perceived inaccuracy of POCTs; impact of POCTs on staff and workflow; perceived patient experience and patient-provider relationship, and issues related to cost, regulation and quality control. Overall, there were mixed attitudes towards use of POCTs. Participants believed the added data provided by POCT may facilitate prompt clinical management, diagnostic certainty and patient-provider communication.
Perceived barriers included inaccuracy of POCT, shortage of clinic staff to support more testing, and uncertainty about their cost-effectiveness.
Conclusions
The potential benefits of using POCTs in family medicine clinics are countered by several barriers. Clinical utility of many POCTs will depend on the extent to which these barriers are addressed. Engagement between clinical researchers, industry, health insurers and the primary care community is important to ensure that POCTs align with clinic and patient needs.
Electronic supplementary material
The online version of this article (doi:10.1186/s12875-016-0549-1) contains supplementary material, which is available to authorized users.
doi:10.1186/s12875-016-0549-1
PMCID: PMC5093922  PMID: 27809865
Point-of-care tests; Near patient testing; Family medicine; Infections
24.  The burden of cardiovascular morbidity in a European Mediterranean population with multimorbidity: a cross-sectional study 
BMC Family Practice  2016;17:150.
Background
Cardiovascular diseases are highly represented in multimorbidity patterns. Nevertheless, few studies have analysed the burden of these diseases in the population with multimorbidity. The objective of this study was to identify and describe the cardiovascular diseases among the patients with multimorbidity.
Methods
We designed a cross-sectional study in patients ≥19 years old assigned to 251 primary health care centres in Catalonia, Spain. The main outcome was cardiovascular morbidity burden, defined as the presence of one or more of 24 chronic cardiovascular diseases in multimorbid patients (≥2 chronic conditions). Two groups were defined, with and without multimorbidity; the multimorbidity group was further divided into cardiovascular and non-cardiovascular subgroups. The secondary outcomes were: modifiable major cardiovascular risk factors (smoking, hypertension, hypercholesterolaemia, diabetes) and cardiovascular risk score (REGICOR, Registre Gironí del Cor). Other variables analysed were: sex, age (19–24, 25–44, 45–64, 65–79, and 80+ years), number of chronic diseases, urban setting, active toxic habits (smoking and alcohol), physical parameters and laboratory tests.
Results
A total of 1,749,710 individuals were included (mean age, 47.4 years [SD: 17.8]; 50.7 % women), of which nearly half (46.8 %) had multimorbidity (95 % CI: 46.9–47.1). In patients with multimorbidity,, the cardiovascular burden was 54.1 % of morbidity (95 % CI: 54.0–54.2) and the four most prevalent cardiovascular diseases were uncomplicated hypertension (75.3 %), varicose veins of leg (20.6 %), “other” heart disease (10.5 %) and atrial fibrillation/flutter (6.7 %). In the cardiovascular morbidity subgroup, 38.2 % had more than one cardiovascular disease. The most prevalent duet and triplet combinations were uncomplicated hypertension & lipid disorder (38.8 %) and uncomplicated hypertension & lipid disorder & non-insulin dependent diabetes (11.3 %), respectively. By age groups, the same duet was the most prevalent in patients aged 45–80 years and in men aged 25–44 years. In women aged 19–44, varicose veins of leg & anxiety disorder/anxiety was the most prevalent; in men aged 19–24, it was uncomplicated hypertension & obesity. Patients with multimorbidity showed a higher cardiovascular risk profile than the non-multimorbidity group.
Conclusions
More than 50 % percent of patients with multimorbidity had cardiovascular diseases, the most frequent being hypertension. The presence of cardiovascular risk factors and the cardiovascular risk profile were higher in the multimorbidity group than the non-multimorbidity group. Hypertension, diabetes and dyslipidaemia constituted the most prevalent multimorbidity pattern.
doi:10.1186/s12875-016-0546-4
PMCID: PMC5093992  PMID: 27809772
Multimorbidity; Cardiovascular morbidity; Cardiovascular risk factors; Comorbidity; Electronic health records; Primary health care
25.  Knowledge, attitudes and practices towards antibiotic use in upper respiratory tract infections among patients seeking primary health care in Singapore 
BMC Family Practice  2016;17:148.
Background
Patients’ expectations can influence antibiotic prescription by primary healthcare physicians. We assessed knowledge, attitude and practices towards antibiotic use for upper respiratory tract infections (URTIs), and whether knowledge is associated with increased expectations for antibiotics among patients visiting primary healthcare services in Singapore.
Methods
Data was collected through a cross-sectional interviewer-assisted survey of patients aged ≥21 years waiting to see primary healthcare practitioners for one or more symptoms suggestive of URTI (cough, sore throat, runny nose or blocked nose) for 7 days or less, covering the demographics, presenting symptoms, knowledge, attitudes, beliefs and practices of URTI and associated antibiotic use. Univariate and multivariate logistic regression was used to assess independent factors associated with patients’ expectations for antibiotics.
Results
Nine hundred fourteen out of 987 eligible patients consulting 35 doctors were recruited from 24 private sector primary care clinics in Singapore. A third (307/907) expected antibiotics, of which a substantial proportion would ask the doctor for antibiotics (121/304, 40 %) and/or see another doctor (31/304, 10 %) if antibiotics were not prescribed. The majority agreed “antibiotics are effective against viruses” (715/914, 78 %) and that “antibiotics cure URTI faster” (594/912, 65 %). Inappropriate antibiotic practices include “keeping antibiotics stock at home” (125/913, 12 %), “taking leftover antibiotics” (114/913, 14 %) and giving antibiotics to family members (62/913, 7 %). On multivariate regression, the following factors were independently associated with wanting antibiotics (odds ratio; 95 % confidence interval): Malay ethnicity (1.67; 1.00–2.79), living in private housing (1.69; 1.13–2.51), presence of sore throat (1.50; 1.07–2.10) or fever (1.46; 1.01–2.12), perception that illness is serious (1.70; 1.27–2.27), belief that antibiotics cure URTI faster (5.35; 3.76–7.62) and not knowing URTI resolves on its own (2.18; 1.08–2.06), while post-secondary education (0.67; 0.48–0.94) was inversely associated. Those with lower educational levels were significantly more likely to have multiple misconceptions about antibiotics.
Conclusion
Majority of patients seeking primary health care in Singapore are misinformed about the role of antibiotics in URTI. Agreeing with the statement that antibiotics cure URTI faster was most strongly associated with wanting antibiotics. Those with higher educational levels were less likely to want antibiotics, while those with lower educational levels more likely to have incorrect knowledge.
Electronic supplementary material
The online version of this article (doi:10.1186/s12875-016-0547-3) contains supplementary material, which is available to authorized users.
doi:10.1186/s12875-016-0547-3
PMCID: PMC5094024  PMID: 27809770
Antibiotic use; Upper Respiratory Tract Infections (URTIs); Primary healthcare; Singapore; Educational level

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