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1.  Depressive mood mediates the influence of social support on health-related quality of life in elderly, multimorbid patients 
BMC Family Practice  2014;15:62.
Background
It is not well established how psychosocial factors like social support and depression affect health-related quality of life in multimorbid and elderly patients. We investigated whether depressive mood mediates the influence of social support on health-related quality of life.
Methods
Cross-sectional data of 3,189 multimorbid patients from the baseline assessment of the German MultiCare cohort study were used. Mediation was tested using the approach described by Baron and Kenny based on multiple linear regression, and controlling for socioeconomic variables and burden of multimorbidity.
Results
Mediation analyses confirmed that depressive mood mediates the influence of social support on health-related quality of life (Sobel’s p < 0.001). Multiple linear regression showed that the influence of depressive mood (β = −0.341, p < 0.01) on health-related quality of life is greater than the influence of multimorbidity (β = −0.234, p < 0.01).
Conclusion
Social support influences health-related quality of life, but this association is strongly mediated by depressive mood. Depression should be taken into consideration in research on multimorbidity, and clinicians should be aware of its importance when caring for multimorbid patients.
Trial registration
ISRCTN89818205
doi:10.1186/1471-2296-15-62
PMCID: PMC3984397  PMID: 24708815
Multimorbidity; Chronic medical conditions; Coping; Primary care; Family practice; Social support; Health-related quality of life; Depression; Elderly patients
2.  Alignment of patient and primary care practice member perspectives of chronic illness care: a cross-sectional analysis 
BMC Family Practice  2014;15:57.
Background
Little is known as to whether primary care teams’ perceptions of how well they have implemented the Chronic Care Model (CCM) corresponds with their patients’ own experience of chronic illness care. We examined the extent to which practice members’ perceptions of how well they organized to deliver care consistent with the CCM were associated with their patients’ perceptions of the chronic illness care they have received.
Methods
Analysis of baseline measures from a cluster randomized controlled trial testing a practice facilitation intervention to implement the CCM in small, community-based primary care practices. All practice “members” (i.e., physician providers, non-physician providers, and staff) completed the Assessment of Chronic Illness Care (ACIC) survey and adult patients with 1 or more chronic illnesses completed the Patient Assessment of Chronic Illness Care (PACIC) questionnaire.
Results
Two sets of hierarchical linear regression models accounting for nesting of practice members (N = 283) and patients (N = 1,769) within 39 practices assessed the association between practice member perspectives of CCM implementation (ACIC scores) and patients’ perspectives of CCM (PACIC). ACIC summary score was not significantly associated with PACIC summary score or most of PACIC subscale scores, but four of the ACIC subscales [Self-management Support (p < 0.05); Community Linkages (p < 0.02), Delivery System Design (p < 0.02), and Organizational Support (p < 0.02)] were consistently associated with PACIC summary score and the majority of PACIC subscale scores after controlling for patient characteristics. The magnitude of the coefficients, however, indicates that the level of association is weak.
Conclusions
The ACIC and PACIC scales appear to provide complementary and relatively unique assessments of how well clinical services are aligned with the CCM. Our findings underscore the importance of assessing both patient and practice member perspectives when evaluating quality of chronic illness care.
Trial registration
NCT00482768
doi:10.1186/1471-2296-15-57
PMCID: PMC3974922  PMID: 24678983
Chronic care; Primary care; Patient surveys
3.  The value of prostate cancer support groups: a pilot study of primary physicians’ perspectives 
BMC Family Practice  2014;15:56.
Background
In Canada, prostate cancer (PCa) is the most common male cancer, and prostate cancer support groups (PCSGs) have prevailed for more than 20 years providing support to men with PCa and their families. While the format, focus and benefits of attending PCSGs have been reported little is known about primary physicians’ (PPs) perceptions of these groups. This article describes Canadian primary physicians’ views about face-to-face and web-based PCSGs.
Methods
Canadian based primary physicians (n = 140) attending a 2012 Continuing Medical Education Conference participated in a pilot survey questionnaire study. The 56-item questionnaire used in this study included six sets of attitudinal items to measure primary physicians’ beliefs about positive and negative influences of PCSGs, reasons for attending PCSGs, the attributes of effective PCSGs, and the value of face-to-face and web-based PCSGs.
Results
Results showed that PCSGs were positively valued, particularly for information sharing, education and psychosocial support. Poor inclusivity, privacy, and accessibility were identified as potential barriers, and recommendations were made for better marketing and web-based PCSGs to increase engagement with potential attendees.
Conclusions
Findings suggest PPs highly valued the role and potential benefits of PCSGs. Information provision and an educational role were perceived as key benefits amid the need to improve local and provincial marketing of PCSGs. The potential for web-based PCSGs to help in the support of PCa patients was also recognized.
doi:10.1186/1471-2296-15-56
PMCID: PMC3972516  PMID: 24673983
Prostate cancer support groups; Primary healthcare providers; Clinician’s attitudes
4.  General practitioner prescribing of single and combination nicotine replacement therapy in the UK: a retrospective database study 
BMC Family Practice  2014;15:47.
Background
Guidance in England and Wales recommends that nicotine replacement therapies (NRTs), varenicline or bupropion should be offered for smoking cessation support. Research on general practitioner (GP) NRT prescribing patterns for smoking cessation is lacking in the published literature.
Methods
UK primary care electronic health records were retrospectively analysed to identify the most common GP initiated NRT prescribing patterns, characterise people who receive NRT and determine whether NRTs given in a first quit attempt are different from subsequent attempts.
Results
The study population comprised 38,954 individuals in UK primary care data with a first ever NRT patch smoking cessation attempt for the period January 2008-December 2011. The majority (64.3%) received NRT patch monotherapy at first smoking cessation attempt, and the most common NRT was 21 mg/24 hours patch monotherapy (15.2%). Of the 35.7% first smoking cessation attempts which were NRT combination therapy, the most common combination was patch + inhalator (56.2%). The proportion of people who started a smoking cessation attempt with combination therapy increased from 25.7% in 2008 to 44.8% in 2011. The majority of the population had one recorded smoking cessation attempt but a significant minority (20.2% N = 7,868) started a second smoking cessation attempt. Second and third attempts, while predominantly patch monotherapy, also demonstrated an increasing use of NRT combinations over the study period (2ndepisode: 20.6%-38.2%; 3rdepisode: 20.0%-36.8%). However, a minority received only non-patch NRT during second and third NRT episodes. Taking into account the 39,068 people prescribed NRT patch during the study period with a history of NRT at baseline (excluded from the analysis), the total proportion of people prescribed NRT patch between 2008–2011 who had more than one NRT episode was 48.4% (46,936/96,986) and of 128,115 NRT users, only 14.7% (N = 18,838) were prescribed bupropion or varenicline prior to NRT use.
Conclusions
The study findings represent new data describing GP NRT prescription patterns in the UK. Given the predominance of NRT patch monotherapy observed, health policy makers and service commissioners should ensure that GPs provide equality of access to all recommended smoking cessation pharmacotherapies.
doi:10.1186/1471-2296-15-47
PMCID: PMC3978098  PMID: 24645823
Nicotine replacement therapy; Smoking cessation; The health improvement network; Observational research
5.  Efficacy of Ambroxol lozenges for pharyngitis: a meta-analysis 
BMC Family Practice  2014;15:45.
Background
Ambroxol has a local anaesthetic action and is marketed for pain relief for sore throat. The objective is to examine the efficacy and safety of ambroxol for the relief of pain associated with acute uncomplicated sore throat.
Methods
A systematic review of the literature and meta-analysis. Selection criteria consisted of randomized controlled trials which compared ambroxol to placebo or any other treatment for sore throat. Two reviewers independently assessed for relevance, inclusion, and risk of bias. Weighted mean differences (WMDs) were calculated and are reported with corresponding 95% confidence intervals (CIs).
Results and conclusion
From 14 potentially relevant citations, five trials reported in three publications met the inclusion criteria, three of them were published twice. Ambroxol lozenges were compared in different dosages (5–30 mg) with mint flavoured lozenges and once with benzocaine. Main outcome was a ratio of pain reduction measured repeatedly over 3 h compared to baseline on 6-item verbal rating scale. A total of 1.772 adult patients participated in the trials. Pain intensity decreased in both study arms. A meta-analysis of the 5 controlled trials resulted in a difference in pain reduction compared to placebo of -0.11 (95% CI [-0.15, -0.07]; p < 0.0001) favouring ambroxol 20 mg. Quality of reporting of the studies was low. Ambroxol is slightly more effective in relieving pain in acute sore throat than mint flavoured lozenges over a period of 3 h. However, the additional benefits of ambroxol beyond three hours, remain unclear given that more than 50% of patients using mint flavoured lozenges for pain relief reported good or very good efficacy after 1 day compared to 69% with ambroxol. Ambroxol is a safe option for individual patients with mainly local symptoms asking for treatment.
doi:10.1186/1471-2296-15-45
PMCID: PMC3975147  PMID: 24621446
Pharyngitis; Sore throat; Mint flavoured lozenges; Ambroxol; Primary care; Pain relief; Meta-analysis
6.  Overcoming the barriers to the diagnosis and management of chronic fatigue syndrome/ME in primary care: a meta synthesis of qualitative studies 
BMC Family Practice  2014;15:44.
Background
The NICE guideline for Chronic Fatigue Syndrome/Myalgic Encephalomyelitis (CFS/ME) emphasises the need for an early diagnosis in primary care with management tailored to patient needs. However, GPs can be reluctant to make a diagnosis and are unsure how to manage people with the condition.
Methods
A meta synthesis of published qualitative studies was conducted, producing a multi-perspective description of barriers to the diagnosis and management of CFS/ME, and the ways that some health professionals have been able to overcome them. Analysis provided second-order interpretation of the original findings and developed third-order constructs to provide recommendations for the medical curriculum.
Results
Twenty one qualitative studies were identified. The literature shows that for over 20 years health professionals have reported a limited understanding of CFS/ME. Working within the framework of the biomedical model has also led some GPs to be sceptical about the existence of the condition. GPs who provide a diagnosis tend to have a broader, multifactorial, model of the condition and more positive attitudes towards CFS/ME. These GPs collaborate with patients to reach agreement on symptom management, and use their therapeutic skills to promote self care.
Conclusions
In order to address barriers to the diagnosis and management of CFS/ME in primary care, the limitations of the biomedical model needs to be recognised. A more flexible bio-psychosocial approach is recommended where medical school training aims to equip practitioners with the skills needed to understand, support and manage patients and provide a pathway to refer for specialist input.
doi:10.1186/1471-2296-15-44
PMCID: PMC3973969  PMID: 24606913
Chronic fatigue syndrome/ME; Barriers and facilitators; Management and diagnosis; Qualitative research; Primary health care
7.  Telemonitoring can assist in managing cardiovascular disease in primary care: a systematic review of systematic reviews 
BMC Family Practice  2014;15:43.
Background
There has been growing interest regarding the impact of telemonitoring and its ability to reduce the increasing burden of chronic diseases, including chronic cardiovascular disease (CVD), on healthcare systems. A number of randomised trials have been undertaken internationally and synthesised into various systematic reviews to establish an evidence base for this model of care. This study sought to synthesise and critically evaluate this large body of evidence to inform clinicians, researchers and policy makers.
Methods
A systematic review of systematic reviews investigating the impact of telemonitoring interventions in the primary care management of CVD was conducted. Reviews were included if they explored primary care based telemonitoring in either CVD, heart failure or hypertension, were reported in the English language and were published between 2000 and 2013. Data was extracted by one reviewer and checked by a second reviewer using a standardised form. Two assessors then rated the quality of each review using the Overview Quality Assessment Questionnaire (OQAQ).
Results
Of the 13 included reviews, four focused on telemonitoring interventions in hypertension or CVD management and the remaining 9 reviews investigated telemonitoring in HF management. Seven reviews scored a five or above on the OQAQ evidencing good quality reviews. Findings suggest that telemonitoring can contribute to significant reductions in blood pressure, decreased all-cause and HF related hospitalisations, reduced all-cause mortality and improved quality of life. Telemonitoring was also demonstrated to reduce health care costs and appears acceptable to patients.
Conclusion
Telemonitoring has the potential to enhance primary care management of CVD by improving patient outcomes and reducing health costs. However, further research needs to explore the specific elements of telemonitoring interventions to determine the relative value of the various elements. Additionally, the ways in which telemonitoring care improves health outcomes needs to be further explored to understand the nature of these interventions.
doi:10.1186/1471-2296-15-43
PMCID: PMC3984731  PMID: 24606887
Systematic review; Telemonitoring; Heart failure; Hypertension; Primary care
8.  Predictors of ICS/LABA prescribing in COPD patients: a study from general practice 
BMC Family Practice  2014;15:42.
Background
A combination of inhaled corticosteroid and long-acting beta2 agonist (ICS/LABA) is used frequently to treat chronic obstructive pulmonary disease (COPD) patients. The aim of the study was to determine whether prescribing ICS/LABA to COPD patients in primary care in 2009/10 was within the GOLD guidelines and whether and to what degree patient characteristics were associated with prescription of these drugs by GPs.
Methods
This was a cross-sectional study in seven Norwegian GP practices. Patients registered with a diagnosis of asthma or COPD in the previous five years were included.
Results
Among the 376 patients included in the analysis, 149 patients had COPD, defined as a post-bronchodilator FEV1/FVC <0.7 and 55.6% of these patients were treated with ICS/LABA. The rate of prescribing was significantly higher in the COPD patients also diagnosed with asthma than in those with COPD as the only diagnosis, 66.7%, and 39.0%, respectively (P = 0.001). The prescribing rate in the latter subgroup would have been 18.6% if the 2007 GOLD guidelines had been followed. One or more exacerbations in the previous year was the strongest predictor of ICS/LABA prescribing in the COPD patients who were not registered with a concomitant diagnosis of asthma (OR 3.2, 95% CI 1.0–10.0) but this association was limited to the patients with severe disease (FEV1% predicted <50) (OR 13.5, 95% CI 1.8–101.1). Cardiovascular disease was associated with decreased ICS/LABA prescribing (OR 0.4, 95% CI 0.2–0.8) in the COPD group. A Kappa coefficient of 0.32 was found between the actual prescribing rate and that recommended in the 2007 GOLD guidelines.
Conclusions
Overprescribing of ICS/LABA for the COPD patients was shown. Previous exacerbation was a strong predictor of ICS/LABA prescribing only in patients with severe COPD. Because of the low emphasis on previous exacerbation when prescribing for COPD patients with mild to moderate disease, the actual prescribing rate agreed more closely with the GOLD guidelines from 2007 than with those published in 2011. Cardiovascular disease was associated with decreased prescribing, indicating that GPs adjust the treatment in cases with multimorbidity.
doi:10.1186/1471-2296-15-42
PMCID: PMC3983887  PMID: 24597538
Prescription; Adrenergic beta2 agonists; Corticosteroids; COPD; Primary care
9.  Care for post-stroke patients at Malaysian public health centres: self-reported practices of family medicine specialists 
BMC Family Practice  2014;15:40.
Background
Provision of post stroke care in developing countries is hampered by discoordination of services and limited access to specialised care. Albeit shortcomings, primary care continues to provide post-stroke services in less than favourable circumstances. This paper aimed to review provision of post-stroke care and related problems among Family Medicine Specialists managing public primary health care services.
Methods
A semi-structured questionnaire was distributed to 121 Family Physicians servicing public funded health centres in a pilot survey focused on improving post stroke care provision at community level. The questionnaire assessed respondents background and practice details i.e. estimated stroke care burden, current service provision and opinion on service improvement. Means and frequencies described quantitative data. For qualitative data, constant comparison method was used until saturation of themes was reached.
Results
Response rate of 48.8% was obtained. For every 100 patients seen at public healthcentres each month, 2 patients have stroke. Median number of stroke patients seen per month is 5 (IQR 2-10). 57.6% of respondents estimated total stroke patients treated per year at each centre was less than 40 patients. 72.4% lacked a standard care plan although 96.6% agreed one was needed. Patients seen were: discharged from tertiary care (88.1%), shared care plan with specialists (67.8%) and patients who developed stroke during follow up at primary care (64.4%). Follow-ups were done at 8-12 weekly intervals (60.3%) with 3.4% on ‘as needed’ basis. Referrals ranked in order of frequency were to physiotherapy services, dietitian and speech and language pathologists in public facilities. The FMS’ perceived 4 important ‘needs’ in managing stroke patients at primary care level; access to rehabilitation services, coordinated care between tertiary centres and primary care using multidisciplinary care approach, a standardized guideline and family and caregiver support.
Conclusions
Post discharge stroke care guidelines and access to rehabilitation services at primary care is needed for post stroke patients residing at home in the community.
doi:10.1186/1471-2296-15-40
PMCID: PMC3945040  PMID: 24580779
Post stroke; Primary care; Healthcare delivery
10.  Agreement between self-reported and general practitioner-reported chronic conditions among multimorbid patients in primary care - results of the MultiCare Cohort Study 
BMC Family Practice  2014;15:39.
Background
Multimorbidity is a common phenomenon in primary care. Until now, no clinical guidelines for multimorbidity exist. For the development of these guidelines, it is necessary to know whether or not patients are aware of their diseases and to what extent they agree with their doctor. The objectives of this paper are to analyze the agreement of self-reported and general practitioner-reported chronic conditions among multimorbid patients in primary care, and to discover which patient characteristics are associated with positive agreement.
Methods
The MultiCare Cohort Study is a multicenter, prospective, observational cohort study of 3,189 multimorbid patients, ages 65 to 85. Data was collected in personal interviews with patients and GPs. The prevalence proportions for 32 diagnosis groups, kappa coefficients and proportions of specific agreement were calculated in order to examine the agreement of patient self-reported and general practitioner-reported chronic conditions. Logistic regression models were calculated to analyze which patient characteristics can be associated with positive agreement.
Results
We identified four chronic conditions with good agreement (e.g. diabetes mellitus κ = 0.80;PA = 0,87), seven with moderate agreement (e.g. cerebral ischemia/chronic stroke κ = 0.55;PA = 0.60), seventeen with fair agreement (e.g. cardiac insufficiency κ = 0.24;PA = 0.36) and four with poor agreement (e.g. gynecological problems κ = 0.05;PA = 0.10).
Factors associated with positive agreement concerning different chronic diseases were sex, age, education, income, disease count, depression, EQ VAS score and nursing care dependency. For example: Women had higher odds ratios for positive agreement with their GP regarding osteoporosis (OR = 7.16). The odds ratios for positive agreement increase with increasing multimorbidity in almost all of the observed chronic conditions (OR = 1.22-2.41).
Conclusions
For multimorbidity research, the knowledge of diseases with high disagreement levels between the patients’ perceived illnesses and their physicians’ reports is important. The analysis shows that different patient characteristics have an impact on the agreement. Findings from this study should be included in the development of clinical guidelines for multimorbidity aiming to optimize health care. Further research is needed to identify more reasons for disagreement and their consequences in health care.
Trial registration
ISRCTN89818205
doi:10.1186/1471-2296-15-39
PMCID: PMC3946039  PMID: 24580758
Agreement; Self-report; Physician report; Chronic diseases; Primary care; Multimorbidity
11.  Family medicine model in Turkey: a qualitative assessment from the perspectives of primary care workers 
BMC Family Practice  2014;15:38.
Background
A person-list-based family medicine model was introduced in Turkey during health care reforms. This study aimed to explore from primary care workers’ perspectives whether this model could achieve the cardinal functions of primary care and have an integrative position in the health care system.
Methods
Four groups of primary care workers were included in this exploratory-descriptive study. The first two groups were family physicians (FP) (n = 51) and their ancillary personnel (n = 22). The other two groups were physicians (n = 44) and midwives/nurses (n = 11) working in community health centres. Participants were selected for maximum variation and 102 in-depth interviews and six focus groups were conducted using a semi-structured form.
Results
Data analysis yielded five themes: accessibility, first-contact care, longitudinality, comprehensiveness, and coordination. Most participants stated that many people are not registered with any FP and that the majority of these belong to the most disadvantaged groups in society. FPs reported that 40-60% of patients on their lists have never received a service from them and the majority of those who use their services do not use FPs as the first point of contact. According to most participants, the list-based system improved the longitudinality of the relationship between FPs and patients. However, based on other statements, this improvement only applies to one quarter of the population. Whereas there was an improvement limited to a quantitative increase in services (immunisation, monitoring of pregnant women and infants) included in the performance-based contracting system, participants stated that services not among the performance targets, such as family planning, postpartum follow-ups, and chronic disease management, could be neglected. FPs admitted not being able to keep informed of services their patients had received at other health institutions. Half of the participants stated that the list-based system removed the possibility of evaluating the community as a whole.
Conclusions
According to our findings, FPs have a limited role as the first point of contact and in giving longitudinal, comprehensive, and coordinated care. The family medicine model in Turkey is unable to provide a suitable structure to integrate health care services.
doi:10.1186/1471-2296-15-38
PMCID: PMC3942270  PMID: 24571275
Family physician; Family medicine; Primary care; Health care reform; Integration
12.  Patients understanding of depression associated with chronic physical illness: a qualitative study 
BMC Family Practice  2014;15:37.
Background
Detection of depression can be difficult in primary care, particularly when associated with chronic illness. Patient beliefs may affect detection and subsequent engagement with management. We explored patient beliefs about the nature of depression associated with physical illness.
Methods
A qualitative interview study of patients registered with general practices in Leeds, UK. We invited patients with coronary heart disease or diabetes from primary care to participate in semi-structured interviews exploring their beliefs and experiences. We analysed transcripts using a thematic approach, extended to consider narratives as important contextual elements.
Results
We interviewed 26 patients, including 17 with personal experience of depression. We developed six themes: recognising a problem, complex causality, the role of the primary care, responsibility, resilience, and the role of their life story. Participants did not consistently talk about depression as an illness-like disorder. They described a change in their sense of self against the background of their life stories. Participants were unsure about seeking help from general practitioners (GPs) and felt a personal responsibility to overcome depression themselves. Chronic illness, as opposed to other life pressures, was seen as a justifiable cause of depression.
Conclusions
People with chronic illness do not necessarily regard depression as an easily defined illness, especially outside of the context of their life stories. Efforts to engage patients with chronic illness in the detection and management of depression may need further tailoring to accommodate beliefs about how people view themselves, responsibility and negative views of treatment.
doi:10.1186/1471-2296-15-37
PMCID: PMC3936902  PMID: 24555886
13.  Health care professionals’ perceptions towards lifelong learning in palliative care for general practitioners: a focus group study 
BMC Family Practice  2014;15:36.
Background
There is a growing need for palliative care. The majority of palliative patients prefer their general practitioner (GP) to organize their palliative home care. General practitioners need a range of competences to perform this task. However, there has been no general description so far of how GPs keep these competences up-to-date. The present study explores current experiences, views and preferences towards training and education in palliative care among GPs, palliative home-care professionals and professionals from organizations who provide training and education.
Methods
Five focus groups were brought together in Belgium, with a total of 29 participants, including members of the three categories mentioned above. They were analysed using a constant comparison method.
Results
The analysis revealed that undergraduate education and continuing medical education (CME) while in practice, is insufficient to prepare GPs for their palliative work. Workplace learning (WPL) through collaboration with specialized palliative home-care nurses seems to be a valuable alternative.
Conclusions
The effectiveness of undergraduate education might be enhanced by adding practical experience. Providers of continuing medical education should look to organize interactive, practice-based and interprofessional sessions. Therefore, teachers need to be trained to run small group discussions. In order to optimize workplace learning, health care professionals should be trained to monitor each other’s practice and to provide effective feedback. Further research is needed to clarify which aspects of interprofessional teamwork (e.g. professional hierarchy, agreements on tasks and responsibilities) influence the effectiveness of workplace learning.
doi:10.1186/1471-2296-15-36
PMCID: PMC3936999  PMID: 24552145
Interprofessional learning; Workplace learning; Interprofessional collaboration; Primary care; Continuing professional development
14.  Irrational prescribing of over-the-counter (OTC) medicines in general practice: testing the feasibility of an educational intervention among physicians in five European countries 
BMC Family Practice  2014;15:34.
Background
Irrational prescribing of over-the-counter (OTC) medicines in general practice is common in Southern Europe. Recent findings from a research project funded by the European Commission (FP7), the “OTC SOCIOMED”, conducted in seven European countries, indicate that physicians in countries in the Mediterranean Europe region prescribe medicines to a higher degree in comparison to physicians in other participating European countries. In light of these findings, a feasibility study has been designed to explore the acceptance of a pilot educational intervention targeting physicians in general practice in various settings in the Mediterranean Europe region.
Methods
This feasibility study utilized an educational intervention was designed using the Theory of Planned Behaviour (TPB). It took place in geographically-defined primary care areas in Cyprus, France, Greece, Malta, and Turkey. General Practitioners (GPs) were recruited in each country and randomly assigned into two study groups in each of the participating countries. The intervention included a one-day intensive training programme, a poster presentation, and regular visits of trained professionals to the workplaces of participants. Reminder messages and email messages were, also, sent to participants over a 4-week period. A pre- and post-test evaluation study design with quantitative and qualitative data was employed. The primary outcome of this feasibility pilot intervention was to reduce GPs’ intention to provide medicines following the educational intervention, and its secondary outcomes included a reduction of prescribed medicines following the intervention, as well as an assessment of its practicality and acceptance by the participating GPs.
Results
Median intention scores in the intervention groups were reduced, following the educational intervention, in comparison to the control group. Descriptive analysis of related questions indicated a high overall acceptance and perceived practicality of the intervention programme by GPs, with median scores above 5 on a 7-point Likert scale.
Conclusions
Evidence from this intervention will estimate the parameters required to design a larger study aimed at assessing the effectiveness of such educational interventions. In addition, it could also help inform health policy makers and decision makers regarding the management of behavioural changes in the prescribing patterns of physicians in Mediterranean Europe, particularly in Southern European countries.
doi:10.1186/1471-2296-15-34
PMCID: PMC3936810  PMID: 24533792
OTC medicines; Primary care; Feasibility study
15.  Understanding “revolving door” patients in general practice: a qualitative study 
BMC Family Practice  2014;15:33.
Background
‘Revolving door’ patients in general practice are repeatedly removed from general practitioners’ (GP) lists. This paper reports a qualitative portion of the first mixed methods study of these marginalised patients.
Methods
We conducted qualitative semi-structured interviews with six practitioner services staff and six GPs in Scotland, utilizing Charmazian grounded theory to characterise ‘revolving door’ patients and their impact from professionals’ perspectives.
Results
‘Revolving door’ patients were reported as having three necessary characteristics; they had unreasonable expectations, exhibited inappropriate behaviours and had unmet health needs. A range of boundary breaches were reported too when ‘revolving door’ patients interacted with NHS staff.
Conclusions
We utilise the ‘sensitising concepts’ of legitimacy by drawing on literature about ‘good and bad’ patients and ‘dirty work designations.’ We relate these to the core work of general practice and explore the role that medical and moral schemas have in how health service professionals understand and work with ‘revolving door’ patients. We suggest this may have wider relevance for the problem doctor patient relationship literature.
doi:10.1186/1471-2296-15-33
PMCID: PMC3930014  PMID: 24524363
16.  Triggering change in diabetes care delivery in general practice: a qualitative evaluation approach using the clinical microsystem framework 
BMC Family Practice  2014;15:32.
Background
In 2008, the Sunshine Coast Division of General Practice (SCDGP) in Queensland, Australia initiated a highly successful Improved Diabetes Management (IDM) program with general practices in a regional area. The IDM program was evaluated against the 10 elements of a high functioning clinical microsystem framework as identified by Nelson et al. (2007) in order to determine key factors contributing to the successful adoption and uptake of the program in participating general practices.
Methods
The evaluation focussed on in-depth key informant interviews with 10 SCDGP staff and general practitioners (GPs) involved in the IDM program. A thematic analysis was undertaken and common emergent themes were reviewed against the 10 elements of high performing clinical microsystem.
Results
While all aspects of the clinical microsystem approach appeared effective in the design, implementation and adoption of the IDM program, several characteristics were crucial. The identification of champions of change in both the division and participating practices, the celebration of positive achievements and the use ‘real data’ from practices to demonstrate improved health outcomes for patients from the practice were instrumental in motivating participating GPs to both implement and sustain changes in their diabetes care delivery.
Conclusion
In designing and redesigning health care, the clinical microsystems approach offers a pathway for the effective uptake of innovation in Australian primary health care; a means of integrating structure, process and outcomes of a care framework for reviewing improvements in the health care delivery process and could lead to improvements in patient health outcomes.
doi:10.1186/1471-2296-15-32
PMCID: PMC3937026  PMID: 24520838
Clinical microsystems; Quality improvement; Diabetes mellitus, Chronic disease management; Health services research
17.  Quality of family history collection with use of a patient facing family history assessment tool 
BMC Family Practice  2014;15:31.
Background
Studies have shown that the quality of family health history (FHH) collection in primary care is inadequate to assess disease risk. To use FHH for risk assessment, collected data must have adequate detail. To address this issue, we developed a patient facing FHH assessment tool, MeTree. In this paper we report the content and quality of the FHH collected using MeTree.
Methods
Design: A hybrid implementation-effectiveness study. Patients were recruited from 2009 to 2012. Setting: Two community primary care clinics in Greensboro, NC. Participants: All non-adopted adult English speaking patients with upcoming appointments were invited to participate. Intervention: Education about and collection of FHH with entry into MeTree. Measures: We report the proportion of pedigrees that were high-quality. High-quality pedigrees are defined as having all the following criteria: (1) three generations of relatives, (2) relatives’ lineage, (3) relatives’ gender, (4) an up-to-date FHH, (5) pertinent negatives noted, (6) age of disease onset in affected relatives, and for deceased relatives, (7) the age and (8) cause of death (Prim Care31:479–495, 2004.).
Results
Enrollment: 1,184. Participant demographics: age range 18-92 (mean 58.8, SD 11.79), 56% male, and 75% white. The median pedigree size was 21 (range 8-71) and the FHH entered into MeTree resulted in a database of 27,406 individuals. FHHs collected by MeTree were found to be high quality in 99.8% (N = 1,182/1,184) as compared to <4% at baseline. An average of 1.9 relatives per pedigree (range 0-50, SD 4.14) had no data reported. For pedigrees where at least one relative has no data (N = 497/1,184), 4.97 relatives per pedigree (range 1-50, SD 5.44) had no data. Talking with family members before using MeTree significantly decreased the proportion of relatives with no data reported (4.98% if you talked to your relative vs. 10.85% if you did not, p-value < 0.001.).
Conclusion
Using MeTree improves the quantity and quality of the FHH data that is collected and talking with relatives prior to the collection of FHH significantly improves the quantity and quality of the data provided. This allows more patients to be accurately risk stratified and offered appropriate preventive care guided by their risk level.
Trial number
NCT01372553
doi:10.1186/1471-2296-15-31
PMCID: PMC3937044  PMID: 24520818
Family history; Data quality; Patient-centered
18.  Skin lesions suspected of malignancy: an increasing burden on general practice 
BMC Family Practice  2014;15:29.
Background
Skin cancer is believed to impose a heavy burden on healthcare services, but the burden of skin lesions suspected of malignancy on primary healthcare has never been evaluated. Therefore the aim of this study was to determine the demand for care in general practice due to these suspected skin lesions (i.e. lesions that are suspected of malignancy by either the patient or the GP).
Methods
Registry study based on data (2001–2010) from the Registration Network Groningen. This is a general practice registration network in the northern part of the Netherlands with an average annual population of approximately 30,000 patients. All patient contacts are coded according to the International Classification of Primary Care (ICPC). Consultations for skin lesions suspected of malignancy were selected according to the assigned ICPC codes. Subsequently, the number of consultations per year and the annual percent change in number of contacts (using the JoinPoint regression program) were calculated and analysed. Additionally, the percentage of patients referred to secondary care or receiving minor surgery within one year after the first contact were calculated.
Results
From 2001 onwards we found an annual increase in demand for care due to skin lesions suspected of malignancy of 7.3% (p < 0.01) and in 2010 the benign:malignant ratio was 10:1. In total 13.0% of the patients were referred and after 2006, minor surgery was performed on 31.2% of the patients. Most surgeries and referrals took place within 30 days.
Conclusions
Suspected skin lesions impose an increasing burden on primary healthcare and most likely on healthcare costs as well. General practitioners should therefore be trained in diagnosing skin lesions suspected of malignancy, as a high diagnostic accuracy can save lives in the case of melanoma, and may also prevent unnecessary, costly, excisions and referrals to secondary healthcare.
doi:10.1186/1471-2296-15-29
PMCID: PMC3930756  PMID: 24517098
Skin Neoplasms; Family practice; Physicians; Family; Netherlands; Referral and consultation; Surgical procedures; Minor
19.  Detection and management of depression in adult primary care patients in Hong Kong: a cross-sectional survey conducted by a primary care practice-based research network 
BMC Family Practice  2014;15:30.
Background
This study aimed to examine the prevalence, risk factors, detection rates and management of primary care depression in Hong Kong.
Methods
A cross-sectional survey containing the PHQ-9 instrument was conducted on waiting room patients of 59 primary care doctors. Doctors blinded to the PHQ-9 scores reported whether they thought their patients had depression and their management.
Results
10,179 patients completed the survey (response rate 81%). The prevalence of PHQ-9 positive screening was 10.7% (95% CI: 9.7%-11.7%). Using multivariate analysis, risk factors for being PHQ-9 positive included: being female; aged ≤34 years; being unmarried; unemployed, a student or a homemaker; having a monthly household income < HKD$30,000 (USD$3,800); being a current smoker; having no regular exercise; consulted a doctor or Chinese medical practitioner within the last month; having ≥ two co-morbidities; having a family history of mental illness; and having a past history of depression or other mental illness. Overall, 23.1% of patients who screened PHQ-9 positive received a diagnosis of depression by the doctor. Predictors for receiving a diagnosis of depression included: having higher PHQ-9 scores; a past history of depression or other mental health problem; being female; aged ≥35 years; being retired or a homemaker; being non-Chinese; having no regular exercise; consulted a doctor within the last month; having a family history of mental health problems; and consulted a doctor in private practice.
In patients diagnosed with depression, 43% were prescribed antidepressants, 11% were prescribed benzodiazepines, 42% were provided with counseling and 9% were referred, most commonly to a counselor.
Conclusion
About one in ten primary care patients screen positive for depression, of which doctors diagnose depression in approximately one in four. At greatest risk for depression are patients with a past history of depression, who are unemployed, or who have multiple illnesses. Patients most likely to receive a diagnosis of depression by a doctor are those with a past history of depression or who have severe symptoms of depression. Chinese patients are half as likely to be diagnosed with depression as non-Chinese patients. Over half of all patients diagnosed with depression are treated with medications.
doi:10.1186/1471-2296-15-30
PMCID: PMC3937039  PMID: 24521526
Mental health; Chinese; Depression; Epidemiology; Primary care; Prevalence; Screening; Detection; Practice-based research network
20.  An education programme to increase general practitioners’ awareness of their patients’ employment: design of a cluster randomised controlled trial 
BMC Family Practice  2014;15:28.
Background
Work and being able to work are important prerequisites for health and well being. Health problems can have a negative influence on the ability to work and not being able to work can be detrimental for patients’ psychosocial well being. Although GPs are aware of this importance they do not always structurally pay attention to patients’ work during their daily practice.
Methods/design
To investigate whether GPs can be trained to increase their awareness of work and improve their skills when dealing with work related problems we designed a cluster randomised controlled trial. The intervention in this trial is a tailored training based on the findings of qualitative research with focus groups of GPs. Gender aspects received specific attention in these focus groups. Primary outcome measures are self efficacy of patients concerning return to work, and GPs’ use of ICPC code Z05 (work problems) and registration of patients’ occupation. Secondary outcome measures are work awareness of GPs as perceived by patients, quality of life, health, use of care and illness related costs. A process evaluation will be part of our study.
Discussion
We investigate a training to increase work awareness among GPs, improve their skills in managing work related problems and structurally register work related data in the EMR. We think this study will make a contribution to better health care for workers by motivating GPs to appreciate their specific needs. It will also add to our knowledge of the complex relationship between gender, work and health.
Trial registration
Trial registration number: NTR3475
doi:10.1186/1471-2296-15-28
PMCID: PMC3923988  PMID: 24507221
Primary health care; RCT; General practitioners; Occupational health physicians; Gender; Absenteism; Presenteeism; Tailored training intervention; Return-to-work; Self-efficacy
21.  Cost-effectiveness of a programme of screening and brief interventions for alcohol in primary care in Italy 
BMC Family Practice  2014;15:26.
Background
As alcohol-related health problems continue to rise, the attention of policy-makers is increasingly turning to Screening and Brief Intervention (SBI) programmes. The effectiveness of such programmes in primary healthcare is well evidenced, but very few cost-effectiveness analyses have been conducted and none which specifically consider the Italian context.
Methods
The Sheffield Alcohol Policy Model has been used to model the cost-effectiveness of government pricing and public health policies in several countries including England. This study adapts the model using Italian data to evaluate a programme of screening and brief interventions in Italy. Results are reported as Incremental Cost-Effectiveness Ratios (ICERs) of SBI programmes versus a ‘do-nothing’ scenario.
Results
Model results show such programmes to be highly cost-effective, with estimated ICERs of €550/Quality Adjusted Life Year (QALY) gained for a programme of SBI at next GP registration and €590/QALY for SBI at next GP consultation. A range of sensitivity analyses suggest these results are robust under all but the most pessimistic assumptions.
Conclusions
This study provides strong support for the promotion of a policy of screening and brief interventions throughout Italy, although policy makers should be aware of the resource implications of different implementation options.
doi:10.1186/1471-2296-15-26
PMCID: PMC3936801  PMID: 24502342
Public health interventions; Alcohol; Primary care; Cost-effectiveness
22.  "Seeing a doctor is just like having a date": a qualitative study on doctor shopping among overactive bladder patients in Hong Kong 
BMC Family Practice  2014;15:27.
Background
Although having a regular primary care provider is noted to be beneficial to health, doctor shopping has been documented as a common treatment seeking behavior among chronically ill patients in different countries. However, little research has been conducted into the reasons behind doctor shopping behavior among patients with overactive bladder, and even less into how this behavior relates to these patients’ illness and social experiences, perceptions, and cultural practices. Therefore, this study examines overactive bladder patients to investigate the reasons behind doctor shopping behavior.
Methods
My study takes a qualitative approach, conducting 30 semi-structured individual interviews, with 30 overactive bladder patients in Hong Kong.
Results
My study found six primary themes that influenced doctor shopping behavior: lack of perceived need, convenience, work-provided medical insurance, unpleasant experiences with doctors, searching for a match doctor, and switching between biomedicine and traditional Chinese medicine. Besides the perceptual factors, participants’ social environment, illness experiences, personal cultural preference, and cultural beliefs also intertwined to generate their doctor shopping behavior. Due to the low perceived need for a regular personal primary care physician, environmental factors such as time, locational convenience, and work-provided medical insurance became decisive in doctor shopping behavior. Patients’ unpleasant illness experiences, stemming from a lack of understanding among many primary care doctors about overactive bladder, contributed to participants’ sense of mismatch with these doctors, which induced them to shop for another doctor.
Conclusions
Overactive bladder is a chronic bladder condition with very limited treatment outcome. Although patients with overactive bladder often require specialty urology treatment, it is usually beneficial for the patients to receive continuous, coordinated, comprehensive, and patient-centered support from their primary care providers. Primary care doctors’ understanding on patients with overactive bladder with empathetic attitudes is important to reduce the motivations of doctor shopping behavior among these patients.
doi:10.1186/1471-2296-15-27
PMCID: PMC3936809  PMID: 24502367
Hong Kong; Doctor shopping; Perceptions; Social environment; Illness and treatment experiences; Personal cultural preference; Cultural beliefs; Overactive bladder patients
23.  A qualitative study of CVD management and dietary changes: problems of ‘too much’ and ‘contradictory’ information 
BMC Family Practice  2014;15:25.
Background
Nutrition education for cardiovascular disease (CVD) management is not effective for all population groups. There is little understanding of the factors that hinder patients from adhering to dietary recommendations.
Methods
37 interviews were conducted with people living with CVD in Adelaide, Australia. Recruitment occurred via General Practitioner (GP) clinics and hospital cardiac rehabilitation programs. Participants were either receiving preventive treatment or active treatment for established CVD.
Results
The volume and contradictory nature of dietary information were the most prominent barriers to making changes identified in interviews, especially by order participants.
Conclusion
Patients will seek out, or come into contact with information which contradicts advice from their GPs. The volume of information may lead them to resort to old and familiar habits. GPs play a valuable role in highlighting key take-home messages and reliable external sources of information. The findings have implications for GP practice given that lifestyle changes are a cost- and clinically-effective means of managing CVD.
doi:10.1186/1471-2296-15-25
PMCID: PMC3916316  PMID: 24495674
General practice; Cardiovascular disease; Lifestyle; Diet; Australia
24.  Nurse-led telecoaching of people with type 2 diabetes in primary care: rationale, design and baseline data of a randomized controlled trial 
BMC Family Practice  2014;15:24.
Background
Despite the efforts of the healthcare community to improve the quality of diabetes care, about 50% of people with type 2 diabetes do not reach their treatment targets, increasing the risk of future micro-and macro-vascular complications. Diabetes self-management education has been shown to contribute to better disease control. However, it is not known which strategies involving educational programs are cost-effective. Telehealth applications might support chronic disease management. Transferability of successful distant patient self-management support programs to the Belgian setting needs to be confirmed by studies of a high methodological quality. “The COACH Program” was developed in Australia as target driven educational telephone delivered intervention to support people with different chronic conditions. It proved to be effective in patients with coronary heart disease after hospitalization. Clinical and cost-effectiveness of The COACH Program in people with type 2 diabetes in Belgium needs to be assessed.
Methods/Design
Randomized controlled trial in patients with type 2 diabetes. Patients were selected based on their medication consumption data and were recruited by their sickness fund. They were randomized to receive either usual care plus “The COACH Program” or usual care alone. The study will assess the difference in outcomes between groups. The primary outcome measure is the level of HbA1c. The secondary outcomes are: Total Cholesterol, LDL-Cholesterol, HDL-Cholesterol, Triglycerides, Blood Pressure, body mass index, smoking status; proportion of people at target for HbA1c, LDL-Cholesterol and Blood Pressure; self-perceived health status, diabetes-specific emotional distress and satisfaction with diabetes care. The follow-up period is 18 months. Within-trial and modeled cost-utility analyses, to project effects over life-time horizon beyond the trial duration, will be undertaken from the perspective of the health care system if the intervention is effective.
Discussion
The study will enhance our understanding of the potential of telehealth in diabetes management in Belgium. Research on the clinical effectiveness and the cost-effectiveness is essential to support policy makers in future reimbursement and implementation decisions.
Trial registration
Belgian number: B322201213625. ClinicalTrials.gov Identifier: NCT01612520
doi:10.1186/1471-2296-15-24
PMCID: PMC3922086  PMID: 24495633
Type 2 diabetes mellitus; Telenursing; RCT; Economic analysis
25.  Primary care quality improvement from a practice facilitator’s perspective 
BMC Family Practice  2014;15:23.
Background
Practice facilitation has proven to be effective at improving care delivery. Practice facilitators are healthcare professionals who work with and support other healthcare providers. To the best of our knowledge, very few studies have explored the perspective of facilitators. The objective of this study was to gain insight into the barriers that facilitators face during the facilitation process and to identify approaches used to overcome these barriers to help practices move towards positive change.
Methods
We conducted semi-structured interviews with four practice facilitators who worked with 84 primary care practices in Eastern Ontario, Canada over a period of five years (2007–2012). The transcripts were analyzed independently by three members of the research team using an open coding technique. A qualitative data analysis using immersion/crystallization technique was applied to interpret the interview transcripts.
Results
Common barriers identified by the facilitators included accessibility to the practice (e.g., difficulty scheduling meetings, short meetings), organizational behaviour (team organization, team conflicts, etc.), challenges with practice engagement (e.g., lack of interest, lack of trust), resistance to change, and competing priorities. To help practices move towards positive change the facilitators had to tailor their approach, integrate themselves, be persistent with practices, and exhibit flexibility.
Conclusions
The consensus on redesigning and transforming primary care in North America and around the world is rapidly growing. Practice facilitation has been pivotal in materializing the transformation in the way primary care practices deliver care. This study provides an exclusive insight into facilitator approaches which will assist the design and implementation of small- and large-scale facilitation interventions.
doi:10.1186/1471-2296-15-23
PMCID: PMC3931473  PMID: 24490746
Practice facilitation; Practice facilitators; Cardiovascular health; Primary care; Quality improvement; Practice culture

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