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1.  Quality of asthma care under different primary care models in Canada: a population-based study 
BMC Family Practice  2015;16:19.
Background
Previous research has shown variations in quality of care and patient outcomes under different primary care models. The objective of this study was to use previously validated, evidence-based performance indicators to measure quality of asthma care over time and to compare quality of care between different primary care models.
Methods
Data were obtained for years 2006 to 2010 from the Ontario Asthma Surveillance Information System, which uses health administrative databases to track individuals with asthma living in the province of Ontario, Canada. Individuals with asthma (n=1,813,922) were divided into groups based on the practice model of their primary care provider (i.e., fee-for-service, blended fee-for-service, blended capitation). Quality of asthma care was measured using six validated, evidence-based asthma care performance indicators.
Results
All of the asthma performance indicators improved over time within each of the primary care models. Compared to the traditional fee-for-service model, the blended fee-for-service and blended capitation models had higher use of spirometry for asthma diagnosis and monitoring, higher rates of inhaled corticosteroid prescription, and lower outpatient claims. Emergency department visits were lowest in the blended fee-for-service group.
Conclusions
Quality of asthma care improved over time within each of the primary care models. However, the amount by which they improved differed between the models. The newer primary care models (i.e., blended fee-for-service, blended capitation) appear to provide better quality of asthma care compared to the traditional fee-for-service model.
Electronic supplementary material
The online version of this article (doi:10.1186/s12875-015-0232-y) contains supplementary material, which is available to authorized users.
doi:10.1186/s12875-015-0232-y
PMCID: PMC4336688
Asthma; Quality of care; Performance measures; Health indicators; Health services use
2.  Timeliness in chronic kidney disease and albuminuria identification: a retrospective cohort study 
BMC Family Practice  2015;16:18.
Background
Chronic kidney disease (CKD) is predominantly managed in primary care in the UK, but there is evidence of under-identification leading to lack of inclusion on practice chronic disease registers, which are necessary to ensure disease monitoring. Guidelines for CKD patients recommend urinary albumin to creatinine ratio (uACR) testing to identify albuminuria to stratify risk and guide management. This study aimed to describe the pattern and associations of timely CKD registration and uACR testing.
Methods
A retrospective cohort of individuals with incident CKD 3–5 (two estimated glomerular filtration rates (eGFR) <60 ml/min/1.73 m2 ≥ three months apart) between 2007 and 2013 was identified from a linked database containing primary and secondary care data. Descriptive statistics and Cox proportional hazards models were used to identify associations with patient characteristics of timely CKD registration and uACR testing (within a year of first low eGFR).
Results
12,988 people with CKD 3–5 were identified from 88 practices and followed for median 3.3 years. During this time period, 3235 (24.9%) were CKD-registered and 4638/12,988 (35.7%) had uACR testing (median time to CKD registration 307 days and to uACR test 379 days). 1829 (14.1%) were CKD-registered and 2229 (17.2%) had uACR testing within one year. Amongst people whose CKD was registered within a year, 676/1829 (37.0%) had uACR testing within a year (vs. 1553/11,159 (13.9%) of those not registered (p < 0.001)). Timely uACR testing varied by year, with a sharp rise in proportion in 2009 (when uACR policy changed). Timely CKD registration was independently associated with lower eGFR, being female, earlier year of joining the cohort, having diabetes, hypertension, or cardiovascular disease but not with age. Timely uACR testing was associated with timely CKD registration, younger age, having diabetes, higher baseline eGFR and later year of joining the cohort.
Conclusions
Better systems are needed to support timely CKD identification, registration and uACR testing in primary care in order to facilitate risk stratification and appropriate clinical management.
Electronic supplementary material
The online version of this article (doi:10.1186/s12875-015-0235-8) contains supplementary material, which is available to authorized users.
doi:10.1186/s12875-015-0235-8
PMCID: PMC4333177
Chronic kidney disease; Albuminuria; Risk; General practice
3.  General practitioners’ perceptions on home medicines reviews: a qualitative analysis 
BMC Family Practice  2015;16:16.
Background
Home Medicines Review (HMR) is an Australian initiative introduced in 2001 to improve quality use of medicines. Medication management services such as HMRs have the potential to reduce medication related problems. In 2011, changes to the HMR program were introduced to allow for referrals directly to accredited pharmacists in addition to the community pharmacy referral model. These changes were introduced to improve efficiency of the process. This study explored the perceptions of Western Australian general practitioners (GPs) on benefits and barriers of the HMR service and process, including their insights into the direct referral model.
Methods
Purposive sampling of GPs who had experience ensured that participants had a working knowledge of the HMR service. Semi structured interviews with 24 GPs from 14 metropolitan Western Australian medical centres between March and May 2013. Transcribing and thematic analysis of data were performed.
Results
Most GPs had positive attitudes towards the HMR service. Main perceived benefits of the service were poly-pharmacy reduction and education for both the GP and patient. Strategies identified to improve the service were introduction of a standard HMR report template for pharmacists and better use of technology. Whilst reliability and GPs’ familiarity were the main perceived benefits of the direct referral model, a number of GPs agreed that patient unfamiliarity with the HMR pharmacist was a barrier.
Conclusions
Despite recognition of the value of the HMR service participating GPs were of the opinion that there are aspects of the HMR service that could be improved. As one of the success factors of HMRs is relying on GPs to utilise this service, this study provides valuable insight into issues that need to be addressed to improve HMR uptake.
doi:10.1186/s12875-015-0227-8
PMCID: PMC4332443
Pharmacists; Home Medicines Reviews; General practitioners
4.  Prescription of antibiotics and anxiolytics/hypnotics to asthmatic patients in general practice: a cross-sectional study based on French and Italian prescribing data 
BMC Family Practice  2015;16:14.
Background
Asthma is often poorly controlled and guidelines are often inadequately followed in medical practice. In particular, the prescription of non-asthma-specific drugs can affect the quality of care. The goal of this study was to measure the frequency of the prescription of antibiotics and anxiolytics/hypnotics to asthmatic patients and to look for associations between sex or age and the prescription of these drugs.
Methods
A cross-sectional study was conducted using computerised medical records from French and Italian general practitioners’ networks. Patients were selected according to criteria adapted from the HEDIS (Healthcare Effectiveness Data and Information Set) criteria. The outcome measure was the number of antibiotics or anxiolytics/hypnotics prescriptions per patient in 1 year. Parallel multivariate models were developed.
Results
The final sample included 3,093 French patients (mean age 27.6 years, 49.7% women) and 3,872 Italian patients (mean age 29.1 years, 48.7% women). In the univariate analysis, the French patients were prescribed fewer antibiotics than the Italian patients (37.1% vs. 42.2%, p < 0.00001) but more anxiolytics/hypnotics (17.8% vs. 6.9%, p < 0.0001). In the multivariate models, the female patients were more likely to receive antibiotics (odds ratio: 1.5 [1.3–1.7]) and anxiolytics/hypnotics (odds ratio: 1.8 [1.5–2.1]).
Conclusions
The prescription of antibiotics and anxiolytics/hypnotics to asthmatic patients is frequent, especially in women. Asthma guidelines should address this issue by referring to other guidelines covering the prescription of non-asthma-specific drugs, and alternative non-pharmacological interventions should be considered.
doi:10.1186/s12875-015-0222-0
PMCID: PMC4326444  PMID: 25655671
Asthma; Antibiotics; Anxiolytics; Hypnotics; Drug prescription; Primary care
5.  Clinical and haematological predictors of antibiotic prescribing for acute cough in adults in Swiss practices – an observational study 
BMC Family Practice  2015;16:15.
Background
Acute cough is a common problem in general practice and is often caused by a self-limiting, viral infection. Nonetheless, antibiotics are often prescribed in this situation, which may lead to unnecessary side effects and, even worse, the development of antibiotic resistant microorganisms worldwide. This study assessed the role of point-of-care C-reactive protein (CRP) testing and other predictors of antibiotic prescription in patients who present with acute cough in general practice.
Methods
Patient characteristics, symptoms, signs, and laboratory and X-ray findings from 348 patients presenting to 39 general practitioners with acute cough, as well as the GPs themselves, were recorded by fourth-year medical students during their three-week clerkships in general practice. Patient and clinician characteristics of those prescribed and not-prescribed antibiotics were compared using a mixed-effects model.
Results
Of 315 patients included in the study, 22% were prescribed antibiotics. The two groups of patients, those prescribed antibiotics and those treated symptomatically, differed significantly in age, demand for antibiotics, days of cough, rhinitis, lung auscultation, haemoglobin level, white blood cell count, CRP level and the GP’s license to self-dispense antibiotics. After regression analysis, only the CRP level, the white blood cell count and the duration of the symptoms were statistically significant predictors of antibiotic prescription.
Conclusions
The antibiotic prescription rate of 22% in adult patients with acute cough in the Swiss primary care setting is low compared to other countries. GPs appear to use point-of-care CRP testing in addition to the duration of clinical symptoms to help them decide whether or not to prescribe antibiotics.
doi:10.1186/s12875-015-0226-9
PMCID: PMC4328046  PMID: 25655784
Acute cough; Antibiotics; Primary care of Switzerland; Point-of-care CRP testing
6.  From patient care to research: a validation study examining the factors contributing to data quality in a primary care electronic medical record database 
BMC Family Practice  2015;16:11.
Background
Electronic Medical Records (EMRs) are increasingly used in the provision of primary care and have been compiled into databases which can be utilized for surveillance, research and informing practice. The primary purpose of these records is for the provision of individual patient care; validation and examination of underlying limitations is crucial for use for research and data quality improvement. This study examines and describes the validity of chronic disease case definition algorithms and factors affecting data quality in a primary care EMR database.
Methods
A retrospective chart audit of an age stratified random sample was used to validate and examine diagnostic algorithms applied to EMR data from the Manitoba Primary Care Research Network (MaPCReN), part of the Canadian Primary Care Sentinel Surveillance Network (CPCSSN). The presence of diabetes, hypertension, depression, osteoarthritis and chronic obstructive pulmonary disease (COPD) was determined by review of the medical record and compared to algorithm identified cases to identify discrepancies and describe the underlying contributing factors.
Results
The algorithm for diabetes had high sensitivity, specificity and positive predictive value (PPV) with all scores being over 90%. Specificities of the algorithms were greater than 90% for all conditions except for hypertension at 79.2%. The largest deficits in algorithm performance included poor PPV for COPD at 36.7% and limited sensitivity for COPD, depression and osteoarthritis at 72.0%, 73.3% and 63.2% respectively. Main sources of discrepancy included missing coding, alternative coding, inappropriate diagnosis detection based on medications used for alternate indications, inappropriate exclusion due to comorbidity and loss of data.
Conclusions
Comparison to medical chart review shows that at MaPCReN the CPCSSN case finding algorithms are valid with a few limitations. This study provides the basis for the validated data to be utilized for research and informs users of its limitations. Analysis of underlying discrepancies provides the ability to improve algorithm performance and facilitate improved data quality.
doi:10.1186/s12875-015-0223-z
PMCID: PMC4324413  PMID: 25649201
Electronic Medical Records; Primary Care; Chronic Disease; Health Information Systems
7.  Who gets a family physician through centralized waiting lists? 
BMC Family Practice  2015;16:10.
Background
North American patients are experiencing difficulties in securing affiliations with family physicians. Centralized waiting lists are increasingly being used in Organisation for Economic Co-operation and Development countries to improve access. In 2011, the Canadian province of Quebec introduced new financial incentives for family physicians’ enrolment of orphan patients through centralized waiting lists, the Guichet d’accès aux clientèles orphelines, with higher payments for vulnerable patients. This study analyzed whether any significant changes were observed in the numbers of patient enrolments with family physicians’ after the introduction of the new financial incentives. Prior to then, financial incentives had been offered for enrolment of vulnerable patients only and there were no incentives for enrolling non-vulnerable patients. After 2011, financial incentives were also offered for enrolment of non-vulnerable patients, while those for enrolment of vulnerable patients were doubled.
Methods
A longitudinal quantitative analysis spanning a five-year period (2008–2013) was performed using administrative databases covering all patients enrolled with family physicians through centralized waiting lists in the province of Quebec (n = 494,697 patients). Mixed regression models for repeated-measures were used.
Results
The number of patients enrolled with a family physician through centralized waiting lists more than quadrupled after the changes in financial incentives. Most of this increase involved non-vulnerable patients. After the changes, 70% of patients enrolled with a family physician through centralized waiting lists were non-vulnerable patients, most of whom had been referred to the centralized waiting lists by the physician who enrolled them, without first being registered in those lists or having to wait because of their priority level.
Conclusion
Centralized waiting lists linked to financial incentives increased the number of family physicians’ patient enrolments. However, although vulnerable patients were supposed to be given precedence, physicians favoured enrolment of healthier patients over those with greater health needs and higher assessed priority. These results suggest that introducing financial incentives without appropriate regulations may lead to opportunistic use of the incentive system with unintended policy consequences.
doi:10.1186/s12875-014-0220-7
PMCID: PMC4328670  PMID: 25649074
Payment; Incentives; Centralized waiting lists; Registry; Enrolment; Vulnerable patients
8.  Results of a survey among GP practices on how they manage patient safety aspects related to point-of-care testing in every day practice 
BMC Family Practice  2015;16:9.
Background
Point-of-care (POC) tests are devices or test strips that can be used near or at the site where care is delivered to patients, enabling a relatively fast diagnosis. Although many general practitioners (GPs) in the Netherlands are using POC tests in their practice, little is known on how they manage the corresponding patient safety aspects.
Methods
To obtain information on this aspect, an invitation to participate in a web-based questionnaire was sent to a random sample of 750 GP practices. Of this sample 111 GP practices returned a complete questionnaire. Data was analysed by using descriptive statistics.
Results
Results show that there is not always attention for quality control measures such as checking storage conditions, executing calibration, and maintenance. In addition, universal hygienic measures, such as washing hands before taking a blood sample, are not always followed. Refresher courses on the use of POC tests are hardly organized. Only a few of the GPs contact the manufacturer of the device when a device failure occurs. Well-controlled aspects include patient identification and actions taken when ambiguous test results are obtained.
Conclusions
We observed a number of risks for errors with POC tests in GP practices that may be reduced by proper training of personnel, introduction of standard operating procedures and measures for quality control and improved hygiene. To encourage proper use of POCT in general practices, a national POCT guideline, dedicated to primary care and in line with ISO standards, should be introduced.
Electronic supplementary material
The online version of this article (doi:10.1186/s12875-014-0217-2) contains supplementary material, which is available to authorized users.
doi:10.1186/s12875-014-0217-2
PMCID: PMC4332919  PMID: 25648985
9.  Missed opportunities: general practitioner identification of their patients’ smoking status 
BMC Family Practice  2015;16:8.
Background
In order to provide smoking cessation support to their patients in line with clinical practice guidelines, general practitioners must first ascertain whether their patients’ use tobacco. This study examined (i) the sensitivity, specificity, positive predictive value and negative predictive value of general practitioner detection of smoking, and (ii) the general practitioner and patient characteristics associated with detection of tobacco use.
Methods
Eligible patients completed a touchscreen computer survey while waiting for an appointment with their general practitioner. Patients self-reported demographic characteristics, medical history, and current smoking status. Following the patient’s consultation, their general practitioner was asked to indicate whether the patient was a current smoker (yes/no/unsure/not applicable). Smoking prevalence, sensitivity, specificity, positive predictive value and negative predictive values (with 95% confidence intervals) were calculated using patient self-report of smoking status as the gold standard. Generalised estimating equations were used to examine the general practitioner and patient characteristics associated with detection of tobacco use.
Results
Fifty-one general practitioners and 1,573 patients in twelve general practices participated. Patient self-report of smoking was 11.3% compared to general practitioner estimated prevalence of 9.5%. Sensitivity of general practitioner assessment was 66% [95% CI 59–73] while specificity was 98% [95% CI 97–98]. Positive predictive value was 78% [95% CI 71–85] and negative predictive value was 96% [95% CI 95–97]. No general practitioner factors were associated with detection of smoking. Patients with a higher level of education or who responded ‘Other’ were less likely to be detected as smokers than patients who had completed a high school or below level of education.
Conclusion
Despite the important role general practitioners play in providing smoking cessation advice and support, a substantial proportion of general practitioners do not know their patient’s smoking status. This represents a significant missed opportunity in the provision of preventive healthcare. Electronic waiting room assessments may assist general practitioners in improving the identification of smokers.
doi:10.1186/s12875-015-0228-7
PMCID: PMC4333157  PMID: 25649312
General practice; Detection; Smoking; Smoking cessation
10.  Prescribing style and variation in antibiotic prescriptions for sore throat: cross-sectional study across six countries 
BMC Family Practice  2015;16:7.
Background
Variation in prescription of antibiotics in primary care can indicate poor clinical practice that contributes to the increase of resistant strains. General Practitioners (GPs), as a professional group, are expected to have a fairly homogeneous prescribing style. In this paper, we describe variation in prescribing style within and across groups of GPs from six countries.
Methods
Cross-sectional study with the inclusion of 457 GPs and 6394 sore throat patients. We describe variation in prescribing antibiotics for sore throat patients across six countries and assess whether variation in “prescribing style” – understood as a subjective tendency to prescribe – has an important effect on variation in prescription of antibiotics by using the concept of prescribing style as a latent variable in a multivariable model. We report variation as a Median Odds Ratio (MOR) which is the transformation of the random effect variance onto an odds ratio; Thus, MOR = 1 means similar odds or strict homogeneity between GPs’ prescribing style, while a MOR higher than 1 denotes heterogeneity in prescribing style.
Results
In all countries some GPs always prescribed antibiotics to all their patients, while other GPs never did. After adjusting for patient and GP characteristics, prescribing style in the group of GPs from Russia was about three times more heterogeneous than the prescribing style in the group of GPs from Denmark – Median Odds Ratio (6.8, 95% CI 3.1;8.8) and (2.6, 95% CI 2.2;4.4) respectively.
Conclusion
Prescribing style is an important source of variation in prescription of antibiotics within and across countries, even after adjusting for patient and GP characteristics. Interventions aimed at influencing the prescribing style of GPs must encompass context-specific actions at the policy-making level alongside GP-targeted interventions to enable GPs to react more objectively to the external demands that are in place when making the decision of prescribing antibiotics or not.
doi:10.1186/s12875-015-0224-y
PMCID: PMC4316394  PMID: 25630870
11.  More negative self-esteem and inferior coping strategies among patients diagnosed with IBS compared with patients without IBS - a case–control study in primary care 
BMC Family Practice  2015;16:6.
Background
Irritable Bowel Syndrome (IBS) is a chronic, relapsing gastrointestinal disorder, that affects approximately 10% of the general population and the majority are diagnosed in primary care. IBS has been reported to be associated with altered psychological and cognitive functioning such as mood disturbances, somatization, catastrophizing or altered visceral interoception by negative emotions and stress. The aim was to investigate the psychosocial constructs of self-esteem and sense of coherence among IBS patients compared to non-IBS patients in primary care.
Methods
A case–control study in primary care setting among IBS patients meeting the ROME III criteria (n = 140) compared to controls i.e. non-IBS patients (n = 213) without any present or previous gastrointestinal complaints. The data were collected through self-reported questionnaires of psychosocial factors.
Results
IBS-patients reported significantly more negative self-esteem (p < 0.001), lower scores for positive self-esteem (p < 0.001), and lower sense of coherence (p < 0.001) than the controls. The IBS-cases were also less likely to report ‘good’ health status (p < 0.001) and less likely to report a positive belief in the future (p < 0.001). After controlling for relevant confounding factors in multiple regressions, the elevation in negative self-esteem among IBS patients remained statistically significant (p = 0.02), as did the lower scores for sense of coherence among IBS cases (p = 0.04).
Conclusions
The more frequently reported negative self-esteem and inferior coping strategies among IBS patients found in this study suggest the possibility that psychological therapies might be helpful for these patients. However these data do not indicate the causal direction of the observed associations. More research is therefore warranted to determine whether these psychosocial constructs are more frequent in IBS patients.
doi:10.1186/s12875-015-0225-x
PMCID: PMC4316793  PMID: 25626450
Primary care; IBS; Self-esteem; Coping; Psychosocial factors
12.  Be SMART: examining the experience of implementing the NHS Health Check in UK primary care 
BMC Family Practice  2015;16:1.
Background
The NHS Health Check was designed by UK Department of Health to address increased prevalence of cardiovascular disease by identifying risk levels and facilitating behaviour change. It constituted biomedical testing, personalised advice and lifestyle support. The objective of the study was to explore Health Care Professionals’ (HCPs) and patients’ experiences of delivering and receiving the NHS Health Check in an inner-city region of England.
Methods
Patients and HCPs in primary care were interviewed using semi-structured schedules. Data were analysed using Thematic Analysis.
Results
Four themes were identified. Firstly, Health Check as a test of ‘roadworthiness’ for people. The roadworthiness metaphor resonated with some patients but it signified a passive stance toward illness. Some patients described the check as useful in the theme, Health check as revelatory. HCPs found visual aids demonstrating levels of salt/fat/sugar in everyday foods and a ‘traffic light’ tape measure helpful in communicating such ‘revelations’ with patients. Being SMART and following the protocolrevealed that few HCPs used SMART goals and few patients spoke of them. HCPs require training to understand their rationale compared with traditional advice-giving. The need for further follow-up revealed disparity in follow-ups and patients were not systematically monitored over time.
Conclusions
HCPs’ training needs to include the use and evidence of the effectiveness of SMART goals in changing health behaviours. The significance of fidelity to protocol needs to be communicated to HCPs and commissioners to ensure consistency. Monitoring and measurement of follow-up, e.g., tracking of referrals, need to be resourced to provide evidence of the success of the NHS Health Check in terms of healthier lifestyles and reduced CVD risk.
doi:10.1186/s12875-014-0212-7
PMCID: PMC4308836  PMID: 25608667
Cardiovascular diseases; Public health; Preventive medicine; Health behaviour; Intervention studies; Qualitative research
13.  Trajectories of multimorbidity: exploring patterns of multimorbidity in patients with more than ten chronic health problems in life course 
BMC Family Practice  2015;16:2.
Background
Physicians are frequently confronted with complex health situations of patients, but knowledge of intensive forms of multimorbidity and their development during life is lacking.
This study explores patterns and trajectories of chronic health problems of patients with multimorbidity particularly those with more than ten conditions and type and variety of organ systems involved in these patterns during life.
Method
Life time prevalence patterns of chronic health problems were determined in patients with illness trajectories accumulating more than ten chronic health problems during life as registered by general practitioners in the South of the Netherlands in the Registration Network Family Practices (RNH).
Results
Overall 4,560 subjects (5%) were registered with more than ten chronic health problems during their life (MM11+), accounting for 61,653 (20%) of the 302,808 registered health problems in the population (N = 87,837 subjects). More than 30% accumulates 4 or more chronic health conditions (MM4-5: 4–5 conditions (N = 14,199; 16.2%); MM6-10: 6–10 conditions (N = 14,365; 16.4%).
Gastro-intestinal, cardiovascular, locomotor, respiratory and metabolic conditions occur more frequently in the MM11+ patients than in the other patients, while the nature and variety of body systems involved in lifetime accumulation of chronic health problem clusters is both generic and specific. Regarding chronic conditions afflicting multiple sites throughout the body, the number of neoplasms seems low (N = 3,592; 5.8%), but 2,461 (49%) of the 4,560 subjects have registered at least one neoplasm condition during life. A similar pattern is noted for inflammation (N = 3,537, 78%), infection (N = 2,451, 54%) and injury (N = 3,401, 75%).
Conclusion
There are many challenges facing multimorbidity research, including the implementation of a longitudinal, life-time approach from a family practice perspective. The present study, although exploratory by nature, shows that both general and specific mechanisms characterize the development of multimorbidity trajectories. A small proportion of patients has a high number of chronic health problems (MM11+) and keeps adding health problems during life. However, GP’s need to realise that more than one third of their patients accumulate four or more chronic health problems (MM4-5 and MM6-10) during life.
doi:10.1186/s12875-014-0213-6
PMCID: PMC4311460  PMID: 25608728
Multimorbidity; Life time prevalence; Chronic health problems; Illness trajectories; General practice; Intensive forms of multimorbidity; Susceptibility
14.  What do general practitioners think about an online self-regulation programme for health promotion? Focus group interviews 
BMC Family Practice  2015;16:3.
Background
Chronic diseases may be prevented through programmes that promote physical activity and healthy nutrition. Computer-tailoring programmes are effective in changing behaviour in the short- and long-term. An important issue is the implementation of these programmes in general practice. However, there are several barriers that hinder the adoption of eHealth programmes in general practice. This study explored the feasibility of an eHealth programme that was designed, using self-regulation principles.
Methods
Seven focus group interviews (a total of 62 GPs) were organized to explore GPs’ opinions about the feasibility of the eHealth programme for prevention in general practice. At the beginning of each focus group, GPs were informed about the principles of the self-regulation programme ‘My Plan’. Open-ended questions were used to assess the opinion of GPs about the content and the use of the programme. The focus groups discussions were audio-taped, transcribed and thematically analysed via NVivo software.
Results
The majority of the GPs was positive about the use of self-regulation strategies and about the use of computer-tailored programmes in general practice. There were contradictory results about the delivery mode of the programme. GPs also indicated that the programme might be less suited for patients with a low educational level or for old patients.
Conclusions
Overall, GPs are positive about the adoption of self-regulation techniques for health promotion in their practice. However, they raised doubts about the adoption in general practice. This barrier may be addressed (1) by offering various ways to deliver the programme, and (2) by allowing flexibility to match different work flow systems. GPs also believed that the acceptability and usability of the programme was low for patients who are old or with low education. The issues raised by GPs will need to be taken into account when developing and implementing an eHealth programme in general practice.
Electronic supplementary material
The online version of this article (doi:10.1186/s12875-014-0214-5) contains supplementary material, which is available to authorized users.
doi:10.1186/s12875-014-0214-5
PMCID: PMC4311516  PMID: 25608851
Health promotion; Physical activity; Healthy nutrition; General practitioners; Self-regulation; eHealth; Tablets; Computer tailoring; Feasibility
15.  Modifiable risk factors associated with prediabetes in men and women: a cross-sectional analysis of the cohort study in primary health care on the evolution of patients with prediabetes (PREDAPS-Study) 
BMC Family Practice  2015;16:5.
Background
Prediabetes is a high-risk state for diabetes development, but little is known about the factors associated with this state. The aim of the study was to identify modifiable risk factors associated with the presence of prediabetes in men and women.
Methods
Cohort Study in Primary Health Care on the Evolution of Patients with Prediabetes (PREDAPS-Study) is a prospective study on a cohort of 1184 subjects with prediabetes and another cohort of 838 subjects without glucose metabolism disorders. It is being conducted by 125 general practitioners in Spain. Data for this analysis were collected during the baseline stage in 2012. The modifiable risk factors included were: smoking habit, alcohol consumption, low physical activity, inadequate diet, hypertension, dyslipidemia, and obesity. To assess independent association between each factor and prediabetes, odds ratios (ORs) were estimated using logistic regression models.
Results
Abdominal obesity, low plasma levels of high-density lipoprotein cholesterol (HDL-cholesterol), and hypertension were independently associated with the presence of prediabetes in both men and women. After adjusting for all factors, the respective ORs (95% Confidence Intervals) were 1.98 (1.41-2.79), 1.88 (1.23-2.88) and 1.86 (1.39-2.51) for men, and 1.89 (1.36-2.62), 1.58 (1.12-2.23) and 1.44 (1.07-1.92) for women. Also, general obesity was a risk factor in both sexes but did not reach statistical significance among men, after adjusting for all factors. Risky alcohol consumption was a risk factor for prediabetes in men, OR 1.49 (1.00-2.24).
Conclusions
Obesity, low HDL-cholesterol levels, and hypertension were modifiable risk factors independently related to the presence of prediabetes in both sexes. The magnitudes of the associations were stronger for men than women. Abdominal obesity in both men and women displayed the strongest association with prediabetes. The findings suggest that there are some differences between men and women, which should be taken into account when implementing specific recommendations to prevent or delay the onset of diabetes in adult population.
doi:10.1186/s12875-014-0216-3
PMCID: PMC4316391  PMID: 25609029
Prediabetes; Modifiable risk factors; Primary health care; Men; Women; Spain
16.  “It’s MAGIC” - development of a manageable geriatric assessment for general practice use 
BMC Family Practice  2015;16:4.
Background
Geriatric assessments are established tools in institutional care since they enable standardized detection of relevant age-related disorders. Geriatric assessments could also be helpful in general practice. However, they are infrequently used in this setting, mainly due to their lengthy administration. The aim of the study was the development of a “manageable geriatric assessment – MAGIC”, specially tailored to the requirements of daily primary care.
Methods
MAGIC was developed based on the comprehensive Standardized Assessment for Elderly People in Primary Care (STEP), using four different methodological approaches: We relied on A) the results of the PRISCUS study by assessing the prevalence of health problems uncovered by STEP, the importance of the respective problems rated by patients and general practitioners, as well as the treatment procedures initiated subsequently to the assessment. Moreover, we included findings of B) a literature analysis C) a review of the STEP assessment by experienced general practitioners and D) focus groups with general practitioners.
Results
The newly created MAGIC assessment consists of 9 items and covers typical geriatric health problems and syndromes: function, falls, incontinence, cognitive impairment, impaired ears and eyes, vaccine coverage, emotional instability and isolation.
Conclusions
MAGIC promises to be a helpful screening instrument in primary care consultations involving elderly multimorbid patients. Applicable within a minimum of time it still covers health problems highly relevant with regard to a potential loss of autonomy. Feasibility will be tested in the context of a large, still ongoing randomized controlled trial on “reduction of potentially inadequate medication in elderly patients” (RIME study; DRKS-ID: DRKS00003610) in general practice.
doi:10.1186/s12875-014-0215-4
PMCID: PMC4320637  PMID: 25608946
Geriatric assessment; General practice; Health services for the aged; Questionnaire design; Chronic diseases
17.  Efficacy and safety of autologous platelet rich plasma for the treatment of vascular ulcers in primary care: Phase III study 
BMC Family Practice  2014;15(1):211.
Background
Vascular ulcers are commonly seen in daily practice at all levels of care and have great impact at personal, professional and social levels with a high cost in terms of human and material resources. Given that the application of autologous platelet rich plasma has been shown to decrease healing times in various different studies in the hospital setting, we considered that it would be interesting to assess the efficacy and feasibility of this treatment in primary care. The objectives of this study are to assess the potential efficacy and safety of autologous platelet rich plasma for the treatment of venous ulcers compared to the conventional treatment (moist wound care) in primary care patients with chronic venous insufficiency (C, clinical class, E, aetiology, A, anatomy and P, pathophysiology classification C6).
Design
We will conduct a phase III, open-label, parallel-group, multicentre, randomized study. The subjects will be 150 patients aged between 40 and 100 years of age with an at least 2-month history of a vascular venous ulcer assigned to ten primary care centres. For the treatment with autologous platelet rich plasma, all the following tasks will be performed in the primary care setting: blood collection, centrifugation, separation of platelet rich plasma, activation of coagulation adding calcium chloride and application of the PRP topically after gelification. The control group will receive standard moist wound care. The outcome variables to be measured at baseline, and at weeks 5 and 9 later include: reduction in the ulcer area, Chronic Venous Insufficiency Quality of Life Questionnaire score, and percentage of patients who require wound care only once a week.
Discussion
The results of this study will be useful to improve the protocol for using platelet rich plasma in chronic vascular ulcers and to favour wider use of this treatment in primary care.
Trial registration
Current Controlled Trials NCT02213952
doi:10.1186/s12875-014-0211-8
PMCID: PMC4311495  PMID: 25547983
Vascular ulcer; Platelet rich plasma; Primary care
18.  Efficacy of GP referral of insufficiently active patients for expert physical activity counseling: protocol for a pragmatic randomized trial (The NewCOACH trial) 
BMC Family Practice  2014;15(1):218.
Background
Physical inactivity is fourth in the list of risk factors for global mortality. General practitioners are well placed to offer physical activity counseling but insufficient time is a barrier. Although referral to an exercise specialist is an alternative, in Australia, these allied health professionals are only publicly funded to provide face-to-face counseling to patients who have an existing chronic illness. Accordingly, this trial aims to determine the efficacy of GP referral of insufficiently active patients (regardless of their chronic disease status) for physical activity counseling (either face-to-face or predominately via telephone) by exercise specialists, based on patients’ objectively assessed physical activity levels, compared with usual care. If the trial is efficacious, the equivalence and cost-effectiveness of face-to-face counseling versus telephone counseling will be assessed.
Methods
This three arm pragmatic randomized trial will involve the recruitment of 261 patients from primary care clinics in metropolitan and regional areas of New South Wales, Australia. Insufficiently active (less than 7000 steps/day) consenting adult patients will be randomly assigned to: 1) five face-to-face counseling sessions, 2) one face-to-face counseling session followed by four telephone calls, or 3) a generic mailed physical activity brochure (usual care). The interventions will operationalize social cognitive theory via a behavior change counseling framework. Participants will complete a survey and seven days of pedometry at baseline, and at three and 12 months post-randomization. The primary analyses will be based on intention-to-treat principles and will compare: (i) mean change in average daily step counts between baseline and 12 months for the combined intervention group (Group 1: face-to-face, and Group 2: telephone) and usual care (Group 3); (ii) step counts at 3 months post-randomization. Secondary outcomes include: self-reported physical activity, sedentary behavior, quality of life, and depression.
Discussion
If referral of primary care patients to exercise specialists increases physical activity, this process offers the prospect of systematically and sustainably reaching a large proportion of insufficiently active adults. If shown to be efficacious this trial provides evidence to expand public funding beyond those with a chronic disease and for delivery via telephone as well as face-to-face consultations.
Trial registration
Australian New Zealand Clinical Trials Registry ACTRN12611000884909.
doi:10.1186/s12875-014-0218-1
PMCID: PMC4305254  PMID: 25543688
Physical activity; Primary care; Referral; Pedometry
19.  Patient education in chronic heart failure in primary care (ETIC) and its impact on patient quality of life: design of a cluster randomised trial 
BMC Family Practice  2014;15(1):208.
Background
Chronic heart failure, is increasing due to the aging population and improvements in heart disease detection and management. The prevalence is estimated at ~10% of the French general practice patient population over 59 years old. The primary objective of this study is to improve the quality of life for heart failure patients though a complex intervention involving patient and general practitioner (GP) education in primary care.
Methods
A randomised, cluster controlled trial, stratified over 4 areas of the Auvergne region in France comparing intervention and control groups. The inclusion criteria are: patients older than 50 years with New York Heart Association (NYHA) stage I, II, or III heart failure, with reduced ejection fraction or with preserved ejection fraction. Heart failure should be confirmed by the patient’s cardiologist according to the European Society of Cardiology guidelines criteria. The exclusion criteria include: severe cognitive disorders, living in an institution, participating in another clinical trial, having NYHA stage IV heart failure, or a lack of French language skills. The complex intervention consists of training at the GP practice with an interactive 2-day workshop to provide a patient’s education programme. GPs are trained to perform case management, lifestyle counselling and motivational interviewing, to educate patients on the main topics including clinical alarm signs, physical activity, diet and cardiovascular risk factors. The patients’ education sessions are scheduled at 1, 4, 7, 10, 13 and 19 months following the start of the trial. The primary outcome to be assessed is the impact on the quality of life as determined using two questionnaires: the Minnesota Living with Heart Failure Questionnaire and SF-36. To detect a difference in the mean quality of life at 19 months, we anticipate studying a minimum of 400 patients from 80 GPs.
Discussion
This trial will provide insight into the effectiveness of a complex intervention to educate patients with heart failure including a 2-day GP workshop and patients’ education programme in the setting of a GP consultation to improve the quality of life in patients with chronic heart failure. This complex intervention tool could be used during initial and further medical training.
Trial registration
ETIC is a cluster-randomised, controlled trial registered on ClinicalTrials.gov [NCT01065142, 2010, Feb 8] and the French drug agency [Agence Nationale de Sécurité du Médicament et des produits de santé; registration number: 2009-A01142-55, on March 5th, 2010].
Electronic supplementary material
The online version of this article (doi:10.1186/s12875-014-0208-3) contains supplementary material, which is available to authorized users.
doi:10.1186/s12875-014-0208-3
PMCID: PMC4305249  PMID: 25539989
Heart failure; Quality of life; Patient education; Primary care; Cluster-randomised controlled trial
20.  Focus groups to explore healthcare professionals’ experiences of care coordination: towards a theoretical framework for the study of care coordination 
BMC Family Practice  2014;15:177.
Background
Strategies to improve care coordination between primary and hospital care do not always have the desired results. This is partly due to incomplete understanding of the key concepts of care coordination. An in-depth analysis of existing theoretical frameworks for the study of care coordination identified 14 interrelated key concepts. In another study, these 14 key concepts were further explored in patients’ experiences. Additionally, “patient characteristics” was identified as a new key concept in patients’ experiences and the previously identified key concept “quality of relationship” between healthcare professionals was extended to “quality of relationship” with the patient. Together, these 15 interrelated key concepts resulted in a new theoretical framework. The present study aimed at improving our understanding of the 15 previously identified key concepts and to explore potentially previous unidentified key concepts and the links between these by exploring how healthcare professionals experience care coordination.
Methods
A qualitative design was used. Six focus groups were conducted including primary healthcare professionals involved in the care of patients who had breast cancer surgery at three hospitals in Belgium. Data were analyzed using constant comparative analysis.
Results
All 15 previously identified key concepts of care coordination were further explored in healthcare professionals’ experiences. Links between these 15 concepts were identified, including 9 newly identified links.
The concept “external factors” was linked with all 6 concepts relating to (inter)organizational mechanisms; “task characteristics”, “structure”, “knowledge and information technology”, “administrative operational processes”, “cultural factors” and “need for coordination”. Five of these concepts related to 3 concepts of relational coordination; “roles”, “quality of relationship” and “exchange of information”. The concept of “task characteristics” was only linked with “roles” and “exchange of information”. The concept “patient characteristics” related with the concepts “need for coordination” and “patient outcome”. Outcome was influenced by “roles”, “quality of relationship” and “exchange of information”.
Conclusions
External factors and the (inter)organizational mechanism should enhance “roles” and “quality of relationship” between healthcare professionals and with the patient as well as “exchange of information”, and setting and sharing of common “goals” to improve care coordination and quality of care.
doi:10.1186/s12875-014-0177-6
PMCID: PMC4319219  PMID: 25539888
Care coordination; Theoretical models (MESH); Qualitative research; Healthcare professionals; Experiences
21.  Chest pain out-of-hours – an interview study of primary care physicians’ diagnostic approach, tolerance of risk and attitudes to hospital admission 
BMC Family Practice  2014;15(1):1127.
Background
Acute chest pain constitutes a considerable diagnostic challenge outside hospitals. This will often lead to uncertainty in choosing the right management, and the physicians’ approach may be influenced by their knowledge of diagnostic measures and their tolerance of risk. The aim of this study was to investigate primary care physicians’ diagnostic approach, tolerance of risk and attitudes to hospital admission in patients with acute chest pain out-of-hours in Norwegian primary care.
Methods
Data were registered prospectively from four Norwegian casualty clinics. Data from structured telephone interviews with 100 physicians shortly after a consultation with a patient presenting at the casualty clinic with “chest pain” were analysed. Tolerance of risk was measured by the Pearson Risk Scale and the Tolerance of Risk Scale, the latter developed for this study.
Results
“Patient history and symptoms” was considered the most important, and “negative ECG” and “effect of sublingual nitroglycerine” the least important aspects in the diagnostic approach. There were no significant differences in length of experience or gender when testing “risk avoiders” against the rest. Almost all physicians felt that their risk assessment out-of-hours was reasonably good, and felt reasonably safe, but only 50% agreed with the statement “I don’t worry about my decisions after I’ve made them”. Concerning chest pain patients only, 51% of the physicians were worried about complaints being made about them, 75% agreed that admitting someone to hospital put patients in danger of being “over-tested”, and 51% were more likely to admit the patient if the patient herself wanted to be admitted.
Conclusions
Physicians working out-of-hours showed considerable differences in their diagnostic approach, and not all physicians diagnose patients with chest pain according to current guidelines and evidence. Continuous medical education must focus on the diagnostic approach in patients with chest pain in primary care and empowerment of physicians through training and emphasis on risk assessment and “tolerance of risk”.
doi:10.1186/s12875-014-0207-4
PMCID: PMC4278232  PMID: 25527871
Chest pain; Primary care; Out-of-hours; Diagnostic approach; Clinical decision rules; Tolerance of risk
22.  Patient safety skills in primary care: a national survey of GP educators 
BMC Family Practice  2014;15(1):206.
Background
Clinicians have a vital role in promoting patient safety that goes beyond their technical competence. The qualities and attributes of the safe hospital doctor have been explored but similar work within primary care is lacking. Exploring the skills and attributes of a safe GP may help to inform the development of training programmes to promote patient safety within primary care.
This study aimed to determine the views of General Practice Educational Supervisors (GPES) regarding the qualities and attributes of a safe General Practitioner (GP) and the perceived trainability of these ‘safety skills’ and to compare selected results with those generated by a previous study of hospital doctors.
Methods
This was a two-stage study comprising content validation of a safety skills questionnaire (originally developed for hospital doctors) (Stage 1) and a prospective survey of all GPES in Scotland (n = 691) (Stage 2).
Results
Stage 1: The content-validated questionnaire comprised 66 safety skills/attributes across 17 broad categories with an overall content validation index of 0.92.
Stage 2: 348 (50%) GPES completed the survey. GPES felt the skills/attributes most important to being a safe GP were honesty (93%), technical clinical skills (89%) and conscientiousness (89%). That deemed least important/relevant to being a safe GP was leadership (36%). This contrasts sharply with the views of hospital doctors in the previous study. GPES felt the most trainable safety skills/attributes were technical skills (93%), situation awareness (75%) and anticipation/preparedness (71%). The least trainable were honesty (35%), humility (33%) and patient awareness/empathy (30%). Additional safety skills identified as relevant to primary care included patient advocacy, negotiation skills, accountability/ownership and clinical intuition (‘listening to that worrying little inner voice’).
Conclusions
GPES believe a broad range of skills and attributes contribute to being a safe GP. Important but subtle differences exist between what primary care and secondary care doctors perceive as core safety attributes. Educationalists, GPs and patient safety experts should collaborate to develop and implement training in these skills to ensure that current and future GPs possess the necessary competencies to engage and lead in safety improvement efforts.
Electronic supplementary material
The online version of this article (doi:10.1186/s12875-014-0206-5) contains supplementary material, which is available to authorized users.
doi:10.1186/s12875-014-0206-5
PMCID: PMC4275946  PMID: 25515429
General practice; Patient safety; Medical education; Skills
23.  Does receipt of 5As services have implications for patients’ satisfaction in India? 
BMC Family Practice  2014;15(1):209.
Background
The 5As model for behavior change counseling is an evidence-based counseling approach. This study aims to explore the relationship between patient satisfaction with counseling services and 5As interventions in tobacco cessation. We also investigated the impact of satisfaction with counseling services on patients’ intention to quit and recommendation of those services to other tobacco users.
Methods
Two cross-sectional surveys were administered among patients and physicians working in primary health care facilities in 12 districts of two states in India. Health facilities and patients were recruited by systematic random and simple random sampling respectively. We limited our analyses to only those patients who were asked about their tobacco consumption. We used multivariable logistic regression to investigate associations between individual components of 5As interventions and patients’ satisfaction with the counseling services.
Results
Patients who reported that they were ‘advised’ to quit (OR: 9.56; 95% CI: 1.89-48.28), ‘assessed’ for readiness to quit (OR 2.1, 95% CI: 1.07-4.15) and offered cessation ‘assistance’ (OR 2.2, 95% CI: 1.17–4.29) were more satisfied with the counseling services. Patients who were satisfied with the counseling services were five times more likely to have an intention to quit tobacco (OR: 5.45, 95% CI: 3.59 to 8.27) and four times as likely to recommend counseling to other tobacco users (OR 3.83; 95% CI:2.46 -5.96).
Conclusions
Incorporating 5As interventions in the delivery of primary care would likely increase patients’ satisfaction with physicians’ delivered counseling services. Patients’ recommendation of counseling services will aid in demand generation for cessation services in primary care.
doi:10.1186/s12875-014-0209-2
PMCID: PMC4287186  PMID: 25515606
Tobacco cessation; 5As interventions; Primary care; India
24.  Swedish general practitioners’ attitudes towards treatment guidelines – a qualitative study 
BMC Family Practice  2014;15(1):3.
Background
Drug therapy in primary care is a challenge for general practitioners (GPs) and the prescribing decision is influenced by several factors. GPs obtain drug information in different ways, from evidence-based sources, their own or others’ experiences, or interactions with opinion makers, patients or colleagues. The need for objective drug information sources instead of drug industry-provided information has led to the establishment of local drug and therapeutic committees. They annually produce and implement local treatment guidelines in order to promote rational drug use. This study describes Swedish GPs’ attitudes towards locally developed evidence-based treatment guidelines.
Methods
Three focus group interviews were performed with a total of 17 GPs working at both public and private primary health care centres in Skåne in southern Sweden. Transcripts were analysed by conventional content analysis. Codes, categories and themes were derived from data during the analysis.
Results
We found two main themes: GP-related influencing factors and External influencing factors. The first theme emerged when we put together four main categories: Expectations and perceptions about existing local guidelines, Knowledge about evidence-based prescribing, Trust in development of guidelines, and Beliefs about adherence to guidelines. The second theme included the categories Patient-related aspects, Drug industry-related aspects, and Health economic aspects. The time-saving aspect, trust in evidence-based market-neutral guidelines and patient safety were described as key motivating factors for adherence. Patient safety was reported to be more important than adherence to guidelines or maintaining a good patient-doctor relationship. Cost containment was perceived both as a motivating factor and a barrier for adherence to guidelines. GPs expressed concerns about difficulties with adherence to guidelines when managing patients with drugs from other prescribers. GPs experienced a lack of time to self-inform and difficulties managing direct-to-consumer drug industry information.
Conclusions
Patient safety, trust in development of evidence-based recommendations, the patient-doctor encounter and cost containment were found to be key factors in GPs’ prescribing. Future studies should explore the need for transparency in forming and implementing guidelines, which might potentially increase adherence to evidence-based treatment guidelines in primary care.
doi:10.1186/s12875-014-0199-0
PMCID: PMC4276045
Qualitative research; Focus groups; Guidelines; Attitudes; Primary care; GPs; Adherence; Drug therapy
25.  Long-term impact of a real-world coordinated lifestyle promotion initiative in primary care: a quasi-experimental cross-sectional study 
BMC Family Practice  2014;15(1):201.
Background
Integration of lifestyle promotion in routine primary care has been suboptimal. Coordinated care models (e.g. screening, brief advice and referral to in-house specialized staff) could facilitate lifestyle promotion practice; they have been shown to increase the quality of services and reduce costs in other areas of care. This study evaluates the long-term impact of a coordinated lifestyle promotion intervention with a multidisciplinary team approach in a primary care setting.
Methods
A quasi-experimental, cross-sectional design was used to compare three intervention centres using a coordinated care model and three control centres using a traditional model of lifestyle promotion care. Outcomes were inspired by using the RE-AIM framework: reach, the proportion of patients receiving lifestyle promotion; effectiveness, self-reported attitudes and competency among staff; adoption, proportion of staff reporting daily practice of lifestyle promotion and referral; and implementation, of the coordinated care model. The impact was investigated after 3 and 5 years. Data collection involved a patient questionnaire (intervention, n = 433–497; control, n = 455–497), a staff questionnaire (intervention, n = 77–76; control, n = 43–56) and structured interviews with managers (n = 8). The χ2 test or Fisher exact test with adjustment for clustering by centre was used for the analysis. Problem-driven content analysis was used to analyse the interview data.
Results
The findings were consistent over time. Intervention centres did not show higher rates for reach of patients or adoption among staff at the 3- or 5-year follow-up. Some conceptual differences between intervention and control staff remained over time in that the intervention staff were more positive on two of eight effectiveness outcomes (one attitude and one competency item) compared with control staff. The Lifestyle team protocol, which included structural opportunities for coordinated care, was implemented at all intervention centres. Lifestyle teams were perceived to have an important role at the centres in driving the lifestyle promotion work forward and being a forum for knowledge exchange. However, resources to refer patients to specialized staff were used inconsistently.
Conclusions
The Lifestyle teams may have offered opportunities for lifestyle promotion practice and contributed to enabling conditions at centre level but had limited impact on lifestyle promotion practices.
doi:10.1186/s12875-014-0201-x
PMCID: PMC4305248  PMID: 25512086
Healthy lifestyle promotion; Primary care; Implementation; Coordinated care; RE-AIM framework; Maintenance

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