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1.  Physician involvement in life transition planning: a survey of community-dwelling older adults 
BMC Family Practice  2015;16:92.
Background
With many information sources for healthy aging and life transitions, it is unknown whether community-dwelling older adults desire physician involvement in future planning decisions. The study aimed to examine older adults’ experiences and opinions concerning four future planning domains: advance care planning, driving, finances, and housing.
Methods
Adults aged ≥55 years living at a large urban, independent living facility were surveyed with an anonymous, voluntary, paper-based, mailed questionnaire. Survey domains were advance care planning, driving, finances, and housing. For each domain, questions assessed confidence, openness to discussions, information sources, and prior and desired future role of the physician in decision-making by domain. Comparisons across and within domains were determined using Chi-square tests.
Results
The response rate was 56 % (N = 457; median age: 75 years; 74 % female). Among advance care planning, driving, and finances, respondents were more confident about what it means to have an advance directive (87 %, 95 % CI 84 − 90 %) than alternative transportation options (46 %, 95 % CI 42 − 51 %). Nearly two-thirds of respondents (64 %, 95 % CI 59 − 68 %) were open to discussing driving cessation, though only one-third (32 %, 95 % CI 28 − 37 %) were open to having a family member determine timing of driving cessation. More individuals (44 %, 95 % CI 39 − 49 %) were open to a physician deciding about when to stop driving. Past discussions with family or friends about advance care planning or finances were common, although past discussions about driving were less common. Respondents reported personal experience and family as key information sources, which were significantly more common than healthcare providers. While prior involvement by physicians in decision-making was rare across all domains, some respondents expressed desire for future physician involvement in all domains, with advance care planning (29 %, 95 % CI 25 − 33 %) and driving safety (24 %, 95 % CI 20 − 28 %) having highest levels of support for future physician involvement.
Conclusions
Some older adults desired more physician involvement in future planning for life transitions, especially related to advance care planning and driving compared to finances and housing. Clinical implications include increased patient-centered care and anticipatory guidance by physicians for aging-related life transitions.
Electronic supplementary material
The online version of this article (doi:10.1186/s12875-015-0311-0) contains supplementary material, which is available to authorized users.
doi:10.1186/s12875-015-0311-0
PMCID: PMC4518510  PMID: 26219548
Advance care planning; Advance directives; Driving; Geriatrics; Doctor-patient relationships
2.  The role of the practice facilitators in Ontario primary healthcare quality improvement 
BMC Family Practice  2015;16:93.
Background
Practice facilitation is a key component of quality improvement in primary healthcare. Studies have reported the effectiveness of practice facilitation in improving quality management and care delivery. However, little has been published about practice facilitators’ training, facilitation activities, and their perceived role in quality improvement in primary healthcare. This study examined practice facilitators’ training and the perceptions of the practice facilitator role in a provincial primary healthcare learning collaborative quality improvement initiative in Ontario, Canada.
Method
Descriptive and qualitative methods were used to outline the practice facilitator training as well as to look into the experiences and perceptions of practice facilitators and primary healthcare teams regarding the practice facilitation role in quality improvement. Data collection included training artifacts, activity logs, self-reflection reports, and semi-structured interviews with practice facilitators and primary healthcare participants. Reflections and interviews were analyzed to identify the role of the practice facilitators from their own experience, and from the perspective of the participants. Descriptive statistics were used to learn about categories of facilitation activities undertaken and frequency of these activities.
Results
Sixteen practice facilitators and seven family healthcare teams participated in the study. Practice facilitators received a two-day intensive training workshop and continued training. Their time was spent mostly working directly with participating teams, continued learning and training, communications and administration. They served as coaches, resource providers, enablers and motivators. Participating teams expressed satisfaction with the practice facilitator role, although they had hoped this position would provide onsite and hands-on support in conducting activities of quality improvement at the practice level.
Conclusions
Practice facilitators played a crucial role in the implementation of quality improvement in Ontario’s learning collaborative program. The practice facilitator role is perceived to be that of a coach, enabler and motivator. This study suggests that the practice facilitator successfully supported participating teams to undertake quality improvement activities in primary healthcare settings.
doi:10.1186/s12875-015-0298-6
PMCID: PMC4520205
Practice facilitator; Quality improvement; Primary healthcare; Qualitative method
3.  Alcohol dependence and treatment utilization in Europe – a representative cross-sectional study in primary care 
BMC Family Practice  2015;16:90.
Background
Alcohol dependence (AD) in Europe is prevalent and causes considerable health burden. Recognition by general practitioners (GPs) and provision of or referral to treatment may contribute to reduce this burden. This paper studied AD prevalence in varying European primary care settings and examined who received treatment.
Methods
In a cross-sectional multi-centre study in six European countries, 358 general practitioners assessed 13,003 primary care patients between January 2013 and January 2014, of which 8,476 patients were interviewed, collecting information on socio-demographics, physical and mental problems, and on alcohol use, problems and treatment. AD diagnoses were determined by GPs’ clinical judgement and a standardized interview. A wide definition for AD treatment included individual and group interventions provided by different health professionals. Descriptive as well as inferential statistics were employed.
Results
AD was prevalent among patients in European primary health care settings (8.7 %, 95 % confidence interval (CI): 8.1-9.3 %). Treatment rates were low (22.3 % of all AD cases, 95 % CI: 19.4-25.2 %). For both prevalence and treatment utilization, considerable country variations were observed. AD was associated with a number of socio-economic disadvantages (e.g. higher unemployment rate) and higher physical (e.g., liver disease, hypertension) and mental comorbidities (e.g., depression, anxiety). Liver problems, mental distress and daily amount of alcohol used were higher among treated versus untreated male patients with AD.
Conclusion
A minority of people identified as having AD received treatment, showing heavier drinking patterns and a higher level of co-morbidity. Different types of treatment, depending on severity of AD, should be considered.
Electronic supplementary material
The online version of this article (doi:10.1186/s12875-015-0308-8) contains supplementary material, which is available to authorized users.
doi:10.1186/s12875-015-0308-8
PMCID: PMC4518612  PMID: 26219430
Alcohol dependence; Composite International Diagnostic Interview; General practitioner; Primary care; treatment; Co-morbidity; Liver disease; Disability; Mental distress
4.  Self-care behavior when suffering from the common cold and health-related quality of life in individuals attending an annual checkup in Japan: a cross-sectional study 
BMC Family Practice  2015;16:91.
Background
The World Health Organization and several governments encourage medical self-care (including self-medication) for minor illnesses. Accordingly, the factors that influence self-care have received research attention, with socioeconomic status identified as one such predictor. Although studies have examined the relationship between socioeconomic status and quality of life (QOL) in patients suffering from respiratory allergies or chronic illnesses, the relationship between QOL and self-care behavior for the common cold, the most common illness seen in primary care, has not been examined. Therefore, we investigated the relationship between QOL and self-care behavior in individuals suffering from the common cold.
Methods
We distributed questionnaires to 499 people who attended an annual public health checkup in Kasama city, Japan. Valid questionnaires were received from 398 participants (mean age = 59.0, SD = 15.8, range = 24–87 years; 61.4 % women). The materials included a question relating to typical actions taken when treating a common cold (self-care or visiting a health clinic), demographics, and the Short Form-8™ (SF-8™)—an 8-item survey that assesses health-related quality of life (HRQOL). The association of care action and HRQOL were investigated using Mann–Whitney U tests with a significance level of p < 0.05.
Results
The mean scores for the Physical Functioning, Role-Physical, Bodily Pain, Social Functioning, Role-Emotional, and Physical Component Summary score of the SF-8™ were significantly higher among the self-care group than the group that preferred visiting a clinic.
Conclusions
HRQOL among individuals who engage in self-care when treating the common cold was observed to be significantly higher than among individuals who preferred to attend a health clinic. It is unclear whether self-care behavior affects QOL, or whether QOL affects self-care behavior; however, this finding highlights the importance of the relationship between QOL and self-care behavior. Additional studies should be conducted in order to investigate the direction of causality between self-care behaviors and QOL further.
doi:10.1186/s12875-015-0300-3
PMCID: PMC4518653  PMID: 26219348
Self-care behavior; Health-related quality of life; Common cold; Short Form-8™
5.  Primary care nurses’ performance in motivational interviewing: a quantitative descriptive study 
BMC Family Practice  2015;16:89.
Background
Motivational interviewing is a collaborative conversational style intended to strengthen motivation to change. It has been shown to be effective in addressing many different lifestyle problems as well as in chronic disease management, and many disease prevention guidelines promote use of motivational interviewing. The aim of the present study was twofold: to assess to what extent the primary care nurses in the study perform motivational interviewing according to the Motivational Interviewing Treatment Integrity Code and to investigate how the participating primary care nurses rated their own performance in motivational interviewing.
Method
The study was based on twelve primary care nurses’ audio-recorded motivational interviewing sessions with patients (total 32 sessions). After each session, the nurses completed a questionnaire regarding their experience of their own performance in motivational interviewing. The audio-recorded sessions were analyzed using Motivational Interviewing Integrity Code 3.1.1.
Results
None of the nurses achieved beginning proficiency in all parts of any motivational interviewing sessions and two nurses did not achieve beginning proficiency in any parts or sessions. Making more complex than simple reflections was the specific verbal behavior/summary score that most nurses achieved. Beginning proficiency/competency in “percent open questions” was the summary score that fewest achieved.
Conclusion
Primary care nurses did not achieve beginning proficiency/competency in all aspects of motivational interviewing in their recorded sessions with patients, where lifestyle change was discussed. This indicates a need for improvement and thus additional training, feedback and supervision in clinical practice with motivational interviewing.
doi:10.1186/s12875-015-0304-z
PMCID: PMC4513379  PMID: 26205692
Self-ratings; Motivational interviewing; Motivational interviewing treatment integrity code; Nurse; Performance; Primary care; Proficiency/competency
6.  Chest pain syndromes are associated with high rates of recidivism and costs in young United States Veterans 
BMC Family Practice  2015;16:88.
Background
Recurrent chest pain is common in patients with and without coronary artery disease. The prevalence and burden of these symptoms on healthcare is unknown.
Objectives
To compare chest pain return visits (recidivism) in patients with unexplained chest pain (UCP) against reference group of patients with coronary artery disease (CAD) and estimate the annual cost of recurrent chest pain.
Methods
In a retrospective cohort study, a Veteran Affairs (VA) administrative and clinical database of Veterans who were deployed to or served in support of the wars in Iraq or Afghanistan was queried for first disease specific ICD-9 code to form two cohorts (UCP or CAD). Patients were followed between 09/2001-09/2010 for the first and cumulative return visits for UCP or cardiac pain (ACS or angina) to clinic, emergency department or admission; or for all-cause death. Time to return was analyzed using Cox regression and negative binomial models and adjusted for age, gender, race, marital status, and risk factors (hypertension, hyperlipidemia, diabetes, smoking and obesity). Direct total costs included inpatient, outpatient and fee basis (non-VA) costs.
Results
Of 749,036 patients, 20,521 had UCP and 5303 had CAD. UCP patients were young and had a lower burden of risk factors than CAD cohort (p < .01). Yet, these patients were likely to return earlier with any chest pain (adjusted Hazard Ratio [aHR] = 1.76; 95 % CI 1.65-1.88); or unexplained chest pain than CAD patients (aHR: 1.89; 95 % CI 1.77-2.01). UCP patients were also likely to return more frequently for any chest pain (aRate Ratio = 1.54; 95 % CI 1.43-1.64) or UCP than CAD patients (aRR =2.63; 95 % CI 2.43-2.87). Per 100 patients, the 1-year cumulative returns were 37 visits for reference group and 45 visits for UCP cohort. The annual costs for chest pain averaged $69,009 for CAD and $57,336 for UCP patients (log geometric mean ratio=1.25; 95 % CI 1.18-1.32).
Conclusion
Chest pain recidivism is common and costly even in patients without known CAD. We need evidence-based guidelines for these patients to minimize returns.
Electronic supplementary material
The online version of this article (doi:10.1186/s12875-015-0287-9) contains supplementary material, which is available to authorized users.
doi:10.1186/s12875-015-0287-9
PMCID: PMC4511555  PMID: 26202799
Chest pain; Recidivism; Costs
7.  Effect evaluation of an interprofessional medication therapy management approach for multimorbid patients in primary care: a cluster-randomized controlled trial in community care (WestGem study protocol) 
BMC Family Practice  2015;16:84.
Background
Pharmaceutical practice worldwide is developing towards patient care. Medication Review (MR) and Medication Therapy Management (MTM) are evolving as the most prominent services in pharmaceutical care and have a strong potential to provide a large benefit for patients and society. MTMs can only be performed in an interprofessional, collaborative setting. Several international studies have explored the effects of a MTM on the quality of therapy and costs. For Germany the data is still deficient. This study aims to provide data on the effects of an interprofessional MTM regarding quality of therapy, quality of life, costs and cost-effectiveness.
Method/Design
The study is designed as a cluster-randomized controlled trial in primary care, involving 12 outpatient clinics (clusters) and 165 patients. Primary care units are allocated to interventions using a Stepped Wedge Design. All units are initially assigned to the control group. After a 6 month observation period, general practitioners (GP) are randomly allocated to one of three groups and the interprofessional medication therapy management approach is implemented sequentially per each group with a lag of 3 months between. The primary outcome is the change in the quality of therapy measured by the MAI (Medication Appropriateness Index). Secondary outcomes include changes in the number of drug related problems, medication complexity, changes in drug-adherence, changes in health-status and function, quality of life, direct costs and the incremental cost-effectiveness ratio. The acceptance of the interprofessional Medication Therapy Management approach is assessed by qualitative methods.
Discussion
The patient interview and brown bag review are activities, typically provided by the pharmacist. In this trial the patient is blinded to the pharmacist. The strength of having the patient blinded to the pharmacists is to exclude skepticism of the patient toward unknown pharmacies, which might be a major confounder in a regional and community setting. A weakness is that some patient related data might reach the pharmacists in a way, which might differ from self-acquired data.
Trial registration
Current controlled trials ISRCTN41595373.
doi:10.1186/s12875-015-0305-y
PMCID: PMC4508809  PMID: 26198433
Polypharmacy; Interprofessional; Medication therapy management; Medication review; Multimorbidity; Complex intervention; Primary care
8.  The role of primary health care services to better meet the needs of Aboriginal Australians transitioning from prison to the community 
BMC Family Practice  2015;16:86.
Background
Aboriginal Australians are more likely than other Australians to cycle in and out of prison on remand or by serving multiple short sentences—a form of serial incarceration and institutionalisation. This cycle contributes to the over-representation of Aboriginal Australians in prison and higher rates of recidivism. Our research examined how primary health care can better meet the health care and social support needs of Aboriginal Australians transitioning from prison to the community.
Methods
Purposive sampling was used to identify 30 interviewees. Twelve interviews were with Aboriginal people who had been in prison; ten were with family members and eight with community service providers who worked with former inmates. Thematic analysis was conducted on the interviewees’ description of their experience of services provided to prisoners both during incarceration and on transition to the community.
Results
Interviewees believed that effective access to primary health care on release and during transition was positively influenced by providing appropriate healthcare to inmates in custody and by properly planning for their release. Further, interviewees felt that poor communication between health care providers in custody and in the community prior to an inmate’s release, contributed to a lack of comprehensive management of chronic conditions. System level barriers to timely communication between in-custody and community providers included inmates being placed on remand which contributed to uncertainty regarding release dates and therefore difficulties planning for release, cycling in and out of prison on short sentences and being released to freedom without access to support services.
Conclusions
For Aboriginal former inmates and family members, release from prison was a period of significant emotional stress and commonly involved managing complex needs. To support their transition into the community, Aboriginal former inmates would benefit from immediate access to culturally- responsive community -primary health care services. At present, however, pre-release planning is not always available, especially for Aboriginal inmates who are more likely to be on remand or in custody for less than six months.
doi:10.1186/s12875-015-0303-0
PMCID: PMC4508903  PMID: 26198338
Primary health care; Prisoners; Criminal justice system; Family practice; Aboriginal Australians
9.  ‘I think positivity breeds positivity’: a qualitative exploration of the role of family members in supporting those with chronic musculoskeletal pain to stay at work 
BMC Family Practice  2015;16:85.
Background
It is proposed that family members are important sources of support in helping those with chronic musculoskeletal pain to remain at work, but the phenomenon remains largely unexplored. The aim of this study was to examine the extent and nature of support provided by family members in this respect.
Methods
Qualitative data were collected from workers and their ‘significant others’ (spouses/partners/close family members) in two un-related studies focused on working with pain; one conducted in the United Kingdom (n = 10 dyads) and one in the Netherlands (n = 21 dyads). Thematic analysis techniques were applied to both sets of data independently, and findings were then assimilated to establish common themes.
Results
Findings were broadly similar in both studies. Workers acknowledged significant other support in helping them to manage their pain and remain at work, and their descriptions of the type of support provided and required were echoed by their significant others. Three common themes were identified - ‘connectivity’, ‘activity’ and ‘positivity’. Worker and significant other responses were largely congruent, but significant others provided more in-depth information on the nature of their support, their concerns and the impact on their relationship.
Conclusions
This research presents novel insights about the specific contribution made by significant others in helping their relatives with chronic musculoskeletal pain to stay at work. These findings add to the under-represented ‘social’ dimension of the biopsychosocial model currently applied to our understanding and treatment of pain, and point to harnessing support from significant others as a potentially effective management strategy.
doi:10.1186/s12875-015-0302-1
PMCID: PMC4509776  PMID: 26198218
Significant others; Family, Work; Chronic pain; Musculoskeletal disorders; Psychosocial
10.  Assessment of the coordination of integrated health service delivery networks by the primary health care: COPAS questionnaire validation in the Brazilian context 
BMC Family Practice  2015;16:87.
Background
Health systems organized as networks and coordinated by the Primary Health Care (PHC) may contribute to the improvement of clinical care, sanitary conditions, satisfaction of patients and reduction of local budget expenditures. The aim of this study was to adapt and validate a questionnaire - COPAS - to assess the coordination of Integrated Health Service Delivery Networks by the Primary Health Care.
Methods
A cross sectional approach was used. The population was pooled from Family Health Strategy healthcare professionals, of the Alfenas region (Minas Gerais, Brazil). Data collection was performed from August to October 2013. The results were checked for the presence of floor and ceiling effects and the internal consistency measured through Cronbach alpha. Construct validity was verified through convergent and discriminant values following Multitrait-Multimethod (MTMM) analysis.
Results
Floor and ceiling effects were absent. The internal consistency of the instrument was satisfactory; as was the convergent validity, with a few correlations lower then 0.30. The discriminant validity values of the majority of items, with respect to their own dimension, were found to be higher or significantly higher than their correlations with the dimensions to which they did not belong.
Conclusion
The results showed that the COPAS instrument has satisfactory initial psychometric properties and may be used by healthcare managers and workers to assess the PHC coordination performance within the Integrated Health Service Delivery Network.
doi:10.1186/s12875-015-0299-5
PMCID: PMC4510885  PMID: 26198100
Primary Health Care; Health Care Networks; Coordination; Psychometric analysis; Validation studies
11.  Implementation of simple telehealth to manage hypertension in general practice: a service evaluation 
BMC Family Practice  2015;16:83.
Background
Hypertension is common and conveys significant risk of morbidity and mortality. However, inadequate control of hypertension is common. Following a successful local use of a simple telehealth intervention (‘Florence’) for the diagnosis and management of hypertension, the Advice & Interactive Messaging (AIM) for Health simple telehealth programme was launched across England in March 2013. Four protocols were developed to diagnose and monitor blood pressure (BP). The aim of this service evaluation was to identify the extent to which predefined service outcomes, regarding ascertainment of a diagnosis of hypertension, and achievement of hypertension control, were met for the hypertension protocols.
Methods
Patients with opportunistic raised BP in general practice or diagnosed hypertension were selected by their usual primary care providers to register onto diagnostic or monitoring hypertension protocols, respectively. Florence sent patients prompts via text messaging to submit readings, educational messages and user satisfaction questions. Patient responses were stored on Florence for review by their primary care health providers. This service evaluation used data from 2963 patients from general practices across England registered onto one of four AIM hypertension protocols from inception to January 2014. Data were extracted from Florence and underwent descriptive analysis.
Results
1166/1468 (79 %) patients were eligible to have a diagnosis of hypertension confirmed/refuted, of which 740 (63 %) had a mean BP in the hypertensive range from one week’s readings. BP control was achieved by only 5-22 % of 1495 patients signed up to one of the three monitoring protocols. Patient engagement with the monitoring protocols was initially good but reduced over time.
Conclusions
Although simple telehealth may be an acceptable tool for diagnosing and monitoring hypertension among responding patient users, and can have a useful role in diagnosis of hypertension (particularly if ambulatory blood pressure monitoring (ABPM) is not possible or is declined), problems were identified. Reduced patient engagement over longer periods and acceptance of suboptimal BP control among patients on monitoring protocols need to be urgently addressed. Empirical work is required to identify barriers to achieving BP control among hypertensive patients using simple telehealth and, consequently, services be developed to address these issues.
doi:10.1186/s12875-015-0301-2
PMCID: PMC4504444  PMID: 26183439
Telehealth; hypertension; implementation; evaluation; satisfaction; primary health care
12.  Parents’ beliefs and knowledge about the management of acute otitis media: a qualitative study 
BMC Family Practice  2015;16:82.
Background
Acute otitis media is a common reason for antibiotic prescribing, despite strong evidence that antibiotics provide minimal benefit. Studies have demonstrated that patients’ (or parents’) expectations of antibiotics often influence general practitioners’ (GPs) decision to prescribe antibiotics, but few have explored parents’ expectations of the management of infections in children, or which factors influence the development of these expectations. This study aimed to explore parents’ knowledge and beliefs about the management of acute otitis media in children.
Methods
Individual semi-structured interviews were conducted with 15 parents of children who had recently presented to their GP with acute otitis media. Parents were recruited at childcare centres or playgroups in Brisbane, Australia.
Results
Many parents did not have an accurate understanding of what causes acute otitis media. GPs were primarily consulted for the management of symptoms such as pain and fever. Others specifically wanted reassurance or were concerned about hearing loss. Most parents assumed that antibiotics were the best treatment option. Parents’ perceptions about the best treatment were mainly based on their previous experience and the advice of the GP. Pain relief medications, such as paracetamol and non-steroidal anti-inflammatory drugs, were not considered by parents to be sufficient treatment on their own.
Conclusion
There is discrepancy between parents’ beliefs and expectations of management of acute otitis media and the evidence-based recommendations. This study provides insights into parents’ expectations of management of acute otitis media, which may help inform clinicians about perceptions and misperceptions that may be valuable to elicit and discuss.
doi:10.1186/s12875-015-0297-7
PMCID: PMC4494645  PMID: 26148678
Otitis media; Knowledge; Family practice; Primary health care; Qualitative research; Antibiotics
13.  Near-patient tests and the clinical gaze in decision-making of Swedish GPs not following current guidelines for sore throat – a qualitative interview study 
BMC Family Practice  2015;16:81.
Background
Excessive antibiotics use increases the risk of resistance. Previous studies have shown that the Centor score combined with Rapid Antigen Detection Test (RADT) for Group A Streptococci can reduce unnecessary antibiotic prescribing in patients with sore throat. According to the former Swedish guidelines RADT was recommended with 2–4 Centor criteria present and antibiotics were recommended if the test was positive. C- reactive protein (CRP) was not recommended for sore throats. Inappropriate use of RADT and CRP has been reported in several studies.
Methods
From a larger project 16 general practitioners (GPs) who stated management of sore throats not according to the guidelines were identified. Half-hour long semi-structured interviews were conducted. The topics were the management of sore throats and the use of near-patient tests. Qualitative content analysis was used.
Results
The use of the near-patient test interplayed with the clinical assessment and the perception that all infections caused by bacteria should be treated with antibiotics. The GPs expressed a belief that the clinical picture was sufficient for diagnosis in typical cases. RADT was not believed to be relevant since it detects only one bacterium, while CRP was considered as a reliable numerical measure of bacterial infection.
Conclusions
Inappropriate use of near-patient test can partly be understood as remnants of outdated knowledge. When new guidelines are introduced the differences between them and the former need to be discussed more explicitly.
doi:10.1186/s12875-015-0285-y
PMCID: PMC4491276  PMID: 26141740
Near-patient tests; Sore throat; Guidelines; Decision-making; Qualitative interview study
14.  Improving treatment adherence for blood pressure lowering via mobile phone SMS-messages in South Africa: a qualitative evaluation of the SMS-text Adherence SuppoRt (StAR) trial 
BMC Family Practice  2015;16:80.
Background
Effective use of proven treatments for high blood pressure, a preventable health risk, is challenging for many patients. Prompts via mobile phone SMS-text messaging may improve adherence to clinic visits and treatment, though more research is needed on impact and patient perceptions of such support interventions, especially in low-resource settings.
Method
An individually-randomised controlled trial in a primary care clinic in Cape Town (2012–14), tested the effect of an adherence support intervention delivered via SMS-texts, on blood pressure control and adherence to medication, for hypertensive patients. (Trial registration: ClinicalTrials.gov NCT02019823). We report on a qualitative evaluation that explored the trial participants’ experiences and responses to the SMS-text messages, and identified barriers and facilitators to delivering adherence support via patients’ own mobile phones. Two focus groups and fifteen individual interviews were conducted. We used comparative and thematic analysis approaches to identify themes and triangulated our analysis amongst three researchers.
Results
Most participants were comfortable with the technology of using SMS-text messages. Messages were experienced as acceptable, relevant and useful to a broad range of participants. The SMS-content, the respectful tone and the delivery (timing of reminders and frequency) and the relational aspect of trial participation (feeling cared for) were all highly valued. A subgroup who benefitted the most, were those who had been struggling with adherence due to high levels of personal stress. The intervention appeared to coincide with their readiness for change, and provided practical and emotional support for improving adherence behaviour. Change may have been facilitated through increased acknowledgement of their health status and attitudinal change towards greater self-responsibility. Complex interaction of psycho-social stressors and health service problems were reported as broader challenges to adherence behaviours.
Conclusion
Adherence support for treatment of raised blood pressure, delivered via SMS-text message on the patient’s own phone, was found to be acceptable, relevant and helpful, even for those who already had their own reminder systems in place. Our findings begin to identify for whom and what core elements of the SMS-text message intervention appear to work best in a low-resource operational setting, issues that future research should explore in greater depth.
Electronic supplementary material
The online version of this article (doi:10.1186/s12875-015-0289-7) contains supplementary material, which is available to authorized users.
doi:10.1186/s12875-015-0289-7
PMCID: PMC4490665  PMID: 26137844
Mobile phone-based SMS-messages; mHealth; Blood pressure treatment; Hypertension; Adherence; South Africa; low-and middle-income countries, primary-care; qualitative methodology, patient perspective
15.  Decisions on statin therapy by patients’ opinions about survival gains: cross sectional survey of general practitioners 
BMC Family Practice  2015;16:79.
Background
Guidelines for primary prevention of cardiovascular disease provide little guidance on how patients’ preferences should be taken into account. We wanted to explore whether general practitioners (GPs) are sensitive to patient preferences regarding survival gains from statin therapy.
Methods
In a cross sectional, online survey 3,270 Norwegian GPs were presented with a 55 year old patient with an unfavourable cardiovascular risk profile. He expressed preferences for statin therapy by indicating a minimum survival gain that would be considered a substantial benefit. This survival gain varied across six versions of the vignette: 8, 4 and 2 years, and 12, 6 and 3 months, respectively. Participants were randomly allocated to one version only. We asked whether the GPs would recommend the patient to take a statin. Subsequently we asked the GPs to estimate the average survival gain of life long simvastatin therapy for patients with a similar risk profile.
Results
We received 1,296 responses (40 %). Across levels of survival gains (8 years to 3 months) the proportion of GPs recommending statin therapy did not vary significantly (OR per level 1.07, 95 % CI 0.99 to 1.16). The GP’s own estimate of survival gain was a statistically significant predictor of recommending therapy (OR per year adjusted for the GPs’ age, sex, speciality attainment and number of patients listed 3.07, CI 2.55 to 3.69).
Conclusion
GPs were insensitive to patient preferences regarding survival gain when recommending statin therapy. The GPs' recommendations were strongly associated with their own estimates of survival gain.
doi:10.1186/s12875-015-0288-8
PMCID: PMC4490724  PMID: 26139240
16.  Determinants of impact of a practice accreditation program in primary care: a qualitative study 
BMC Family Practice  2015;16:78.
Background
Practice accreditation is a widely used method to assess and improve the quality of healthcare services. In the Netherlands, a practice accreditation program was implemented in primary medical care. We aimed to identify determinants of impact of a practice accreditation program, building on the experiences of primary care professionals who had participated in this program.
Methods
An interview study was done to document the experiences of 33 participating primary care professionals and used to identify determinants of outcomes. The Consolidated Framework for Implementation Research (CFIR) was used as framework for the qualitative analysis.
Results
After analyzing 23 interviews saturation was reached. The practice accreditation program is based on structured quality improvement, but only some of its elements were identified as determinants of impact. Factors that were perceived to facilitate implementation of the program were: designating one person responsible for the program, ensuring clear lines of communication within the whole practice team and having affinity with or stimulate enthusiasm for improving quality of care. Contextual factors such as participation in a care group and being connected to the GP educational institute were important for actual change. The accreditation program was perceived to have positive effects on team climate and commitment to quality of care in the practice team. The perception was that patient care was not directly influenced by the accreditation program. Receiving a certificate for completing the accreditation program seemed to have little added value to participants.
Conclusions
Practice accreditation may have positive outcomes on quality of care, but not all planned elements may contribute to its outcomes. Both factors in the accreditation process and in the context were perceived as determinants of quality improvement. The challenge is to build on facilitating factors, while reducing the elements of accreditation that do not contribute to its impact.
Electronic supplementary material
The online version of this article (doi:10.1186/s12875-015-0294-x) contains supplementary material, which is available to authorized users.
doi:10.1186/s12875-015-0294-x
PMCID: PMC4490740  PMID: 26137870
Practice accreditation program; CVRM; Qualitative study; Primary care; Implementation
17.  Design of the POINT study: Pharmacotherapy Optimisation through Integration of a Non-dispensing pharmacist in a primary care Team (POINT) 
BMC Family Practice  2015;16:76.
Background
In the Netherlands, 5.6 % of acute hospital admissions are medication-related. Almost half of these admissions are potentially preventable. Reviewing medication in patients at risk in primary care might prevent these hospital admissions. At present, implementation of medication reviews in primary care is suboptimal: pharmacists lack access to patient information, pharmacists are short of clinical knowledge and skills, and working processes of pharmacists (focus on dispensing) and general practitioners (focus on clinical practice) match poorly. Integration of the pharmacist in the primary health care team might improve pharmaceutical care outcomes.
The aim of this study is to evaluate the effect of integration of a non-dispensing pharmacist in general practice on the safety of pharmacotherapy in the Netherlands.
Methods
The POINT study is a non-randomised controlled intervention study with pre-post comparison in an integrated primary care setting. We compare three different models of pharmaceutical care provision in primary care: 1) a non-dispensing pharmacist as an integral member of a primary care team, 2) a pharmacist in a community pharmacy with a predefined training in performing medication reviews and 3) a pharmacist in a community pharmacy (care as usual). In all models, GPs remain accountable for individual medication prescription. In the first model, ten non-dispensing clinical pharmacists are posted in ten primary care practices (including 5 – 10 000 patients each) for a period of 15 months. These non-dispensing pharmacists perform patient consultations, including medication reviews, and share responsibility for the pharmaceutical care provided in the practice. The two other groups consist of ten primary care practices with collaborating pharmacists. The main outcome measurement is the number of medication-related hospital admissions during follow-up. Secondary outcome measurements are potential medication errors, drug burden index and costs. Parallel to this study, a qualitative study is conducted to evaluate the feasibility of introducing a NDP in general practice.
Discussion
As the POINT study is a large-scale intervention study, it should provide evidence as to whether integration of a non-dispensing clinical pharmacist in primary care will result in safer pharmacotherapy. The qualitative study also generates knowledge on the optimal implementation of this model in primary care. Results are expected in 2016.
Trial registration number
NTR4389, The Netherlands National Trial Register, 07-01-2014.
doi:10.1186/s12875-015-0296-8
PMCID: PMC4489035  PMID: 26135582
Pharmacotherapy; Polypharmacy; Non-dispensing clinical pharmacist; General practice; Primary care; Hospitalisation
18.  Improving antimicrobial prescribing in Irish primary care through electronic data collection and surveillance: a feasibility study 
BMC Family Practice  2015;16:77.
Background
The increase in the spread of antimicrobial resistance (AMR) in bacterial pathogens and limited availability of new antimicrobials places immense pressure on general practitioners (GPs) to prescribe appropriately. Currently, electronic antimicrobial prescribing data is not routinely collected from GPs in Ireland for surveillance purposes to assess regional specific fluctuations or trends in antimicrobial prescribing. The current study aimed to address this issue by assessing the feasibility of remotely extracting antimicrobial prescribing data from primary care practices in Ireland, for the purpose of assessing prescribing quality using the European Surveillance of Antimicrobial Consumption (ESAC) drug specific quality indicators.
Methods
Participating practices (n = 30) uploaded data to the Irish Primary Care Research Network (IPCRN). The IPCRN data extraction facility is integrated within the practice patient management software system and permitted the extraction of anonymised patient prescriptions for a one year period, from October 2012 to October 2013. The quality of antimicrobial prescribing was evaluated using the twelve ESAC drug specific quality indicators using the defined daily dose (DDD) per 1,000 inhabitants per day (DID) methodology. National and European prescribing surveillance data (based on total pharmacy sales) was obtained for a comparative analysis.
Results
Antimicrobial prescriptions (n = 57,079) for 27,043 patients were obtained from the thirty study practices for a one year period. On average, study practices prescribed a greater proportion of quinolones (37 % increase), in summer compared with winter months, a variation which was not observed in national and European data. In comparison with national data, study practices prescribed higher proportions of β-lactamase-sensitive penicillins (4.98 % vs. 4.3 %) and a greater use of broad spectrum compared to narrow-spectrum antimicrobials (ratio = 9.98 vs. 6.26) was observed. Study practices exceeded the European mean for prescribing combinations of penicillins, including β-lactamase inhibitors.
Conclusions
This research demonstrates the feasibility and potential use of direct data extraction of anonymised practice data directly through the patient management software system. The data extraction methods described can facilitate the provision of routinely collected data for sustained and inclusive surveillance of antimicrobial prescribing. These comparisons may initiate further improvements in antimicrobial prescribing practices by identifying potential areas for improvement.
doi:10.1186/s12875-015-0280-3
PMCID: PMC4489398  PMID: 26135455
Antimicrobial prescribing; Quality of care; Primary care; Electronic data extraction
19.  Treatment of hip/knee osteoarthritis in Dutch general practice and physical therapy practice: an observational study 
BMC Family Practice  2015;16:75.
Background
A multidisciplinary, guideline-based Stepped-Care-Strategy (SCS), has recently been developed to improve the management of hip and knee osteoarthritis (OA). To date, it is unknown to what extent current Dutch OA care is consistent with the SCS, both with respect to the content of care as well as the sequence of care. Furthermore, there is a lack of clarity regarding the role of different health care providers in the performance of OA care according to the SCS. Therefore, the main purpose of this study is to describe the content of primary care in patients with hip/knee OA, including the compliance to the SCS and taking into account the introduction of patient self-referral to physical therapy.
Methods
Data were used from NIVEL Primary Care Database. In total, 12.118 patients with hip/knee OA who visited their GP or physical therapist were selected. Descriptive statistics were used to compare the content of care in GP-referred and self-referred patients to physical therapy.
Results
Content of care performed by GPs mostly concerned consultations, followed by NSAID prescriptions and referrals to secondary care. Both prescriptions of acetaminophen and referrals to physical therapy respectively dietary therapy were rarely mentioned. Nevertheless, still 65% of the patients in physical therapy practice were referred by their GP. Compared to GP-referred patients, self-referred patients more often presented recurrent complaints and were treated less often by activity-related exercise therapy. Education was rarely registered as singular intervention, neither in GP-referred nor in self-referred patients.
Conclusion
In accordance with the SCS, less advanced interventions are more often applied than more advanced interventions. To optimize the adherence to the SCS, GPs could reconsider the frequent use of NSAIDs instead of analgesics and the low referral rate to allied health care. Self-referral to physical therapy partially distorts both the low referral rate in general practice and the low application rate of education as singular intervention in physical therapy practice. Further research is recommended to evaluate the effects of task-shifting in OA care, taking into account the content of the SCS.
Electronic supplementary material
The online version of this article (doi:10.1186/s12875-015-0295-9) contains supplementary material, which is available to authorized users.
doi:10.1186/s12875-015-0295-9
PMCID: PMC4483212  PMID: 26116374
Osteoarthritis; Primary health care; General practice; Physical therapy specialty; Community health services; Referral and consultation
20.  Previous experiences and emotional baggage as barriers to lifestyle change - a qualitative study of Norwegian Healthy Life Centre participants 
BMC Family Practice  2015;16:73.
Background
Changing lifestyle is challenging and difficult. The Norwegian Directorate of Health recommends that all municipalities establish Healthy Life Centres targeted to people with lifestyle issues. Little is known about the background, experiences and reflections of participants. More information is needed about participants to shape effective lifestyle interventions with lasting effect. This study explores how participants in a lifestyle intervention programme describe previous life experiences in relation to changing lifestyle.
Methods
Semi-structured qualitative in-depth interviews were performed with 23 participants (16 women and 7 men) aged 18 – 70 years. The data were analysed using systematic text condensation searching for issues describing participants’ responses, and looking for the essence, aiming to share the basis of life-world experiences as valid knowledge.
Results
Participants identified two main themes: being stuck in old habits, and being burdened with emotional baggage from their previous negative experiences. Participants expressed a wish to change their lifestyles, but were unable to act in accordance with the health knowledge they possessed. Previous experiences with lifestyle change kept them from initiating attempts without professional assistance. Participants also described being burdened by an emotional baggage with problems from childhood and/or with family, work and social life issues. Respondents said that they felt that emotional baggage was an important explanation for why they were stuck in old habits and that conversely, being stuck in old habits added load to their already emotional baggage and made it heavier.
Conclusions
Behavioural change can be hard to perform as psychological distress from life baggage can influence the ability to change. The study participants’ experience of being stuck in old habits and having substantial emotional baggage raises questions as to whether or not Healthy Life Centres are able to help participants who need to make a lifestyle change.
doi:10.1186/s12875-015-0292-z
PMCID: PMC4476174  PMID: 26100276
Primary healthcare; Health behaviour; Lifestyle change; Multi-comorbidity; Overweight; Qualitative research
21.  Knowledge gaps and acceptability of abbreviated alcohol screening in general practice: a cross-sectional survey of hazardous and non-hazardous drinkers 
BMC Family Practice  2015;16:72.
Background
General practice provides a unique setting where hazardous alcohol consumption can be screened for and behavioural interventions can be implemented in a continuous care model. Our aim was to assess in a general practice population, the prevalence of hazardous drinking, the knowledge and attitudes surrounding alcohol, and the acceptability of brief interventions in alcohol.
Methods
A cross-sectional survey in a practice in South London, performed as part of a wider service evaluation. Questionnaires were offered to adult patients awaiting their appointments. Responses were stratified according to hazardous drinking, as per the abbreviated ‘Alcohol Use Disorders Identification Test’ (AUDIT-C).
Results
Of 179 respondents (30 % male), 34 % yielded an AUDIT-C ≥5 and 18 % reported that they never drink alcohol. Male and Caucasian patients were more likely to self-report hazardous drinking, who in turn were more likely to believe in the health benefits of moderate consumption. Little over half of patents thought that alcohol is a risk factor for cancer and were misinformed of its calorific content, suggesting two targets for future improvement. Patients’ knowledge about what is a single ‘unit’ of alcohol was below that expected by random chance 66 % agreed that alcohol screening should feature in all GP consultations.
Conclusions
While awareness of alcohol related health risks is generally good, future efforts may benefit from focusing on the association with cancer and calories. Our findings question the utility of the ‘unit’ system, as well as dissemination of suggested ‘health benefits’ of moderate consumption. General practice initiatives in screening and brief advice for alcohol deserve further study.
doi:10.1186/s12875-015-0290-1
PMCID: PMC4474561  PMID: 26092292
Alcohol drinking; Binge drinking; General practice; Primary health care; Early medical intervention; Health education; Mass screening
22.  Evaluation of the quality of care of a multi-disciplinary Risk Factor Assessment and Management Programme for Hypertension (RAMP-HT) 
BMC Family Practice  2015;16:71.
Background
There is some evidence to support a risk-stratified, multi-disciplinary approach to manage patients with hypertension in primary care. The aim of this study is to evaluate the quality of care (QOC) of a multi-disciplinary Risk Assessment and Management Programme for Hypertension (RAMP-HT) for hypertensive patients in busy government-funded primary care clinics in Hong Kong. The objectives are to develop an evidence-based, structured and comprehensive evaluation framework on quality of care, to enhance the QOC of the RAMP-HT through an audit spiral of two evaluation cycles and to determine the effectiveness of the programme in reducing cardiovascular disease (CVD) risk.
Method/Design
A longitudinal study is conducted using the Action Learning and Audit Spiral methodologies to measure whether pre-set target standards of care intended by the RAMP-HT are achieved. A structured evaluation framework on the quality of structure, process and outcomes of care has been developed based on the programme objectives and literature review in collaboration with the programme workgroup and health service providers. Each participating clinic is invited to complete a structure of care evaluation questionnaire in each evaluation cycle. The data of all patients who have enrolled into the RAMP-HT in the pre-defined evaluation periods are used for the evaluation of the process and outcomes of care in each evaluation cycle. For evaluation of the effectiveness of RAMP-HT, the primary outcomes including blood pressure (both systolic and diastolic), low-density lipoprotein cholesterol and estimated 10-year CVD risk of RAMP-HT participants are compared to those of hypertensive patients in usual care without RAMP-HT.
Discussion
The QOC and effectiveness of the RAMP-HT in improving clinical and patient-reported outcomes for patients with hypertension in normal primary care will be determined. Possible areas for quality enhancement and standards of good practice will be established to inform service planning and policy decision making.
Electronic supplementary material
The online version of this article (doi:10.1186/s12875-015-0291-0) contains supplementary material, which is available to authorized users.
doi:10.1186/s12875-015-0291-0
PMCID: PMC4471929  PMID: 26088560
Hypertension; Management programme; Multi-disciplinary; Primary Care; Quality of care; Risk Assessment; Risk Stratification
23.  Comparison of STI-related consultations among ethnic groups in the Netherlands: an epidemiologic study using electronic records from general practices 
BMC Family Practice  2015;16:70.
Background
Currently, surveillance of sexually transmitted infections (STIs) among ethnic minorities (EM) in the Netherlands is mainly performed using data from STI centers, while the general practitioner (GP) is the most important STI care provider. We determined the frequency of STI-related episodes at the general practice among EM, and compared this with the native Dutch population.
Methods
Electronic medical records from 15–to 60-year-old patients registered in a general practice network from 2002 to 2011 were linked to the population registry, to obtain (parental) country of birth. Using diagnoses and prescription codes, we investigated the number of STI-related episodes per 100,000 patient years by ethnicity. Logistic regression analyses (crude and adjusted for gender, age, and degree of urbanization) were performed for 2011 to investigate differences between EM and native Dutch.
Results
The reporting rate of STI-related episodes increased from 2004 to 2011 among all ethnic groups, and was higher among EM than among native Dutch, except for Turkish EM. After adjustment for gender, age, and degree of urbanization, the reporting rate in 2011 was higher among Surinamese [Odds Ratio (OR) 1.99, 95 % confidence interval (CI) 1.70-2.33], Antillean/Aruban (OR 2.48, 95 % CI 2.04-3.01), and Western EM (OR 1.24, 95 % CI 1.11-1.39) compared with native Dutch, whereas it was lower among Turkish EM (OR 0.48, 95 % CI 0.37-0.61). Women consulted the GP relatively more frequently regarding STIs than men, except for Turkish and Moroccan women.
Conclusions
Most EM consult their GP more often for STI care than native Dutch. However, it remains unclear whether this covers the need of EM groups at higher STI risk. As a first point of contact for care, GPs can play an important role in reaching EM for (proactive) STI/HIV testing.
Electronic supplementary material
The online version of this article (doi:10.1186/s12875-015-0281-2) contains supplementary material, which is available to authorized users.
doi:10.1186/s12875-015-0281-2
PMCID: PMC4470336  PMID: 26084618
Sexually transmitted infections (STI); STD; HIV; Testing; Ethnicity; General practice; Primary care
24.  Reasons for disagreement regarding illnesses between older patients with multimorbidity and their GPs – a qualitative study 
BMC Family Practice  2015;16:68.
Background
Chronic conditions are the most common themes in doctor-patient communication, especially for older patients with multimorbidity and their GPs. Former quantitative studies identified a variety of socio-demographic and health-related factors which were associated with the (dis-)agreement between medical records and patient self-reported diseases. The aim of this qualitative study was to identify reasons for disagreement regarding illnesses between patients and their GPs.
Methods
We conducted three focus groups with GPs (n = 15) and three focus groups with multimorbid patients aged 65 to 85 (n = 21). The participants were recruited from the MultiCare Cohort Study. Focus groups were audiotaped and transcribed verbatim. The transcripts of the focus groups were analysed using the qualitative content analysis according to Mayring. Categories were determined deductively and inductively.
Results
The analysis revealed seven themes concerning reasons for disagreement regarding illnesses between patients and their GPs: problems with communication and cooperation between health care professionals, disease management by the GP and the patient, the documentation behaviour of the GP, communication challenges between GP and patient, differences in the understanding of a disease between GP and patient, the prioritization and rating of diseases by GP and patient and obliviousness, repression and avoidance by the patient.
Conclusions
For older patients with multimorbidity, our study demonstrated that there is a need to enhance the cooperation between GPs, specialists and outpatient care, a demand to improve doctor-patient communication and a need for interventions to increase patients’ knowledge of diseases.
Electronic supplementary material
The online version of this article (doi:10.1186/s12875-015-0286-x) contains supplementary material, which is available to authorized users.
doi:10.1186/s12875-015-0286-x
PMCID: PMC4450605  PMID: 26032949
Disagreement; Chronic diseases; Focus groups; Illnesses; Multimorbidity; Physician report; Primary care; Qualitative study; Self-report
25.  Effectiveness of a PLISSIT model intervention in patients with type 2 diabetes mellitus in primary care: design of a cluster-randomised controlled trial 
BMC Family Practice  2015;16:69.
Background
Sexual dysfunction is prevalent in patients with type 2 diabetes mellitus, but remains one of the most frequently neglected complications in diabetes care. Both patients and care providers appear to have difficulty with discussing sexual problems in diabetes care. A sexual counselling model for care providers, such as the PLISSIT model, might be a useful tool to improve the discussion of sexual issues in patients with type 2 diabetes mellitus. PLISSIT stands for Permission, Limited Information, Specific Suggestions, and Intensive Therapy. Even though the use of the PLISSIT model has often been recommended in diabetes care, no evidence with regards to its effectiveness in patients with type 2 diabetes mellitus exists. This study describes the design of a cluster-randomised controlled trial evaluating the effectiveness of a PLISSIT-model intervention in men and women with type 2 diabetes mellitus in primary care.
Methods/Design
Patients with type 2 diabetes mellitus, aged 40–75 years, who indicate to be dissatisfied about their sexual functioning and that they would like to talk about their sexual problem(s) with their general practitioner are recruited. All participants receive an information leaflet from the practice nurse. In the intervention group, each participant will also receive sexual counselling based on the PLISSIT model from their general practitioner. In the control group, usual care will be provided to those participants requesting an appointment with their general practitioner when the information leaflet was not deemed sufficient. Primary outcomes include sexual functioning, satisfaction about sexual function, and quality of life. Secondary outcomes are depressive symptoms, sexual distress, emotional well-being, and treatment satisfaction. Outcomes will be measured by means of self-report questionnaires at baseline, and after 3 and 12 months post-baseline. Treatment satisfaction will be assessed in telephone interviews.
Discussion
This paper describes the design of a cluster-randomised controlled trial that will investigate the effectiveness of a PLISSIT-model intervention in patients with type 2 diabetes mellitus in primary care. Our study will add important and currently missing insight into the effectiveness of PLISSIT on important patient-reported outcomes of men and women with type 2 diabetes mellitus.
Trial registration
Dutch Trial Registry NTR4807.
doi:10.1186/s12875-015-0283-0
PMCID: PMC4450606  PMID: 26032852
PLISSIT; Type 2 diabetes mellitus; Sexual dysfunction; Randomised controlled trial; Primary care

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