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1.  Patterns of physical co-/multi-morbidity among patients with serious mental illness: a London borough-based cross-sectional study 
BMC Family Practice  2014;15:117.
Background
Serious mental illness (SMI) is associated with elevated mortality compared to the general population; the majority of this excess is attributable to co-occurring common physical health conditions. There may be variation within the SMI group in the distribution of physical co/multi-morbidity. This study aims to a) compare the pattern of physical co- and multi-morbidity between patients with and without SMI within a South London primary care population; and, b) to explore socio-demographic and health risk factors associated with excess physical morbidity among the SMI group.
Methods
Data were obtained from Lambeth DataNet, a database of electronic patient records derived from general practices in the London borough of Lambeth. The pattern of 12 co-morbid common physical conditions was compared by SMI status. Multivariate ordinal and logistic regression analyses were conducted to assess the strength of association between each condition and SMI status; adjustments were made for potentially confounding socio-demographic characteristics and for potentially mediating health risk factors.
Results
While SMI patients were more frequently recorded with all 12 physical conditions than non-SMI patients, the pattern of co-/multi-morbidity was similar between the two groups. Adjustment for socio-demographic characteristics – in particular age and, to a lesser extent ethnicity, considerably reduced effect sizes and accounted for some of the associations, though several conditions remained strongly associated with SMI status. Evidence for mediation by health risk factors, in particular BMI, was supported.
Conclusions
SMI patients are at an elevated risk of a range of physical health conditions than non-SMI patients but they do not appear to experience a different pattern of co-/multimorbidity among those conditions considered. Socio-demographic differences between the two groups account for some of the excess in morbidity and known health risk factors are likely to mediate the association. Further work to examine a wider range of conditions and health risk factors would help determine the extent of excess mortality attributable to these factors.
doi:10.1186/1471-2296-15-117
PMCID: PMC4062514  PMID: 24919453
Serious mental illness; Mental health; Physical health; Comorbidity; Multimorbidity
2.  Ultrasound-diagnosed disorders in shoulder patients in daily general practice: a retrospective observational study 
BMC Family Practice  2014;15:115.
Background
Ultrasound imaging (US) is considered an accurate and widely available method to diagnose subacromial disorders. Yet, the frequency of the specific US-diagnosed shoulder disorders of patients with shoulder pain referred from general practice is unknown. We set out to determine the frequency of specific US-diagnosed shoulder disorders in daily practice in these patients and to investigate if the disorders detected differ between specific subgroups based on age and duration of pain.
Methods
A predefined selection of 240 ultrasound reports of patients with shoulder pain (20 reports for each month in 2011) from a general hospital (Orbis Medical Centre Sittard-Geleen, The Netherlands) were descriptively analysed. Inclusion criteria were: (i) referral from general practice, (ii) age ≥18 years, and (iii) unilateral shoulder examination. Subgroups were created for age (<65 years and ≥65 years) and duration of pain (acute or subacute (<12 weeks) and chronic (≥12 weeks)). The occurrence of each specific disorder is expressed as absolute and relative frequencies.
Results
With 29%, calcific tendonitis was the most frequently diagnosed disorder, followed by subacromial-subdeltoid bursitis (12%), tendinopathy (11%), partial-thickness tears (11%), full-thickness tears (8%) and AC-osteoarthritis (0.4%). For 40% of patients, no disorders were found on US. Significantly more full thickness-tears were found in the ≥65 years group. ‘No disorders’ was reported significantly more often in the <65 years group. The supraspinatus tendon was the most frequently affected tendon (72%).
Conclusions
Calcific tendonitis is the most common US-diagnosed disorder affecting patients in general practice, followed by subacromial-subdeltoid bursitis, tendinopathy, partial- and full-thickness tears and AC-osteoarthritis. Full-thickness tears were diagnosed significantly more frequently in patients ≥65 years, while ‘no disorders’ was more frequently reported in patients <65 years. Our findings imply that patients can be stratified into diagnostic subgroups, allowing more tailored treatment than currently applied.
doi:10.1186/1471-2296-15-115
PMCID: PMC4057656  PMID: 24916105
Shoulder; Shoulder impingement syndrome; Rotator cuff; Ultrasound; General practice
3.  The National Cancer Institute’s Health Information National Trends Survey [HINTS]: a national cross-sectional analysis of talking to your doctor and other healthcare providers for health information 
BMC Family Practice  2014;15:111.
Background
The need to understand preferred sources of health information remains important to providing patient-centered care. The Internet remains a popular resource for health information, but more traditional sources may still be valid for patients during a recent health need. This study sought to understand the characteristics of patients that turn to their doctor or healthcare provider first for a recent health or medical information need.
Methods
Using the national cross-sectional survey, Health Information National Trend Study [HINTS], characteristics of those who sought a doctor or healthcare provider for a recent health information need were compared to other sources. Weighted survey responses from Cycle 1 and Cycle 2 of the HINTS survey were used for multivariable logistic regression.
Results
A total 5,307 patient responses were analyzed. Overall, those who seek a doctor or healthcare provider first for a health need are female, 46–64 years, White non-Hispanic, educated, in good health and users of the Internet. Yet, adjusted logistic regressions showed that those who sought a doctor or healthcare provider first during a recent health information need compared to other sources were most likely to be 65+ years, in poor health, less educated and have health insurance.
Conclusions
Patients who seek their doctor or healthcare provider first for health information rather than other sources of information represent a unique population. Doctors or healthcare providers remain an important resource for these patients during recent needs, despite the wide use of the Internet as a source of health information.
doi:10.1186/1471-2296-15-111
PMCID: PMC4055386  PMID: 24906558
Health information needs; Sources for health information; Doctor-patient communication; National cross-sectional survey
4.  Identifying patients with medically unexplained physical symptoms in electronic medical records in primary care: a validation study 
BMC Family Practice  2014;15:109.
Background
When medically unexplained physical symptoms (MUPS) become persistent, it may have major implications for the patient, the general practitioner (GP) and for society.
Early identification of patients with MUPS in electronic medical records (EMRs) might contribute to prevention of persistent MUPS by creating awareness among GPs and providing an opportunity to start stepped care management. However, procedures for identification of patients with MUPS in EMRs are not well established yet. In this validation study we explore the test characteristics of an EMR screening method to identify patients with MUPS.
Methods
The EMR screening method consists of three steps. First, all patients ≥18 years were included when they had five or more contacts in the last 12 months. Second, patients with known chronic conditions were excluded. Finally, patients were included with a MUPS syndrome or when they had three or more complaints suggestive for MUPS. We compared the results of the EMR screening method with scores on the Patient Health Questionnaire-15 (PHQ-15), which we used as reference test. We calculated test characteristics for various cut-off points.
Results
From the 1223 patients in our dataset who completed the PHQ-15, 609 (49/8%) scored ≥5 on the PHQ-15. The EMR screening method detected 131/1223 (10.7%) as patients with MUPS. Of those, 102 (77.9%) scored ≥5 on the PHQ-15 and 53 (40.5%) scored ≥10. When compared with the PHQ-15 cut-off point ≥10, sensitivity and specificity were 0.30 and 0.93 and positive and negative predictive values were 0.40 and 0.89, respectively.
Conclusions
The EMR screening method to identify patients with MUPS has a high specificity. However, many potential MUPS patients will be missed. Before using this method as a screening instrument for selecting patients who might benefit from structured care, its sensitivity needs to be improved while maintaining its specificity.
doi:10.1186/1471-2296-15-109
PMCID: PMC4052805  PMID: 24903850
5.  Tools for measuring patient safety in primary care settings using the RAND/UCLA appropriateness method 
BMC Family Practice  2014;15:110.
Background
The majority of patient contacts occur in general practice but general practice patient safety has been poorly described and under-researched to date compared to hospital settings. Our objective was to produce a set of patient safety tools and indicators that can be used in general practices in any healthcare setting and develop a ‘toolkit’ of feasible patient safety measures for general practices in England.
Methods
A RAND/UCLA Appropriateness Method exercise was conducted with a panel of international experts in general practice patient safety. Statements were developed from an extensive systematic literature review of patient safety in general practice. We used standard RAND/UCLA Appropriateness Method rating methods to identify necessary items for assessing patient safety in general practice, framed in terms of the Structure-Process-Outcome taxonomy. Items were included in the toolkit if they received an overall panel median score of ≥7 with agreement (no more than two panel members rating the statement outside a 3-point distribution around the median).
Results
Of 205 identified statements, the panel rated 101 as necessary for assessing the safety of general practices. Of these 101 statements, 73 covered structures or organisational issues, 22 addressed processes and 6 focused on outcomes.
Conclusions
We developed and tested tools that can lead to interventions to improve safety outcomes in general practice. This paper reports the first attempt to systematically develop a patient safety toolkit for general practice, which has the potential to improve safety, cost effectiveness and patient experience, in any healthcare system.
doi:10.1186/1471-2296-15-110
PMCID: PMC4060097  PMID: 24902490
Primary health care; Consensus; Patient safety; Quality indicators
6.  The predictors of glucose screening: the contribution of risk perception 
BMC Family Practice  2014;15:108.
Background
The prevention of type 2 diabetes is a challenge for health institutions. Periodic blood glucose screening in subjects at risk for developing diabetes may be necessary to implement preventive measures in patients prior to the manifestation of the disease and to efficiently diagnose diabetes. Not only medical aspects, but also psychological and social factors, such as the perception of risk (the individuals’ judgment of the likelihood of experiencing an adverse event) influence healthy or preventive behaviors. It is still unknown if risk perception can have an effect on health behaviors aimed at reducing the risk of diabetes (glucose screening). The objective of study was to identify factors that influence glucose screening frequency.
Methods
Eight hundred randomized interviews, which were stratified by socioeconomic level, were performed in Mexico City. We evaluated the perception of risk of developing diabetes, family history, health status and socioeconomic variables and their association with glucose screening frequency.
Results
Of the study participants, 55.6% had not had their glucose levels measured in the last year, whereas 32.8% of the subjects reported having monitored their glucose levels one to three times per year and 11.5% had their levels monitored four or more times per year. Risk perception was significantly associated with the frequency of blood glucose screening. Having a first-degree relative with diabetes, being older than 45 years and belonging to a middle socioeconomic level increased the probability of subjects seeing a doctor for glucose screening.
Conclusions
Glucose screening is a complex behavior that involves the subjects’ perception of threat, defined as feeling vulnerable to the development of diabetes, which is determined by the subject’s environment and his previous experience with diabetes.
doi:10.1186/1471-2296-15-108
PMCID: PMC4051958  PMID: 24894017
Diabetes; Risk perception; Glucose screening
7.  Patients with persistent medically unexplained physical symptoms: a descriptive study from Norwegian general practice 
BMC Family Practice  2014;15:107.
Background
Further research on effective interventions for patients with peristent Medically Unexplained Physical Symptoms (MUPS) in general practice is needed. Prevalence estimates of such patients are conflicting, and other descriptive knowledge is needed for development and evaluation of effective future interventions. In this study, we aimed to estimate the consultation prevalence of patients with persistent MUPS in general practice, including patients’ characteristics and symptom pattern, employment status and use of social benefits, and the general practitioners’ (GPs) management strategy.
Method
During a four-week period the participating Norwegian GPs (n = 84) registered all consultations with patients who met a strict definition of MUPS (>3 months duration and function loss), using a questionnaire with simple tick-off questions. Analyses were performed with descriptive statistics for all variables and split analysis on gender and age.
Results
The GPs registered 526 patients among their total of 17 688 consultations, giving a consultation prevalence of persistent MUPS of 3%. The mean age of patients was 46 years, and 399 (76%) were women. The most frequent group of symptoms was musculoskeletal problems, followed by asthenia/fatigue. There was no significant gender difference in symptom pattern. Almost half of the patients were currently working (45%), significantly more men. The major GP management strategy was supportive counseling.
Conclusion
A consultation prevalence rate of 3% implies that patients with persistent MUPS are common in general practice. Our study disclosed heterogeneity among the patients such as differences in employment status, which emphasizes the importance of personalized focus rather than unsubstantiated stereotyping of “MUPS patients” as a group.
doi:10.1186/1471-2296-15-107
PMCID: PMC4041895  PMID: 24885524
Prevalence; Cross-sectional studies; Somatoform disorders; Employment; Primary health care
8.  Communicating cardiovascular disease risk: an interview study of General Practitioners’ use of absolute risk within tailored communication strategies 
BMC Family Practice  2014;15:106.
Background
Cardiovascular disease (CVD) prevention guidelines encourage assessment of absolute CVD risk - the probability of a CVD event within a fixed time period, based on the most predictive risk factors. However, few General Practitioners (GPs) use absolute CVD risk consistently, and communication difficulties have been identified as a barrier to changing practice. This study aimed to explore GPs’ descriptions of their CVD risk communication strategies, including the role of absolute risk.
Methods
Semi-structured interviews were conducted with a purposive sample of 25 GPs in New South Wales, Australia. Transcribed audio-recordings were thematically coded, using the Framework Analysis method to ensure rigour.
Results
GPs used absolute CVD risk within three different communication strategies: ‘positive’, ‘scare tactic’, and ‘indirect’. A ‘positive’ strategy, which aimed to reassure and motivate, was used for patients with low risk, determination to change lifestyle, and some concern about CVD risk. Absolute risk was used to show how they could reduce risk. A ‘scare tactic’ strategy was used for patients with high risk, lack of motivation, and a dismissive attitude. Absolute risk was used to ‘scare’ them into taking action. An ‘indirect’ strategy, where CVD risk was not the main focus, was used for patients with low risk but some lifestyle risk factors, high anxiety, high resistance to change, or difficulty understanding probabilities. Non-quantitative absolute risk formats were found to be helpful in these situations.
Conclusions
This study demonstrated how GPs use three different communication strategies to address the issue of CVD risk, depending on their perception of patient risk, motivation and anxiety. Absolute risk played a different role within each strategy. Providing GPs with alternative ways of explaining absolute risk, in order to achieve different communication aims, may improve their use of absolute CVD risk assessment in practice.
doi:10.1186/1471-2296-15-106
PMCID: PMC4042137  PMID: 24885409
Cardiovascular disease risk; Prevention; General practice; Primary care; Doctor-patient communication; Risk communication; Risk perception
9.  Complex consultations in primary care: a tool for assessing the range of health problems and issues addressed in general practice consultations 
BMC Family Practice  2014;15:105.
Background
There is an increasing recognition that many consultations in general practice involve several problems covering multiple disease domains. However there is a paucity of reliable tools and techniques to understand and quantify this phenomenon. The objective was to develop a tool that can be used to measure the number and type of problems discussed in primary care consultations.
Methods
Thirteen consultations between general practitioners and patients were initially videoed and reviewed to identify the problems and issues discussed. An iterative process involving a panel of clinicians and researchers and repeated cycles of testing and development was used to develop a measurement proforma and coding manual for assessment of video recorded consultations. The inter-rater reliability of this tool was assessed in 60 consultations.
Results
The problems requiring action were usually readily identified. However the different dimensions of the problem and how they were addressed required the identification and definition of ‘issues’. A coding proforma was developed that allowed quantification of the numbers and types of health problems and issues discussed. Ten categories of issues were identified and defined. At the consultation level, inter-rater agreements for the number of problems discussed (within ±1), types of problems and issues were 98.3%, 96.5% and 90% respectively. The tool has subsequently been used to analyse 229 consultations.
Conclusion
The iterative approach to development of the tool reflected the complexity of doctor-patient interactions. A reliable tool has been developed that can be used to analyse the number and range of problems managed in primary care consultations.
doi:10.1186/1471-2296-15-105
PMCID: PMC4046503  PMID: 24885298
Primary health care; Consultation; Clinical coding
10.  Safety relevant knowledge of orally anticoagulated patients without self-monitoring: a baseline survey in primary care 
BMC Family Practice  2014;15:104.
Background
Effective and safe management of oral anticoagulant treatment (OAT) requires a high level of patient knowledge and adherence. The aim of this study was to assess patient knowledge about OAT and factors associated with patient knowledge.
Methods
This is a baseline survey of a cluster-randomized controlled trial in 22 general practices with an educational intervention for patients or their caregivers. We assessed knowledge about general information on OAT and key facts regarding nutrition, drug-interactions and other safety precautions of 345 patients at baseline.
Results
Participants rated their knowledge about OAT as excellent to good (56%), moderate (36%) or poor (8%). However, there was a discrepancy between self-rated knowledge and evaluated actual knowledge and we observed serious knowledge gaps. Half of the participants (49%) were unaware of dietary recommendations. The majority (80%) did not know which non-prescription analgesic is the safest and 73% indicated they would not inform pharmacists about OAT. Many participants (35-75%) would not recognize important emergency situations. After adjustment in a multivariate analysis, older age and less than 10 years education remained significantly associated with lower overall score, but not with self-rated knowledge.
Conclusions
Patients have relevant knowledge gaps, potentially affecting safe and effective OAT. There is a need to assess patient knowledge and for structured education programs.
Trial registration
Deutsches Register Klinischer Studien (German Clinical Trials Register): DRKS00000586.
Universal Trial Number (UTN U1111-1118-3464).
doi:10.1186/1471-2296-15-104
PMCID: PMC4045910  PMID: 24885192
11.  Primary prevention in general practice – views of German general practitioners: a mixed-methods study 
BMC Family Practice  2014;15:103.
Background
Policy efforts focus on a reorientation of health care systems towards primary prevention. To guide such efforts, we analyzed the role of primary prevention in general practice and general practitioners’ (GPs) attitudes toward primary prevention.
Methods
Mixed-method study including a cross-sectional survey of all community-based GPs and focus groups in a sample of GPs who collaborated with the Institute of General Practice in Berlin, Germany in 2011. Of 1168 GPs 474 returned the mail survey. Fifteen GPs participated in focus group discussions. Survey and interview guidelines were developed and tested to assess and discuss beliefs, attitudes, and practices regarding primary prevention.
Results
Most respondents considered primary prevention within their realm of responsibility (70%). Primary prevention, especially physical activity, healthy eating, and smoking cessation, was part of the GPs’ health care recommendations if they thought it was indicated. Still a quarter of survey respondents discussed reduction of alcohol consumption with their patients infrequently even when they thought it was indicated. Similarly 18% claimed that they discuss smoking cessation only sometimes. The focus groups revealed that GPs were concerned about the detrimental effects an uninvited health behavior suggestion could have on patients and were hesitant to take on the role of “health policing”. GPs saw primary prevention as the responsibility of multiple actors in a network of societal and municipal institutions.
Conclusions
The mixed-method study showed that primary prevention approaches such as lifestyle counseling is not well established in primary care. GPs used a selective approach to offer preventive advice based upon indication. GPs had a strong sense that a universal prevention approach carried the potential to destroy a good patient-physician relationship. Other approaches to public health may be warranted such as a multisectoral approach to population health. This type of restructuring of the health care sector may benefit patients who are unable to afford specific prevention programmes and who have competing demands that hinder their ability to focus on behavior change.
doi:10.1186/1471-2296-15-103
PMCID: PMC4046439  PMID: 24885100
General practice; Primary prevention; Physician-patient relationship
12.  Influenza vaccination during pregnancy: a qualitative study of the knowledge, attitudes, beliefs, and practices of general practitioners in Central and South-Western Sydney 
BMC Family Practice  2014;15:102.
Background
Pregnant women have an increased risk of influenza complications. Influenza vaccination during pregnancy is safe and effective, however coverage in Australia is less than 40%. Pregnant women who receive a recommendation for influenza vaccination from a health care provider are more likely to receive it, however the perspectives of Australian general practitioners has not previously been reported. The aim of the study was to investigate the knowledge, attitudes, beliefs, and practices of general practitioners practicing in South-Western Sydney, Australia towards influenza vaccination during pregnancy.
Methods
A qualitative descriptive study was conducted, with semi-structured interviews completed with seventeen general practitioners in October 2012. A thematic analysis was undertaken by four researchers, and transcripts were analysed using N-Vivo software according to agreed codes.
Results
One-third of the general practitioners interviewed did not consider influenza during pregnancy to be a serious risk for the mother or the baby. The majority of the general practitioners were aware of the government recommendations for influenza vaccination during pregnancy, but few general practitioners were confident of their knowledge about the vaccine and most felt they needed more information. More than half the general practitioners had significant concerns about the safety of influenza vaccination during pregnancy. Their practices in the provision of the vaccine were related to their perception of risk of influenza during pregnancy and their confidence about the safety of the vaccine. While two-thirds reported that they are recommending influenza vaccination to their pregnant patients, many were adopting principles of patient-informed choice in their approach and encouraged women to decide for themselves whether they would receive the vaccine.
Conclusions
General practitioners have varied knowledge, attitudes, and beliefs about influenza vaccination during pregnancy, which influence their practices. Addressing these could have a significant impact on improving vaccine uptake during pregnancy.
doi:10.1186/1471-2296-15-102
PMCID: PMC4038848  PMID: 24884996
Influenza; Vaccine; Pregnancy; General practitioners; Recommendation
13.  Exploration of population and practice characteristics explaining differences between practices in the proportion of hospital admissions that are emergencies 
BMC Family Practice  2014;15:101.
Background
Emergency (unscheduled) and elective (scheduled) use of secondary care varies between practices. Past studies have described factors associated with the number of emergency admissions; however, high quality care of chronic conditions, which might include increased specialist referrals, could be followed by reduced unscheduled care. We sought to characterise practices according to the proportion of total hospital admissions that were emergency admissions, and identify predictors of this proportion.
Method
The study included 229 general practices in Leicestershire, Northamptonshire and Rutland, England. Publicly available data were obtained on scheduled and unscheduled secondary care usage, and on practice and patient characteristics: age; gender; list size; observed prevalence, expected prevalence and the prevalence gap of coronary heart disease, hypertension and stroke; deprivation; headcount number of GPs per 1000 patients; total and clinical quality and outcomes framework (QOF) scores; ethnicity; proportion of patients seen within two days by a GP; proportion able to see their preferred GP. Using the proportion of admissions that were emergency admissions, seven categories of practices were created, and a regression analysis was undertaken to identify predictors of the proportion.
Results
In univariate analysis, practices with higher proportions of admissions that were emergencies tended to have fewer older patients, higher proportions of male patients, fewer white patients, greater levels of deprivation, smaller list sizes, lower recorded prevalence of coronary heart disease and stroke, a bigger gap between the expected and recorded levels of stroke, and lower proportions of total and clinical QOF points achieved. In the multivariate regression, higher deprivation, fewer white patients, more male patients, lower recorded prevalence of hypertension, more outpatient appointments, and smaller practice list size were associated with higher proportions of total admissions being emergencies.
Conclusion
In monitoring use of secondary care services, the role of population characteristics in determining levels of use is important, but so too is the ability of practices to meet the demands for care that face them. The level of resources, and the way in which available resources are used, are likely to be key in determining whether a practice is able to meet the health care needs of its patients.
doi:10.1186/1471-2296-15-101
PMCID: PMC4037431  PMID: 24884797
Primary care; Health services; Health planning
14.  Extending the authority for sickness certification beyond the medical profession: the importance of ‘boundary work’ 
BMC Family Practice  2014;15:100.
Background
The study aimed to explore the views of general practitioners (GPs), nurses and physiotherapists towards extending the role of sickness certification beyond the medical profession in primary care.
Methods
Fifteen GPs, seven nurses and six physiotherapists were selected to achieve varied respondent characteristics including sex, geographical location, service duration and post-graduate specialist training. Constant-comparative qualitative analysis of data from 28 semi-structured telephone interviews was undertaken.
Results
The majority of respondents supported the extended role concept; however members of each professional group also rejected the notion. Respondents employed four different legitimacy claims to justify their views and define their occupational boundaries in relation to sickness certification practice. Condition-specific legitimacy, the ability to adopt a holistic approach to sickness certification, system efficiency and control-related arguments were used to different degrees by each occupation. Practical suggestions for the extension of the sickness certification role beyond the medical profession are underpinned by the sociological theory of professional identity.
Conclusions
Extending the authority to certify sickness absence beyond the medical profession is not simply a matter of addressing practical and organisational obstacles. There is also a need to consider the impact on, and preferences of, the specific occupations and their respective boundary claims. This paper explores the implications of extending the sick certification role beyond general practice. We conclude that the main policy challenge of such a move is to a) persuade GPs to relinquish this role (or to share it with other professions), and b) to understand the ‘boundary work’ involved.
doi:10.1186/1471-2296-15-100
PMCID: PMC4030269  PMID: 24884678
Professional boundaries; Sick certification; Qualitative methods; Sociology of professions; Primary care
15.  Type 2 diabetes patients’ perspectives on lifestyle counselling and weight management in general practice: a qualitative study 
BMC Family Practice  2014;15:97.
Background
Lifestyle counselling is a pivotal aspect of diabetes care. But general practitioners (GPs) often have problems in finding their role in patients’ weight management. The aims of this study were to investigate the experiences of type 2 diabetes patients with lifestyle counselling from their GPs and to explore how patients’ preferences regarding counselling are embedded in the context of self-management and wider cultural aspects of nutrition.
Methods
Narrative interviews were conducted with 35 people with type 2 diabetes aged between 35 and 77 years. The interviews were transcribed verbatim and analysed using the thematic framework method.
Results
Many patients had a strong feeling of personal responsibility for weight reduction as integral to diabetes self-management but found it difficult to integrate the changes their disease requires into their self-management activities. They attached great importance to their GPs’ advice on diet. While some patients appreciated direct communication, others regarded dramatic pictures as either unhelpful or offending. A serious problem was the incompatibility of the dietary recommendations with daily life resulting in a reluctance to adjust the whole diet to the needs of diabetes care.
Conclusions
Ambivalence towards patient self-management and tensions between the necessary changes to patients’ lifestyles and their culture, makes the GP’s role difficult and full of conflict. Instead of focusing exclusively on the guidelines of diabetes management and provision of information, GPs should explore the patients’ capabilities of self-management through open communication and accept their patients’ wishes to protect nutrition as part of their culture.
doi:10.1186/1471-2296-15-97
PMCID: PMC4027991  PMID: 24885605
Type 2 diabetes; Physician-patient relations; Obesity; Eating; Patient education; Family practice; Qualitative research
16.  Decreasing trends in patient satisfaction, accessibility and continuity of care in Finnish primary health care – a 14-year follow-up questionnaire study 
BMC Family Practice  2014;15:98.
Background
The aim here was to explore trends in patient satisfaction with primary health care and its accessibility and continuity, and to explore whether through reforms and improvements some of the essential goals had been achieved over a 14-year period of time in Finland.
Methods
Nine questionnaire surveys were conducted over a period of 14 years among patients attending within one week in the 65 health centres in the Tampere University Hospital catchment area. A total of 147,394 responded out of a sample of 333,648 patients. The response rate varied yearly from 53% to 37%.
Results
Patient satisfaction with care in Finnish health centres decreased by nearly 9 percentage units from 1998 to 2011. The fall-off was most marked in the age-group over 64 years. There was a 20 percentage unit’s reduction in ease of access as reported by patients. Respondents also reported that the continuity of care had deteriorated.
Conclusions
Despite major reforms in Finnish health care policy, patients seem to be less satisfied. Our findings challenge both Finnish authorities and GPs to improve the accessibility and continuity of care in primary health services.
doi:10.1186/1471-2296-15-98
PMCID: PMC4030039  PMID: 24885700
Accessibility; Continuity; Patient satisfaction; Primary health care; Questionnaire survey
17.  Developing a good practice model to evaluate the effectiveness of comprehensive primary health care in local communities 
BMC Family Practice  2014;15:99.
Background
This paper describes the development of a model of Comprehensive Primary Health Care (CPHC) applicable to the Australian context. CPHC holds promise as an effective model of health system organization able to improve population health and increase health equity. However, there is little literature that describes and evaluates CPHC as a whole, with most evaluation focusing on specific programs. The lack of a consensus on what constitutes CPHC, and the complex and context-sensitive nature of CPHC are all barriers to evaluation.
Methods
The research was undertaken in partnership with six Australian primary health care services: four state government funded and managed services, one sexual health non-government organization, and one Aboriginal community controlled health service. A draft model was crafted combining program logic and theory-based approaches, drawing on relevant literature, 68 interviews with primary health care service staff, and researcher experience. The model was then refined through an iterative process involving two to three workshops at each of the six participating primary health care services, engaging health service staff, regional health executives and central health department staff.
Results
The resultant Southgate Model of CPHC in Australia model articulates the theory of change of how and why CPHC service components and activities, based on the theory, evidence and values which underpin a CPHC approach, are likely to lead to individual and population health outcomes and increased health equity. The model captures the importance of context, the mechanisms of CPHC, and the space for action services have to work within. The process of development engendered and supported collaborative relationships between researchers and stakeholders and the product provided a description of CPHC as a whole and a framework for evaluation. The model was endorsed at a research symposium involving investigators, service staff, and key stakeholders.
Conclusions
The development of a theory-based program logic model provided a framework for evaluation that allows the tracking of progress towards desired outcomes and exploration of the particular aspects of context and mechanisms that produce outcomes. This is important because there are no existing models which enable the evaluation of CPHC services in their entirety.
doi:10.1186/1471-2296-15-99
PMCID: PMC4038362  PMID: 24885812
18.  The patient perspective on overactive bladder: a mixed-methods needs assessment 
BMC Family Practice  2014;15:96.
Background
While overactive bladder is often managed in the primary care setting, a number of barriers including embarrassment, poor communication, and low patient adherence contribute to the under-treatment of patients with burdensome urinary symptoms. In order to address these challenges, it is crucial to have a fundamental understanding of patient perspectives toward OAB and urinary symptoms. To meet this aim, researchers designed and conducted a study to identify patients’ knowledge, experiences and attitudes, barriers to treatment adherence, and desires and tendencies regarding patient/clinician communications.
Methods
A mixed-methods qualitative/quantitative needs assessment of patients with overactive bladder and/or urinary symptoms. Researchers conducted in-depth qualitative interviews via telephone with 40 patients. Interview results informed the design and dissemination of a quantitative survey, which was completed by 200 self-selected respondents who had previously identified themselves as having overactive bladder or bladder problems. Statistical and qualitative analysis of results were conducted.
Results
Among survey respondents, an average of 3.5 years elapsed between symptom onset and seeking diagnosis by a physician. In the long term most patients do not experience improvement in symptoms. Medication non-adherence is common and is related to therapy effectiveness and adverse effects. Patients clearly indicate that communication and patient/physician relationships are important to them and they would prefer the clinician initiate the conversation on overactive bladder. Patient experiences, perspectives, and attitudes toward their bladder symptoms differ in many ways from clinicians’ assumptions.
Conclusions
The significant time gap between symptom onset and diagnosis indicates ongoing need for screening and diagnosis of overactive bladder. Contrary to guideline recommendations, urinalysis and physical examination are not widely used in clinical practice. Many patients experience no improvement in symptoms over time. Patients indicate that clinician/patient relationships and communication regarding their condition are important.
doi:10.1186/1471-2296-15-96
PMCID: PMC4030445  PMID: 24885491
Overactive bladder; OAB; Needs assessment; Patient survey; Patient perspective
19.  Patient presentation and physician management of upper respiratory tract infections: a retrospective review of over 5 million primary clinic consultations in Hong Kong 
BMC Family Practice  2014;15:95.
Background
Upper respiratory tract infection (URTI) has a significant healthcare burden worldwide. Considerable resources are consumed through health care consultations and prescribed treatment, despite evidence for little or no effect on recovery. Patterns of consultations and care including use of symptomatic medications and antibiotics for upper respiratory tract infections are poorly described.
Methods
We performed a retrospective review of computerized clinical data on patients presenting to all public primary care clinics in Hong Kong with symptoms of respiratory tract infections. International Classification of Primary care (ICPC)codes used to identify patients included otitis media (H71), streptococcal pharyngitis (R72), acute URTI (R74), acute sinusitis (R75), acute tonsillitis (R76), acute laryngitis (R77), and influenza (R80). Sociodemographic variables such as gender, age, chronic illness status, attendance date, type and duration of drug prescribed were also collected.
Results
Of the 5,529,755 primary care consultations for respiratory symptoms from 2005 to 2010, 98% resulted in a prescription. Prescription patterns of symptomatic medication were largely similar across the 5 years. In 2010 the mean number of drugs prescribed per consultation was 3.2, of which the commonly prescribed medication were sedating antihistamines (79.9%), analgesia (58.9%), throat lozenges (40.4%) and expectorant cough syrup (33.8%). During the study period, there was an overall decline in antibiotic prescription (8.1% to 5.1%). However, in consultations where the given diagnosis was otitis media (H71), streptococcal pharyngitis (R72), acute sinusitis (R75) or acute laryngitis (R76), over 90% resulted in antibiotic prescription.
Conclusion
There was a decline in overall antibiotic prescription over the study period. However, the use of antibiotics was high in some conditions e.g. otitis media and acute laryngitis a. Multiple symptomatic medications were given for upper respiratory tract infections. Further research is needed to develop clinical and patients directed interventions to reduce the number of prescriptions of symptomatic medications and antibiotics that could reduce costs for health care services and iatrogenic risk to patients.
doi:10.1186/1471-2296-15-95
PMCID: PMC4030026  PMID: 24885376
Upper respiratory tract infection; Primary care; Pharmacology
20.  Health care needs of cancer survivors in general practice: a systematic review 
BMC Family Practice  2014;15:94.
Background
The number of cancer survivors is increasing due to improved treatments. Consequently, general practitioners will treat more and more cancer survivors in the upcoming years. Only little is known about the care needs of these survivors and guidelines to support general practitioners in their treatment of these patients are lacking. The aim of this study was to gain insight in the health care needs of cancer survivors in general practice.
Methods
A systematic review on cancer survivors’ general practice needs was conducted in PubMed, Embase and the Cochrane Library of Systematic Reviews. Eligible studies could be qualitative or quantitative studies examining cancer survivors’ needs in general practice. Studies of adult survivors, with any cancer type, considered free of active disease and no longer receiving active treatment, were included. For each study a quality score was given using a form developed specifically for this study. Statements about survivors’ general practice needs were collected and corresponding themes were grouped.
Results
Fifteen studies were included, of which twelve were qualitative. Most mentioned general practice needs were psychosocial needs, mainly being support received form the GP, followed by a need for help with medical issues, and a need for information on cancer, recovery, late treatment effects and on adjusting to life after treatment.
Conclusions
Cancer survivors have different types of general practice needs that are currently not or insufficiently met. This review provides a starting point for the development of new guidelines for general practitioners to support in cancer survivorship.
doi:10.1186/1471-2296-15-94
PMCID: PMC4031325  PMID: 24885266
Cancer survivors; Care needs; Primary health care; General practitioner; Family physician
21.  Identification of factors associated with diagnostic error in primary care 
BMC Family Practice  2014;15:92.
Background
Missed, delayed or incorrect diagnoses are considered to be diagnostic errors. The aim of this paper is to describe the methodology of a study to analyse cognitive aspects of the process by which primary care (PC) physicians diagnose dyspnoea. It examines the possible links between the use of heuristics, suboptimal cognitive acts and diagnostic errors, using Reason’s taxonomy of human error (slips, lapses, mistakes and violations). The influence of situational factors (professional experience, perceived overwork and fatigue) is also analysed.
Methods
Cohort study of new episodes of dyspnoea in patients receiving care from family physicians and residents at PC centres in Granada (Spain). With an initial expected diagnostic error rate of 20%, and a sampling error of 3%, 384 episodes of dyspnoea are calculated to be required. In addition to filling out the electronic medical record of the patients attended, each physician fills out 2 specially designed questionnaires about the diagnostic process performed in each case of dyspnoea. The first questionnaire includes questions on the physician’s initial diagnostic impression, the 3 most likely diagnoses (in order of likelihood), and the diagnosis reached after the initial medical history and physical examination. It also includes items on the physicians’ perceived overwork and fatigue during patient care. The second questionnaire records the confirmed diagnosis once it is reached. The complete diagnostic process is peer-reviewed to identify and classify the diagnostic errors. The possible use of heuristics of representativeness, availability, and anchoring and adjustment in each diagnostic process is also analysed. Each audit is reviewed with the physician responsible for the diagnostic process. Finally, logistic regression models are used to determine if there are differences in the diagnostic error variables based on the heuristics identified.
Discussion
This work sets out a new approach to studying the diagnostic decision-making process in PC, taking advantage of new technologies which allow immediate recording of the decision-making process.
doi:10.1186/1471-2296-15-92
PMCID: PMC4024115  PMID: 24884984
Primary care; Diagnostic errors; Decision-making
22.  A monitoring and feedback tool embedded in a counselling protocol to increase physical activity of patients with COPD or type 2 diabetes in primary care: study protocol of a three-arm cluster randomised controlled trial 
BMC Family Practice  2014;15:93.
Background
Physical activity is important for a healthy lifestyle. Although physical activity can delay complications and decrease the burden of the disease, the level of activity of patients with chronic obstructive pulmonary disease (COPD) or type 2 Diabetes Mellitus (DM2) is often far from optimal. To stimulate physical activity, a monitoring and feedback tool, consisting of an accelerometer linked to a smart phone and webserver (It’s LiFe! tool), and a counselling protocol for practice nurses in primary care was developed (the Self-management Support Program). The main objective of this study is to measure the longitudinal effects of this counselling protocol and the added value of using the tool.
Methods/Design
This three-armed cluster randomised controlled trial with 120 participants with COPD and 120 participants with DM2 (aged 40–70), compares the counselling protocol with and without the use of the tool (group 1 and 2) with usual care (group 3). Recruitment takes place at GP practices in the southern regions of the Netherlands. Randomisation takes place at the practice level. The intended sample (three arms of 8 practices) powers the study to detect a 10-minute difference of moderate and intense physical activity per day between groups 1 and 3. Participants in the intervention groups have to visit the practice nurse 3–4 times for physical activity counselling, in a 4-6-month period. Specific activity goals tailored to the individual patient's preferences and needs will be set. In addition, participants in group 1 will be instructed to use the tool in daily life. The primary outcome, physical activity, will be measured in all groups with a physical activity monitor (PAM). Secondary outcomes are quality of life, general - and exercise - self-efficacy, and health status. Follow-up will take place after 6 and 9 months. Separately, a process evaluation will be conducted to explore reasons for trial non-participation, and the intervention’s acceptability for participating patients and nurses.
Discussion
Results of this study will give insight into the effects of the It’s LiFe! monitoring and feedback tool combined with care from a practice nurse for people with COPD or DM2 on physical activity.
Trial registration
ClinicalTrials.gov: NCT01867970
doi:10.1186/1471-2296-15-93
PMCID: PMC4030038  PMID: 24885096
Physical activity; Self-management support; Primary care nursing; Remote sensing technology
23.  Receptionist rECognition and rEferral of PaTients with Stroke (RECEPTS) study - protocol of a mixed methods study 
BMC Family Practice  2014;15:91.
Background
As the first point of contact for patients and witnesses of stroke, General Practice receptionists can be instrumental in deciding the urgency of clinical contact. Despite the considerable complexity of this task, reception staff are not clinically trained. Minimising the time taken to access thrombolysis is crucial in acute stroke as treatment must be initiated within 4.5 hours of the onset, and the earlier the better, to achieve the best outcomes. Research suggests that patients who first contact their General Practice following the onset of stroke symptoms are less likely to receive thrombolysis, in part due to significant delays within Primary Care.
This study therefore aims to understand the role of General Practice receptionists, with particular interest in receptionist’s ability to recognise people who may be suffering from a stroke and to handle such patients as a medical emergency.
Methods
The Receptionist rECognition and rEferral of PaTients with Stroke (RECEPTS) study will be a Primary Care based mixed methods study. 60 General Practices in the West Midlands will be recruited. Each practice will receive 10 unannounced simulated patient telephone calls, after the 10 calls questionnaires will be administered to each receptionist. These will examine the behaviour of receptionists towards patients presenting in Primary Care with stroke symptoms, and their knowledge of stroke symptoms. An embedded qualitative study will use interviews and focus groups to investigate the views of General Practice staff on the receptionists’ role in patient referral and whether training in this area would be helpful.
Discussion
The results of the RECEPTS study will have important implications for providers of Primary Care. The study will establish current practice in UK primary care in terms of General Practice receptionists’ knowledge of the presentation and appropriate referral of those who may be suffering a stroke. It will highlight training needs and how such training might be best delivered.
doi:10.1186/1471-2296-15-91
PMCID: PMC4030067  PMID: 24884883
Medical receptionists; General Practice; Family practice; Health Services Administration; Simulation; Patient; Research; Qualitative; Questionnaires
24.  Design of the INTEGRATE study: effectiveness and cost-effectiveness of a cardiometabolic risk assessment and treatment program integrated in primary care 
BMC Family Practice  2014;15:90.
Background
The increasing prevalence of cardiometabolic disease (CMD) in combination with an ageing population is a major public health problem. Early detection and management of individuals at risk for CMD is required to prevent future health problems with associated costs. General practice is the optimal health care setting to accomplish this goal. Prevention programs for identification and treatment of patients with an increased risk for CMD in primary care have been proven feasible. However, the effectiveness and cost-effectiveness have yet to be demonstrated. The ‘Personalized Prevention Approach for CardioMetabolic Risk’ (PPA CMR) is such a prevention program. The objective of the INTEGRATE study is to investigate the effectiveness and cost-effectiveness of PPA CMR, as well as to establish determinants for participation and compliance.
Methods
The INTEGRATE study is designed as a stepped-wedge randomized controlled trial with a waiting list control group. In approximately 40 general practices, all enlisted patients without CMD aged 45–70 years, are invited to participate in PPA CMR. After an online risk estimation, patients with a score above risk threshold are invited to the GP for additional measurements, detailed risk profiling and tailored treatment of risk factors through medication and/or lifestyle counseling. At baseline and after twelve months of follow-up lifestyle, health and work status of all participants are established with online questionnaires. Additionally after twelve months, we will determine health care utilization, costs of PPA CMR and compliance. Primary endpoints are the number of newly detected patients with CMD and changes in individual risk factors between the intervention and waiting list control group. Medical data will be extracted from the GPs’ electronic medical records. In order to assess factors related to participation, we will send questionnaires to non-participants and assess characteristics of participating practices. For all participants, additional demographic characteristics will be available through Statistics Netherlands.
Discussion
The INTEGRATE study will provide insight into the effectiveness and cost-effectiveness of PPA CMR as well as determinants for participation and compliance, which represents essential information to guide further large-scale implementation of primary prevention programs for CMD.
Trial registration number
NTR4277, The Netherlands National Trial Register, 26-11-2013.
doi:10.1186/1471-2296-15-90
PMCID: PMC4022539  PMID: 24884779
Cardiometabolic disease; Prevention; (Primary) screening; Non-participation; Primary care; Family practice; Effectiveness; Economic evaluation; RCT
25.  Implementing tobacco dependence treatment during clinical consultations: a qualitative study of clinicians’ experiences, perceptions and behaviours in a South African primary health care setting 
BMC Family Practice  2014;15:85.
Background
Evidence suggests that healthcare providers (HCPs) in South Africa do not consistently offer tobacco dependence treatment (TDT) during clinical consultations. In order to understand and explain this behaviour in a South African context, we conducted a qualitative exploration of HCPs’ experiences, perceptions and behaviours regarding TDT.
Methods
Individual qualitative interviews were conducted with physicians and nurses who were purposively selected. Themes were identified from interview transcripts using content analysis. Findings were triangulated and peer-reviewed, and were also verified by the participants.
Results
Fifteen physicians and four nurses were interviewed, none of whom used tobacco. These participants perceived TDT as an important task, but could not consistently implement it during clinical consultations due to health systems constraints (time-constraints because of patient-overload, the unavailability of cessation medications and a lack of support for referrals), misperceptions and misconceptions (negative outcome expectations about the effectiveness and feasibility of TDT), socio-cultural barriers (counselling older persons was perceived as challenging) and personal limitations (perceived low self-efficacy, poor knowledge and skills on implementing any evidence-based TDT framework). Patients are therefore selectively screened based on clinical relevance and offered only prescriptive brief advice. Participants recommended several systems changes, including academic detailing of tobacco status, training HCPs and incorporating tobacco cessation medications in the Essential Drug List.
Conclusion
The reported selective screening and limited TDT interventions offered by HCPs are related to interactions between health systems constraints, personal limitations, and misperceptions and misconceptions about the effectiveness and feasibility of TDT during clinical consultation. Implementing the recommended systems changes has the potential to improve the implementation of TDT in South African primary health care (PHC).
doi:10.1186/1471-2296-15-85
PMCID: PMC4017704  PMID: 24886595
Healthcare provider; Behaviours; Primary care; Tobacco dependence treatment

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