Scandinavian Journal of Primary Health Care最新文献

Background: The 15-method is a primary healthcare tool for opportunistic screening and brief intervention for alcohol-related problems. A Danish feasibility test of the 15-method suggested that adjustments might enhance its fit to Danish general practice. This study reports on user-involving workshops aimed at refining a Danish version of the 15-method.

Methods: Using a participatory design approach, we conducted iterative cycles of planning, user workshops, evaluating and revising design. Workshops engaged five general practitioners, three nurses, four patients, four researchers, a project manager, a graphics designer and a behavioral design specialist. Through prototyping and scenario enacting, participants co-developed solutions to improve the 15-method's structure and usability. Prototypes were field tested and evaluated.

Results: The 15-method's treatment step was shortened from four consultations to three by re-structuring of the patient material and increasing flexibility in transitioning from screening to treatment. A quick guide was developed as a shared reference for patients and healthcare professionals, alongside visual aids such as flyers and posters. The healthcare manual was re-designed for flexibility and updated to include varied screening approaches. Field testing confirmed that these adjustments enhanced usability and interdisciplinary collaboration.

Conclusion: The participatory design process effectively refined the 15-method for Danish general practice. Future studies will assess the effectiveness of the adapted version on a larger scale.

Objective: To explore how trainee doctors in general practice navigate patient expectations and requests for non-indicated procedures or tests, and what factors may pressure them into practising defensively.

Design and setting: A qualitative interview study with 13 GP trainees from the Capital Region and Region Zealand in Denmark. An interview guide was developed based on existing literature and a pilot interview with an experienced GP. Data were coded in NVivo (version 15) and analysed using thematic analysis.

Results: The trainees described several challenges when facing patient requests for unnecessary procedures or tests. These challenges were linked to their own uncertainty, patient expectations and behavior, as well as external factors. The trainees described experiencing self-doubt and uncertainty, particularly when their clinical judgement was questioned by patients. Managing patient expectations, especially when patients were worried, sought tangible evidence, or had private health insurance, was described as challenging. Additionally, clinical values and a stressful environment was said to further influence decision-making processes. Together, these factors sometimes pressured the trainees into adopting a more defensive approach. With more experience, many developed greater confidence and argumentation, making it easier to refuse patient requests while maintaining a good relationship.

Conclusion: Our study indicates that uncertainty, patient expectations, and external circumstances may, in certain situations, pressure Danish GP trainees into practising defensively. Managing and navigating both their own and the patient's uncertainty emerges as a key challenge. Future research is needed to explore how trainees can be better supported and educated in managing uncertainty and patient expectations in general practice.

Background: Rising demand and workforce shortages challenge European healthcare systems. Unscheduled healthcare, including out-of-hours (OOH) primary care, is often managed through telephone triage. Improving triage quality is essential to maintain accessible and sustainable unscheduled care across Europe.

Aim: To describe the role and organization of telephone triage in OOH primary care services that provide care for patients with urgent unscheduled health problems.

Design: A cross-national questionnaire-based expert study.

Methods: We developed a web-based questionnaire that was distributed to members of a European research network on OOH primary care (EurOOHnet), aiming to have one informant per country. Questionnaire data were validated through email consultation with informants.

Results: Expert informants from 16 countries completed the survey. Most countries had general practice care, ambulance care, and emergency departments to provide urgent unscheduled care. Access routes to unscheduled care varied considerably between countries; 11 countries used telephone triage. Three triage models were identified: 1) Triage to care, 2) Advice and referral, and 3) Advice helplines. Self-advice tools, triage preparation tools, and chatbots were uncommon.

Conclusion: We identified three triage models that had different roles related to access to unscheduled care. Telephone triage is used frequently to fit demand to available resources.

Purpose: To shed a nuanced light on the experiences of taking part in a rehabilitation programme using acceptance and commitment therapy (ACT) for people living with persistent pain and fatigue.

Materials and methods: The ACT intervention, designed by the Pain Clinic of a University Hospital, consisted of six four-hour sessions, each for four groups of 6-8 participants, given over the course of four months. An interdisciplinary research team thematically analysed 13 post-programme individual interviews with people aged 21 to 54 with different symptoms and diagnoses using systematic text condensation.

Results: Participants reported that while illness had led to feelings of loneliness, loss and failure, participating in a safe and supportive group setting led to a nurturing sense of shared community, understanding and learning. Increased self-awareness, self-acceptance and self-compassion were valued outcomes of the programme. Most felt that they had acquired new tools, such as exercises, practices and altered ways of thinking. A few participants were uncomfortable with the sharing practices and felt that the programme brought few benefits for them.

Conclusions: The study indicates the value of a sense of community and experiencing illness as a shared human condition. Learning to see oneself as worthy of self-compassion, suggested in the literature as key to pain rehabilitation, was connected to group validation and ACT-specific sessions. Information, exercises and sharing practices could have been even better targeted and tailored to individual participants.

Objectives: Out-of-hours services (OOHS) worldwide exhibit diverse organisational models, especially within the European Union. This study aims to describe the transformation of OOHS in Region Zealand, Denmark, from a General Practitioner cooperative (GP-OOHS) to a regional organization/service, known as the 1818 Medical Helpline (1818).

Study design: Retrospective cohort study.

Methods: GP-OOHS data (January 2017-October 2023) during the transition from GP-cooperative to Regional Service (October 2022) were analysed. Coded and timestamped services retrieved from the billing system were used to identify patient pathways, defined as services within a 12-hour window. Descriptive statistics were applied.

Results: A total of 2,572,951 patient pathways were recorded, with 2,258,072 under GP-out-of-hours service and 314,879 under the 1818. Overall, patient pathway volumes declined from 412,116 in 2017 to 314,879 in 2022, and admissions fell from 64,555 to 59,967. The median patient age was 35 years. The GP-out-of-hours service had a higher average monthly volume of patient pathways (32,726 vs. 25,940), while 1818 showed a higher proportion of emergency department admissions within 24 h (19.0% vs. 17.6%), the number of admissions fell from 8.2 per 100,000 inhabitants to 7.1 per 100,000 inhabitants. Interrupted time series analysis showed that the previously increasing tendency in ED admissions flattened following the transition. Although the absolute number of children admitted decreased, the proportion of admissions increased due to overall decline in patient pathways. Face-to-face consultations (31.4% vs. 27.1%) and home visits (9.4% vs. 3.4%) were more frequent in GP-out-of-hours service, both being associated with higher admission rates.

Conclusions: OOHS patient pathways declined over the study period and continued to decline following the organizational change. The absolute number of emergency department admissions also decreased, while the relative proportion of admissions increased. These findings indicate a continued decline in OOHS activity and a slight shift toward more acute cases after the reorganisation.

Background: Screening and brief interventions (SBIs) for alcohol use are effective but challenging to implement in primary care settings. Universal screening is resource-intensive and may not align with general practitioners' (GPs) perceived professional role. Pragmatic case finding (PCF), which integrates alcohol discussions into clinically relevant contexts, may provide a feasible alternative to traditional SBI.

Aim: This study aimed to assess the feasibility and acceptability of tailored, theory-based educational outreach visits (EOVs) to embed PCF in primary care, explore its influence on professional practice in addressing alcohol, and examine changes in determinants of GP behaviour pre- and post-implementation.

Design and setting: Four EOVs were delivered in GP clinics in Stavanger and Oslo, Norway, involving 37 GPs and 22 support staff, to enhance GPs' ability to manage alcohol-related health problems.

Method: A mixed-methods feasibility study comprising semi-structured group interviews and quantitative surveys. Group interviews explored GPs' experiences, while the Determinants of Implementation Behaviour Questionnaire (DIBQ) assessed changes in knowledge, skills and intentions. Qualitative data were thematically analysed. Quantitative data were analysed using descriptive statistics.

Results: GPs (n = 10) perceived the EOVs as feasible and acceptable, preferring in-person over remote delivery. Key themes included greater awareness of alcohol's health impacts, sustaining awareness of hidden cases, reducing stigma through normalised discussions, and balancing motivation with the challenge of changing entrenched habits. Survey findings (n = 19) showed a gradual, positive shift in GPs' knowledge, skills, and goals to discuss alcohol.

Conclusion: The EOVs were feasible and acceptable for embedding PCF in primary care. They may strengthen GPs' capacity to address alcohol in routine consultations, but further research is needed to assess fidelity, sustainability, and patient-level outcomes.

Trial registration number: ClinicalTrials.gov ID: NCT04725552.

Background: During the COVID-19 pandemic, the use of macrolides, specifically azithromycin, for respiratory tract infections (RTIs) in primary care increased in several countries. In Norway, antibiotic treatment of COVID-19 was never recommended.

Objectives: To investigate the antibiotic treatment for RTIs in Norwegian primary care, comparing pre-pandemic and pandemic periods.

Methods: We defined RTI episodes and antibiotic treatment using several national registries including demographic and residency data from Statistics Norway, reimbursement claims from the Norwegian Registry for Primary Health Care, antibiotic dispensing from the Norwegian Prescription Database, and deaths from the Norwegian Cause of Death Registry, for the years 2018-2021.

Results: Approximately 80% of the 4 904 376 total RTI episodes during the study period were handled exclusively in daytime general practice (DGP). Use of electronic consultations for RTI episodes increased from less than 1% to more than 50%. Throughout the study period, most RTI episodes were handled without antibiotic use. The antibiotic treatment rate for RTI episodes dropped during the pandemic, relative risk (RR) 0.52, 95% confidence interval (CI) 0.52-0.52, compared to pre-pandemic. Over half of all antibiotic treatments for RTIs were phenoxymethylpenicillin, and the distribution of antibiotic types was relatively stable during the study period, except for some temporary changes in the initial months of the pandemic. DGP handled most of the influx of RTIs during the first month of the COVID-19 pandemic in primary care, without increasing antibiotic use.

Conclusions: DGP handled most of the influx of RTIs during the initial phase of the COVID-19 pandemic in primary care. During the pandemic antibiotic treatment for RTIs was reduced, and the distribution of antibiotic types barely changed.

Introduction: Irritable bowel syndrome (IBS) is a common condition that should be diagnosed using the Rome criteria and limited laboratory testing. The aim of this retrospective, medical record-based study was to evaluate the adherence of Swedish primary health care practitioners to diagnostic guidelines for IBS.

Methods: Using the electronic patient register in primary care, we identified 1943 new IBS cases in patients aged 18-65 between January 2015 and December 2019 in Region Örebro County. A random sample of 400 patients was selected and their medical records were scrutinized to evaluate diagnostic methods.

Results: Of the 309 eligible medical records, only 36.2% of patients met the Rome III or IV criteria. The criteria were explicitly documented in 4.9% of cases, and subclassification was noted in 5.5%. There were no significant differences in diagnostic practices between GPs and other physicians. Only 9.4% were diagnosed without laboratory testing, although 69.9% did not undergo all recommended tests according to local guidelines. Rectoscopy was performed in 14.2%, while 9.7% and 5.8% of patients were referred for colonoscopy or CT, respectively, with significantly higher referral rates in patients over 40 years. Men were more frequently referred for colonoscopy while other diagnostic procedures showed no significant sex differences.

Conclusions: Adherence to IBS diagnostic guidelines in Swedish primary care seems to be limited among both GPs and non-GPs. The documented use of Rome criteria is minimal, and guideline-compliant laboratory testing is insufficient. Increased awareness and structured implementation of IBS diagnostic criteria are warranted.

Background: In Denmark, transgender and nonbinary (TNB) individuals must consult their General Practitioner (GP) to access gender-affirming healthcare (GAHC). TNB individuals report unmet health needs and higher incidences of mental health challenges compared to cisgender peers. Cultural safety, involving a 'safe space,' could reduce healthcare inequities.

Objectives: This study aims to identify the factors, according to TNB individuals in Denmark, that create, maintain, and disrupt a 'safe space' in general practice.

Method: Twelve semi-structured qualitative interviews with TNB individuals aged 20 to 43 were conducted, transcribed verbatim, and analysed using Systematic Text Condensation.

Main findings: Participants felt unsafe with GPs due to negative experiences related to being transgender, leading to healthcare avoidance. They valued GPs who respected chosen names, showed interest in transgender care, and were upfront about limitations. A significant issue was lack of GP knowledge on transgender healthcare, often requiring participants to educate their GPs. Participants emphasised the need for doctors to avoid assumptions about patients based on gender identity. Participants did not believe that a 'safe space' can be realised but wish for a 'safer space'.

Conclusion: Trans individuals feel unsafe when consulting their GP due to past and present negative experiences, which leads to healthcare avoidance. A 'safer space' encompasses; respecting chosen names, showing an interest in transgender care, listening and meeting patients on their terms. The study highlights the importance of educating GPs on respectful interactions, suggesting that adopting the concept of a 'safer space' as a medical term could improve healthcare for TNB individuals.