Scandinavian Journal of Primary Health Care最新文献

Background: Antibiotic prescription rates can be affected by pandemic measures such as lockdowns, social distancing, and remote consultations in general practice. Therefore, such emergency states may negatively affect antimicrobial stewardship, specifically in out-of-hours (OOH) primary care. As contact patterns changed in the COVID-19 pandemic, it would be relevant to explore the impact on antimicrobial stewardship.

Aim: To study the impact of the pandemic on antibiotic prescription rates in OOH primary care, overall and per age group.

Methods: This cross-sectional register-based study used routine data from OOH primary care in the Central Denmark Region. We included all patient contacts in two equivalent time periods: pre-pandemic and pandemic period. The main outcome measure was defined as the number of antibiotic prescriptions per contact (antibiotic prescription rate).

Results: The overall antibiotic prescription rate decreased during the first year of the pandemic compared to the pre-pandemic period (RR = 0.97, 95%CI: 0.96-0.98). Likewise, the rate decreased for clinic consultations (RR = 0.63, 95%CI: 0.62-0.64). However, an increase was seen for telephone consultations (RR = 1.73, 95%CI: 1.70-1.76). The decline in clinic consultations was largest for consultations involving children aged 0-10 years (RR = 0.53, 95%CI: 0.51-0.56).

Conclusion: Antibiotic prescription rates in Danish OOH primary care decreased during the first year of the COVID-19 pandemic, especially for young children. Prescription rates decreased in clinic consultations, whereas the rates increased in telephone consultations. Further research should explore if antibiotic prescription rates have returned to pre-pandemic levels, and if the introduction of video consultations has affected antibiotic prescription patterns in OOH primary care.

Objective: To examine cardiovascular risk factors in 40-year-old participants in the health screening program targeted health dialogues (THDs).

Design: Cross-sectional study.

Setting: 99 Swedish healthcare centers.

Intervention: Metabolic risk factors and health behaviors were assessed. THDs were provided.

Subjects: 1831 (62.3%) THD participants that consented to take part in the research project.

Main outcome measures: (1) Prevalence of metabolic risk factors (blood pressure, LDL cholesterol, fasting plasma glucose, BMI, waist-hip ratio) and unhealthy behaviors (tobacco, alcohol, diet, physical activity) by sex, education, and place of birth. (2) Associations between different health behaviors and between the number of unhealthy behaviors and prevalence of metabolic risk factors. (3) THD participation by sociodemographics compared to age-matched controls.

Results: Men had a higher prevalence of all metabolic risk factors, excessive alcohol use and tobacco use than women. Lower educated individuals had a higher prevalence of metabolic risk factors (except for LDL cholesterol) and tobacco use than highly educated. Participants born outside Sweden had a higher prevalence of obesity, high waist-hip ratio, and tobacco use. Participants with 3-4 unhealthy behaviors had significantly higher prevalence of each of the metabolic risk factors except BMI. Women, highly educated and Swedish-born participants were slightly over-represented in the THDs.

Conclusion: Considering the associations between unhealthy behaviors and metabolic risk factors, the THD method, covering lifestyle as well as objective health measures, may be an appropriate method for early identification of individuals at risk for future non-communicable diseases in the whole population with a specific focus on certain groups.

Clinicaltrials.gov: NCT04912739.

Objective: To explore the views of general practitioners and physiotherapists on the current model of care for patients with musculoskeletal disorders in Norwegian primary care, and if the English First Contact Practitioner model, where patients have access to multiple professional groups with musculoskeletal health expertise, could inform service development.

Design, setting, and subjects: We analysed interviews with five GPs and 11 physiotherapists and used Lipsky's theories about street-level bureaucracy and Foucault's theories of mechanisms of power and institutional structures to explore task shifting and cooperation between different professions.

Results and interpretation: The empirical material reflected a multi-faceted discourse about skill-mix in primary care, where financial factors, perceptions about competence, and task preferences moderated attitudes to task shifting. Competition and cooperation coexist between the professions, and the seemingly gradual blurring between historical hegemony and new models of care creates both alliances and rivalries. Examples of deviations from the Choosing Wisely principles and evidence-based practice indicate that both general practitioners and physiotherapists balance the roles of patient advocate, gatekeeper, and homo economicus, in a context where task shifting is challenged by established practice. It appears that the management of patients with musculoskeletal disorders is fragmented and to some extent reflects a supply-driven system.

Introduction: The prevalence of sleep disorders and use of sleep medication, particularly melatonin, are rising among adolescents and young adults (13-24 years). In Denmark, melatonin is approved for use in children with autism and ADHD up to 18 years of age, with other prescriptions being off-label in these age groups. The perspectives of medical practitioners on prescribing sleep medications to this age group remain largely unexplored.

Aim: This study aims to investigate the considerations of general practitioners (GPs) and child and adolescent psychiatrists (psychiatrists) when prescribing and deprescribing sleep medications for 13-24-year-olds.

Methods: We conducted qualitative semi-structured interviews with 10 GPs and six psychiatrists. Data were analyzed using an inductive approach.

Results: Psychiatrists typically prescribed melatonin with the expectation that deprescription would occur in general practice. Despite the universal goal of deprescription, it was hindered by various challenges. GPs identified patient motivation and a clear focus on deprescription as facilitative factors and expressed a need for enhanced emphasis on these aspects in general practice.

Discussion and implications: The findings align with existing prescription trends and literature on factors that promote and inhibit deprescription. The study underscores the complexities of deprescribing sleep medications for adolescents and young adults, suggesting the need for expanded guidelines and enhanced continuing education for GPs.

Conclusions: The research highlights significant discrepancies among medical practitioners regarding the deprescription process of sleep medications for young individuals, complicated by multiple factors. This underscores the need for better guidelines and further studies.

Introduction: Health-promotion approaches to address stress-related exhaustion disorders, reduce personal suffering, improve coping and participation in everyday life are needed in primary care. The aim of this study was to investigate self-reported health and well-being before and after an intervention focusing on well-being with photo-supported conversations (BeWell^TM).

Material and methods: Eighty-one patients (69 women), 20-67 years old, with exhaustion disorders were recruited at Swedish primary health care centres (PHCC) to a controlled clinical study. The intervention group (n = 40) were offered BeWell^™ by therapists in addition to care as usual. Controls (n = 41) received only care as usual. The primary outcome, self-rated symptoms of exhaustion (Karolinska exhaustion disorder scale, KEDS), and secondary outcomes, anxiety and depression, sense of coherence, quality of life, occupational balance, and work ability, were assessed by validated questionnaires. Non-parametric statistical analyses were used to compare data collected directly after the treatment period with baseline measures.

Results: Demographics and self-rated baseline measures of health and well-being were comparable between the groups, apart from sick leave being more common in the intervention group. Participants in the intervention group reduced their level of exhaustion more than the control group (median difference on KEDS -9.0 vs -4.0, p = .035). However, the size of the KEDS reduction was related to baseline KEDS and, not independently associated with group assignment. Both groups improved regarding secondary outcome measures.

Conclusion: Stress-related symptoms decreased considerably over the treatment period for both groups. The potential benefit of the BeWell^™, which was intended to facilitate recovery, needs to be further evaluated.

Objective: Nurse practitioners (NPs) have recently been introduced in Norwegian homecare services. The NP role is still in an early implementation phase without standardized role descriptions. NPs are dependent on collaborating with general practitioners (GPs) in the care and treatment of patients. However, little is known about how NPs in Norway experience this collaboration. This study aims to explore how NPs working in homecare services describe their collaborative experiences with GPs, and what influence this collaboration.

Design: The study had a qualitative descriptive design, applying individual, semi structured interviews to generate data from five Norwegian nurse practitioners working in homecare services. Data were analyzed using systematic text condensation.

Findings: The NPs had varied experiences regarding the collaboration with GPs. NPs stated their role as unclear, lacking standards and job descriptions. The NPs experienced that some GPs were uncertain about the NPs competence, which inhibited collaboration and restricted the NPs utilization of their full capability.NPs experienced a higher degree of collaboration with GPs they knew, and they indicated that trust was the key to facilitate collaboration. The NPs also noted the challenges of establishing relationships with GPs due to the lack of formal meetings and the physical separation of their workplaces.

Conclusion: Interpersonal dynamics, organizational structures and systemic frameworks influenced the collaboration between GPs and NPs in homecare services. Trust was identified as an important prerequisite for collaboration.

Objectives: To explore the perceptions and views of remote consultations and patient care of primary care physicians (PCPs) who work remotely regularly and have experience performing remote consultations.

Design: A qualitative study using thematic analysis.

Setting: Four online focus group interviews with 17 PCPs, working with one private health care provider, with public and private primary care patients.

Subjects: PCPs who had performed video or online chat consultations with primary care patients for at least 6 months.

Main outcome measurements: PCPs' perceptions and views working remotely in online chat and video consultations.

Results: Two main themes describing how PCPs perceived remote consultations emerged: 1) remote consultations have an impact on the way physicians work, and 2) remote consultations have an impact on the service system and patients. The subthemes of the first main theme included the physicians' new way of working, impacts on physicians' well-being, and impacts on communication and physician competences. The subthemes for the second main theme were the importance of smoothness of services for the patients, patient suitability, and technical liabilities.

Conclusion: Remote consultations provide PCPs with a new way of working that could improve work-life balance. However, it is important to maintain sufficient clinical competence through versatile work. Digital consultations can make contacting healthcare smoother and easier for patients if the patient selection is performed carefully. Online chat seems suitable for singular contacts and simple issues, but remote consultations could be used to sustain continuity of care.

Background: Incidence of peptic ulcer bleeding can be substantially reduced by prophylactic use of proton pump inhibitors (PPIs) in patients at risk, but use of PPI varies among risk patients, and substantial under-prescribing may exist. The variation in prophylactic prescribing among general practices remains unknown.

Methods: A nationwide register-based cross-sectional study analyzing the proportion of patients at risk of ulcer bleeding receiving PPI treatment within Danish general practices. Using logistic regression, we analyze associations between general practice characteristics and prophylactic treatment among patients at risk of ulcer bleeding listed with the general practice.

Results: In most general practices, less than 40% of the patients at increased risk of ulcer bleeding were covered by PPI. Geographical variation was present, where practice location outside the capital area was associated with higher odds of PPI coverage among their risk patients. Partnership practices with GPs with a mean age ≥65 years or with only female GPs were associated with higher odds of providing prophylaxis among their risk patients compared to practices with a mean GP age <45 years or with only male GPs. Similar associations were not found for single-handed practices.

Conclusions: A significant under-prescribing of ulcer prophylaxis is common across all general practice characteristics, and only few associations with practice characteristics were present. Most efforts to rationalize PPI prescribing have aimed at reducing overprescribing but the findings point to under-prescribing as a problem as well. Development of new methods to assist GPs in identifying individuals at risk of ulcer complications is needed.

Background: Acute coronary syndrome (ACS) and acute myocardial infarction (AMI) account for a large portion of cardiovascular deaths. Signs and symptoms for these syndromes, such as chest pain, are non-specific and can be caused by a variety of non-cardiac conditions, especially in low-prevalence settings such as general practice. The diagnostic value of these signs and symptoms can be assessed using diagnostic meta-analyses, but the last one dates from 2012.

Methods: We performed a diagnostic meta-analysis in accordance with PRISMA guidelines. We searched PubMed, Embase and CENTRAL from 2006 to 2024. We included studies that assessed the diagnostic accuracy of thirteen different signs and symptoms. We divided patients into two subgroups (AMI and ACS) on which analysis was performed independently.

Results: We selected 24 articles for inclusion. Our analysis indicates that signs and symptoms have a limited role in the diagnosis of AMI or ACS. The most useful (highest diagnostic odds ratios, DOR) in the diagnosis of AMI were pain radiating to both arms (DOR 2.95 (95%CI 1.57-5.06)), absence of chest wall tenderness (DOR 3.51 (95%CI 1.64-6.61)), pain radiating to the right arm (DOR 5.17 (95%CI 1.77-11.9)) and sweating (DOR 5.75 (95%CI 2.51-11.4)). For ACS these were pain radiating to the right arm (DOR 3.9 (95%CI 0.7-12.6)) and absence of chest wall tenderness (DOR 7.73 (95%CI 2.19-19.8)).

Conclusion: We report the accuracy of thirteen signs and symptoms in the diagnosis of AMI and ACS. These can be useful to calibrate general practitioners' diagnostic assessment of chest pain in primary care settings.

Background: The focus of research and management of Dupuytren's disease (DD) is shifting from relieving symptoms in the later stages of disease towards the prevention of contractures. Treatment services might likewise shift towards primary care. Studying characteristics of DD patients who seek medical care for the first time, may identify a symptomatic target group for early DD treatments. We present the first study that estimates the incidence and prevalence of DD in primary care by applying a text-mining algorithm to registration data.

Methods: This is a population-based cohort study using electronic health records from Dutch general practices involved in a regional research network. Descriptive statistics were used to describe sex, age, comorbidities and lifestyle factors, the latter two were identified via International Classification of Primary Care (ICPC) codes. Incidence rate was calculated as number of patients with a first contact for DD/1000 person years for the years 2017-2021, point prevalence as the percentage of patients with a contact for DD in 2021. DD contacts were identified using a text-mining algorithm.

Results: The incidence ranged between 1.41 and 1.72/1000 person years and the overall prevalence was 1.99%. Incidence and prevalence are higher among males and increase with age, peaking between 61 and 80 years.

Conclusions: Our results of prevalence and incidence of DD in primary care give an insight into the relevant population of patients with symptomatic DD that might be the future target group for potential disease controlling treatments.