Scandinavian Journal of Primary Health Care最新文献

Denmark is known for its good population health, largely attributable to its effective healthcare system. This analysis of the Danish primary healthcare system with focus on general practice describes the system's overall structure, function, and financing. Further, it reviews some of the recent developments in organization and decentralization from secondary to primary care. Finally, we discuss some of the key challenges that primary care faces and potential areas for improvement to ensure a sustainable Danish healthcare system of high quality.

Aim: To (1) explore perceived access to general practice, relationship with the general practitioner (GP) and previous experiences with general practice among the Danish population and (2) analyse the associations with sex, age, chronic disease and health literacy.

Methods: A cross-sectional nationwide survey study among 100,000 randomly selected adults aged 20 years or above. Questionnaire data comprised items covering the perceived access to, relationship and previous experiences with GP contacts, chronic disease and health literacy. Data were linked to register data. Descriptive statistics and multivariable logistic regression models were applied.

Results: A total of 27,713 (30%) individuals were included. More than a third reported difficulties with talking to the GP secretary (35%) and with getting an appointment with their preferred doctor (44%). Some 80% reported high confidence in the GP, whereas previous negative experiences and insufficient consultation time were reported by 33% and 46%, respectively. Females and individuals with health literacy challenges in terms of being less able to actively engage with healthcare professionals were more likely to report difficulties with access to and previous negative experiences with general practice. Individuals with higher age, chronic disease(s) and health literacy challenges in terms of feeling less understood and supported, and less ability to actively engage with healthcare providers were less confident in their GP.

Conclusions: This study highlights difficulties related to accessing general practice and previous negative experiences among different population groups. Since some individuals are more likely to encounter these challenges, differentiating healthcare services may promote greater equity in health.

Background: The majority of individuals in Sweden with type 2 diabetes have their sole health care provider in primary health care. Metformin treatment often causes gastrointestinal side-effects. Our aim was to construct and validate a questionnaire assessing gastrointestinal symptoms before and after starting metformin treatment for type 2 diabetes.

Methods: In the Interaction Between Metformin and Microbiota (MEMO) study, 54 participants rated six gastrointestinal symptoms at baseline and after 2 months of metformin treatment in a questionnaire (measured change, i.e. the difference between assessments at these two time points), as well as direct assessment of perceived change in symptoms after 2 months in a separate validation questionnaire (reported change, i.e. how participants themselves have perceived the change between the same two time points). Spearman's ρ was calculated and reported with its 95% CI.

Results: The agreement between reported and measured change of symptoms, measured as Spearman's ρ, was above 0.4 for 4 out of 6 symptoms (poor appetite 0.60 [95% CI 0.39-0.75], loose stool or diarrhea 0.58 [95% CI 0.37-0.74], flatulence 0.45 [95% CI 0.21-0.64], and abdominal pain 0.45 [95% CI 0.20-0.65]). The agreement was lower for nausea and vomiting, although these were numerically above 75% in agreement, likely due to few symptomatic participants overall.

Conclusion: For common side-effect symptoms associated with metformin treatment, our study shows that symptom change measured as the difference between assessments at two different time-points was in overall agreement, validating the usability of the constructed questionnaire for metformin side-effects.

Background: GP recruitment and retention difficulties challenge the traditional general practice model. Task-shifting and relieving GPs from financial risk have been suggested to make primary care more attractive. In Sweden's multiprofessional team-based primary care system, GPs usually work as salaried employees and there is extensive task-shifting. Salaried employment facilitates mobility, potentially leading to high turnover. The opportunity to work on fixed contracts can also increase turnover rates.

Aim: To describe practice turnover rates and examine associations with practice characteristics in a Swedish region.

Design and setting: Analysis of observational register data from Skåne, Sweden (1.4 million residents).

Method: Turnover rates were calculated for 157 primary care practices in 2010-2018. The main dataset included all physicians - permanent and temporary workers - regularly providing care in each month. To understand the role of temporary workers, a supplementary analysis was performed on permanently employed GPs and registrars at 80 public practices in 2019. Associations between turnover and practice characteristics were examined in bivariate analyses and multiple regressions.

Results: Annual practice turnover rates ranged between 20-40% (mean 30%), showing no time trend. The high rates mainly reflected the use of temporary GPs; in the supplementary analysis of permanent GPs and registrars, the mean annual turnover rate in 2019 was 13-15%. Turnover was higher for practices with socially deprived patients or high workload. Private practices had lower turnover conditional on the higher workload.

Conclusion: The results indicate that a primary care system with salaried GPs facilitates GP mobility, which in turn creates barriers to continuity of care.

Background: Out-of-hours primary care (OOH-PC) plays a key role in initial stroke triage, yet the accuracy of telephone assessments by general practitioners (GPs) and their impact on prehospital stroke care remain insufficiently studied.

Aims: To evaluate the sensitivity of stroke and transient ischemic attack (TIA) identification by GPs during OOH-PC telephone triage and examine associations with time from first call to admission, treatment rates, and admission pathways.

Patients and methods: We conducted a retrospective cohort study including patients admitted to stroke centers in the Central Denmark Region (2020-2022) following OOH-PC contact within 48 h. Triage classification was based on GP documentation and compared with final hospital diagnoses. Outcomes included triage sensitivity, intravenous thrombolysis (IVT) rates, and time to admission.

Results: Among 4414 patients, 2738 had a final diagnosis of stroke or TIA, of whom 1728 were triage positive, corresponding to a sensitivity of 63.1% (95% CI, 61.2-64.9). Among patients with acute ischemic stroke (AIS) and symptom onset ≤3 h before OOH-PC contact, 387 of 544 were identified (71.1%, 95% CI, 67.2-74.8). Triage-positive AIS patients had higher IVT rates (adjusted difference: 8.9%, 95% CI, 5.4-12.5) and shorter call-to-admission time. In early-presenting AIS, the adjusted IVT difference was 10.9% (95% CI, 1.4-20.5), and triage-negative patients more often presented with impaired consciousness and visual symptoms.

Conclusions: GPs demonstrated moderate sensitivity in telephone triage of stroke in OOH-PC. Symptom presentation differed between triage groups, suggesting recognition may be influenced by symptom type as well as time from onset.

Background: Around 95% of all websites selling medicines globally are illegal and contribute to the spread of substandard and falsified medicines. Hence, it is important to identify legal pharmacies when accessing medicines online. During 2022-2024, 250 million prescriptions were legally dispensed in Sweden, and 69% were prescribed in primary care. Pharmacists and general practitioners are key healthcare professionals who can guide people to safe online purchases. The overall aim was to describe Swedes' online purchasing habits for medicines.

Methods: We used a cross-sectional design and collected information from the general population through an annual digital questionnaire for three years in a row, 2022-2024. In total, 6006 respondents, 18-79 years old, were included.

Results: Fifty-two percent had bought medicines online in the last year. Most respondents, 91%, did not recognise the common EU logo mandatory for authorised online pharmacies. People buying over-the-counter medicines online were significantly younger than those buying prescription-only medicines online. Female gender and higher level of education were associated with more online purchases of medicines. Most respondents' purchasing habits were not influenced by external factors. Reasons for increased online purchases were, for example, that it helps planning regarding access to treatment.

Conclusions: Half of the study participants have used online pharmacies, but fewer than 10% know how to identify a safe online pharmacy, i.e. many are at risk for fraud. Increasing this knowledge by informing those who prefer online purchases has the possibility to use the advantages and avoid the risks associated with online purchases of medicines.

Introduction: Values clarification, a key but under-implemented component of shared decision-making (SDM), involves identifying what matters to a patient relevant to a health decision. It is especially important for patients with limited health literacy (LHL), who often struggle to express preferences. General practitioners (GPs) play a central role in facilitating this process, yet their experiences are underexplored.

Aim: To explore how GPs experience values clarification with patients with LHL, the challenges they face, and which support or strategies they consider helpful to better integrate values clarification into decision-making.

Methods: We conducted semi-structured interviews with 15 GPs purposively selected from practices in lower socioeconomic areas. Interviews were audio-recorded, transcribed verbatim, and analyzed using the framework method.

Results: Four themes emerged: GPs consider values clarification important but challenging; it goes hand in hand with problem analysis; trust and continuity of care are essential foundations; and relatives can support and hinder the process. GPs described two contrasting situations: patients with LHL adopting a passive role, prompting a more paternalistic approach, and patients with LHL with strong expectations that can conflict with clinical guidelines. GPs expressed needs for training, prompts or scripts, and strategies to explore expectations before consultations.

Conclusion: Values clarification in the context of SDM with patients with LHL is complex and context dependent. Given their ongoing relationships with patients, GPs are well-positioned to facilitate this. GPs' experiences indicate that values clarification may occur throughout the consultation - often intertwined with problem analysis - reflecting the dynamic nature of SDM in general practice.

Background: Primary health care is in the unique position of being a first level of support and care to individuals with mental health problems. The focus in this service is on diagnosis, medical treatment, and symptom reduction. However, to access it is perceived as challenging by both patients and providers. An increased understanding of the lived experience of encountering primary health care may be beneficial for the delivery of a tailored mental health service to patients.

Aim: To explore the lived experience of encounters with primary health care of a person with mental health problems.

Methods: Eleven in-depth interviews were conducted online between October 2022 and April 2023. A descriptive phenomenology study in accordance with Giorgi was used to analyze the material.

Results: The essence of the lived experience of being a patient with MHP was a desire to be embraced by health professionals, which was the general construction based on four themes, To come from a place of loneliness and vulnerability, To sense mental health was viewed as problematic, To not be in control and To feel safe.

Conclusions: The lived experience of being a patient with mental health problems was described as everyday challenges due to their mental health. They never knew whether the support was there for them as patients when encountering primary health care. Acknowledging patients as experts on their life situation is the core element in person-centered care. It is therefore crucial for further research to include patients' experiential knowledge to inform clinical practice and to improve clinical outcomes.

Purpose: To examine the association between uncomplicated urinary tract infections and subsequent type 2 diabetes (T2D) diagnosis in women. Materials and methods: We included 1,840,044 women without previously diagnosed type 2 diabetes (T2D) or redeemed antidiabetic drugs. Results and conclusions: During the 12-year study period, women with uncomplicated urinary tract infections (cystitis and pyelonephritis), diagnosed within two years before T2D, did not have higher subsequent risks of T2D compared to those without urinary tract infections.

Background: In Sweden 70,000 people suffer fragility fractures annually, including 16,000 hip fractures with one-year mortality of up to 25%. Strategies to prevent falls, improve physical function, and enhance bone strength have shown mixed results.

Aim: To evaluate the incidence of hip and other fragility fractures following a fracture prevention intervention and assess baseline risk factors for long-term fracture outcomes.

Methods: 1,233 rural Swedish women aged 70-100 years in 2002 were followed until 2021 after a primary care-based, non-randomized graded fracture prevention intervention 2002-2004 that included physical activity, fall prevention, and pharmacological treatment tailored to hip fracture risk. Fractures were identified through radiology reports 2002-2021.

Results: The most common fractures occurred in the hip with 236 women sustaining 268 hip fractures with highest incidence in women aged 90-94 years. One-year hip fracture mortality was 27%. Hip fractures occurred in 17.7% of the intervention group (77/434) and 19.9% of controls (159/799, p = 0.36). Repeated fragility fractures occurred in 14.1% of the intervention group and 18.6% of controls (OR 0.71; 95% CI 0.53-1.0, p = 0.047), particularly when one fracture involved the hip (OR 0.54 (95% CI 0.31-0.95), p = 0.037). Increasing age (HR 1.8-4.0), height >167 cm (HR 1.6; 95% CI 1.1-2.2), and weight <60 kg (HR 1.5; 95% CI 1.1-2.0) were significant baseline risk factors.

Conclusions: We noticed a non-significant reduction in hip fractures after 20 years, yet repeated fractures were less frequent in the intervention group suggesting a potential long-term benefit. Older, taller and lighter women were at greater risk for hip fracture.