Scandinavian Journal of Primary Health Care最新文献

Background: The Danish primary care sector is responsible for the majority of antibiotic prescriptions, with upper respiratory tract infections, particularly acute rhinosinusitis (ARS), being a key contributor. This study explored the decision-making process regarding antibiotic use for ARS among general practitioners (GPs) and doctors in training working in general practice.

Methods: Nine semi-structured interviews were conducted with 10 doctors. Interviews were audio-recorded, transcribed verbatim and analyzed using systematic text condensation.

Results: Four key themes were developed: (1) 'It all starts before the consultation': staff-led triage shaping ARS care, (2) two diagnostic worlds: experienced intuition vs. rule-bound caution, (3) C-reactive protein (CRP) in the crossfire: guide, reassurance or irrelevant in antibiotic decision-making and (4) 'Sometimes it's a negotiation': managing patient expectations without losing stewardship. Although diagnosing ARS was often straightforward, distinguishing bacterial from viral infections proved difficult. C-reactive protein testing was common, but its reliability was questioned. Antibiotic prescribing decisions were influenced by patient history, comorbidities and risk factors. While antibiotics were rarely considered necessary initially, patient expectations and doctor-patient relationships sometimes influenced prescribing.

Conclusions: This study illustrates the complexity of diagnosing and managing ARS, shaped by clinical uncertainty, competing priorities and non-clinical pressures. Variation in doctor involvement, diagnostic practices and CRP thresholds reveals the challenges of standardization. Training, guidelines and patient education are valued but may not ensure optimal antibiotic use. Diagnostic decisions are relational, negotiated and context-specific, influenced by public health concerns, patient needs and workflow demands. Without acknowledging this complexity, antibiotic stewardship efforts could potentially fall short.

Background: Anorexia nervosa is a potentially lethal psychiatric disorder characterised by restrictive eating and weight loss. Adolescent patients were treated as outpatients using a novel method which involved coaching the parents to take full responsibility for their child's nutrition. In this follow-up cohort study, we compared the long-term outcomes of patients treated in primary care using the family-based coaching method (FBcM-PC) with those treated in tertiary care using traditional treatment.

Methods: The cohort included all adolescent patients with a restrictive eating disorder treated initially in Oulu University Hospital and/or Oulu Primary Health Care centre between 2013 and 2019. Patients (n = 168) were contacted and asked to fill out a health questionnaire. Altogether 73 (43%) responded (30 from the FBcM-PC and 43 from the traditional treatment group). The outcome variables - depression, anxiety, eating disorder symptoms and need for medical appointments - were compared between the treatment groups.

Results: Upon follow-up after a mean of 6.6 years, 77% of the FBcM-PC and 54% of the traditional treatment groups did not need medical appointments (p = 0.052). No differences were found in self-reported health, depression or anxiety between the study groups. Concerns about weight and shape were reported by 40% of both groups. 87% of the FBcM-PC and 9% of the traditional treatment group received outpatient treatment only (p < 0.001).

Conclusion: Adolescent anorexia nervosa patients treated mainly in primary care had at least as favourable long-term outcomes as those treated in tertiary care. The results of this study encourage further development of outpatient treatment methods in primary care.

Background: Online symptom checkers are increasingly used for diagnostic support and triage. However, evidence on their performance and evaluations with real-world data remains limited.

Objective: The aim of this study was to evaluate the performance of a digital symptom checker using clinical vignettes derived from real-world cases that had previously been incorrectly triaged.

Methods: A patient-facing, rule-based digital symptom checker used in Swedish primary care was assessed in this study. Vignettes were constructed from cases reported to the Swedish Health and Social Care Inspectorate due to erroneous telephone triage. We hypothesized that the digital symptom checker could provide appropriate triage for these cases. Seven physicians independently simulated patients by entering symptoms in the symptom checker based on each vignette. Triage outcomes were assessed against the Swedish National Triage Guidelines (RGS), evaluating the accuracy and the safety of the triage recommendation.

Results: A total of 69 unique vignettes yielded 483 individual trials. After excluding 93 trials due to significant deviations from the original vignette description (adding or omitting symptoms), 390 trials were included in the primary analysis. The symptom checker achieved 91% accuracy (95% CI 88-94%) and 94% safety (95% CI 91-96%).

Conclusions: The symptom checker demonstrated high accuracy and safety when triaging a subset of vignettes based on real-world cases that had been previously erroneously triaged. This study also highlights the difficulties of using vignettes when evaluating symptom checkers. To our knowledge, this is the first study to evaluate such systems using vignettes based on actual patient cases with known triage errors.

Objective: An inter-municipal out-of-hours (OOH) district covers several municipalities with one centralized casualty clinic. These OOH districts are large geographical areas with long driving times to the casualty clinic. Remote OOH units were established in two OOH districts in Norway, to secure better access to the OOH service. Patients were offered video consultations with nurse-led appointments at the remote OOH units. The aim was to investigate contact rates and distribution of consultation types before and after the remote units were established. Design. An observational study with pre- and post-data collected from municipalities with and without (controls) remote OOH units.

Setting: Two OOH districts, Førde and Molde, with five and four remote OOH units, respectively.

Subjects: Inhabitants contacting the Local Emergency Communications Centers (LEMCs) in the two areas.

Results: In municipalities that established remote OOH units the contact rates to the LEMCs decreased by 15% in Førde and 16% in the Molde OOH districts in 2021, compared with 2019. Control municipalities had an increased rate of 7% and 2%, respectively. Consultation rates decreased by 16% and 12% in municipalities with remote OOH units in Førde and Molde, respectively. In 2021, 7% of contacts from municipalities with remote OOH units in Førde OOH district and 3% in Molde OOH district ended in a consultation at a remote OOH unit. In the Molde OOH district, where the traditional casualty clinic was replaced with remote OOH units, home visits and callouts decreased by 76% and 86% from 2019 to 2021.

Conclusion: Establishing remote OOH units could have decreased contact and consultation rates in both districts. Most contacts were handled with actions other than a remote OOH unit encounter with video consultation. There was a large reduction of home visits and callouts in the Molde OOH district in 2021, compared with 2019.

Background: General practitioners (GPs) who supervise medical students during clinical placements are valuable resources for medical universities. However, several countries struggle with recruiting supervisors. More knowledge about GPs' attitudes and factors that motivate them to be supervisors, is essential for developing targeted recruitment strategies and effective follow-up by universities.

Objective: We aimed to investigate GPs' attitudes to and motivation for supervising medical students in clinical placements.

Methods: A web-based questionnaire was sent to all GPs in Norway in February 2022. Both active supervisors' and non-supervisors' responses were collected. Attitudes were reported as scores on a five-point Likert scale in response to 21 statements, while motivation was reported by highlighting the most important motivational factors among 15 items. Descriptive statistics were used to rank the statements and motivation factors. Independent sample t-test and ANOVA were used to analyse differences in mean scores across subgroups.

Results: We received 1466 responses (29%), of whom 498 (34%) were active supervisors. Results revealed positive attitudes towards supervising medical students in clinical placements, even among non-supervisors. Statements about the supervisor role and its importance regarding recruitment, professional stimulation and clinical teaching competence, were scored high. Many agreed that supervising students increased their workload. 'Recruitment contribution' was the most selected motivation item.

Conclusion: Recruitment contribution, professional development, workday variation and the feeling of fulfilment contribute to GPs' motivation to supervise. The results indicate a promising future for recruiting clinical supervisors.

Background: Exhaustion disorder (ED) is one of the most rapidly increasing causes of sick leave in Sweden. The prolonged recovery time from ED creates a dilemma on both the societal and individual level. How patients experience the encounter with health care is critical for the recovery from ED. The aim of this study was to explore how patients with ED experience the encounter with health care.

Method: Data from 23 semi‑structured interviews with ED patients were analysed using content analysis.

Results: One of the main findings was that patients want to be listened to and taken seriously in the encounter with health care. However, patients experience that healthcare struggles to meet these expectations. Several informants reported not being listened to, worrying symptoms were overlooked, an individualised care plan was lacking, and patients experienced that they were prematurely dismissed. This created an experience of unsafety, and that could inadvertently maintain the stress response and negatively influence recovery for patients with stress‑related disorders.

Conclusion: It is paramount to convey an experience of predictability, despite the fact that patients undergo an unpredictable process related to their ED illness. By combining the traditional load‑recovery theory with the generalised unsafety theory of stress, we can tap into the potential to enhance recovery for patients with ED. We suggest that if the encounter with healthcare provides an experience of generalised safety, the conditions for patients with stress‑related disorders to recover would be distinctly enhanced.

Background: The prescription rate for antibiotics for acute sinusitis in primary care remains high, despite evidence showing their limited effectiveness. GPs frequently encounter patient demands for antibiotics, which can influence their decision-making process.

Aim: This study aimed to explore the help-seeking and expectations of patients experiencing symptoms of acute sinusitis, with a particular focus on their desire for antibiotics. We sought to understand why patients seek their GP for sinusitis, what kind of treatment they hope to receive, and how they perceive their influence on the GP's treatment decision.

Methods: We conducted 12 semi-structured interviews with patients who had consulted their GP for acute sinusitis from various regions across Norway. The qualitative analysis was performed using systematic text condensation.

Results: We developed 3 main themes:1. 'Pain and exhaustion'- Patients primarily consulted their GP for acute sinusitis seeking medication to alleviate pain and accelerate recovery.2. 'I trust the GP, but mainly myself'- While patients expressed trust in their GPs, they also had clear expectations of receiving the specific treatment they sought. 3. 'Antibiotics works'- Most patients associated medication with antibiotics and believed they were effective against sinusitis.

Conclusion: Patients with sinusitis primarily visited their GP to seek relief from pain and to obtain medication that they believe could speed up recovery, which often meant antibiotics. These findings suggest a continuing need for measures targeting both doctors and patients to align treatment expectations, improve adherence to clinical guidelines, and adjust patient expectations. Better pain management of sinusitis should be emphasized.

Objective: Quality measures in healthcare are crucial for improving outcomes and ensuring patient safety. This study investigated the evolution, implementation, and impact of Primary Care Quality (PCQ). The PCQ aims to facilitate nationwide quality benchmarking, serving as a tool for quality improvement (QI) and research.

Design/settings: A descriptive design outlining the development and operationalisation of the PCQ, a national framework for automatic and systematic data collection and feedback.

Results: The national PCQ system is a tool for continuous QI in primary care in Sweden. PCQ has achieved extensive adoption, with over 97% of Swedish primary care centres, both private and public driven, utilising the platform for automatic data extraction from patient records and data visualisation. Quality indicators were developed through a structured approach involving primary care professionals, evidence-based clinical practices, and expert contributions from established knowledge organisations, reflecting the breadth of general practice. Data are automatically retrieved from medical records and visualised in real time, with the possibility of benchmarking at an aggregate level and identifying individuals locally at primary care centres. The PCQ has facilitated improvements by enabling quality dialogue among healthcare professionals and supporting continuous local QI. Regionally, the PCQ supports needs assessments and patient safety initiatives. Nationally, it establishes standardised indicators for quality measurement, enabling effective benchmarking and strategic healthcare planning.

Conclusions: The implementation of the national PCQ system provided a framework and tool for continuous QI in primary care. The system has influenced national standardization of primary care indicators, with quality improvement results demonstrated regionally and locally through the PCQ.

Background: Out-of-hours primary care (OOH-PC) is essential for treating urgent health problems. However, the high demand for these services has increased the workload.

Objective: To investigate the interprofessional collaboration in OOH-PC and task shifting from general practitioners (GPs) to nurses, specifically the professional practices and the perceived experiences of GPs and nurses.

Methods: This explorative case study was based on observations and interviews, using normalisation process theory as the theoretical framework. Observations were conducted in two OOH-PC clinics in the Central Denmark Region, followed by individual semi-structured interviews with five GPs and six nurses working in these clinics. Data were collected from March to October 2022.

Results: GPs and nurses worked together in a team-based workflow based on different roles and skills but joint tasks. The nurses handled patients with injuries and performed diagnostic tests. A team-based workflow with task shifting was supported by familiarity within the team, with nurses performing informal coordination tasks and having formal support like protocols, training, and GP supervision. GPs and nurses appreciated the team-based workflow, as it facilitated efficient resource use and high job satisfaction. However, both groups expressed concerns about the sustainability of OOH-PC clinics.

Conclusion: Task shifting from GPs to nurses in OOH-PC is feasible in a team-based workflow, resulting in efficient use of available resources and high job satisfaction. However, task shifting should not aim to replace GPs with nurses. Instead, their roles and skills should be seen as complementary, which calls for task sharing.