Scandinavian Journal of Primary Health Care最新文献

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: 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.

Aims: This study investigates changes in the quality of information in sickness certificates over time, before and after the 2011 national introduction of a revised sickness certificate, and identified factors associated with certificate quality.

Methods: Four experts independently assessed the quality of a total of 783 sickness certificates issued in primary care in 2004, 2009, and 2012. A Global Quality Score (GQS) was constructed by the research group, rating quality on a 10-point scale. The cut-off for high quality was set to GQS >5. The inter-rater reliability of the GQS was tested using Intra-Class Correlation and internal consistency by Pearson correlation coefficients (r). Sickness certificates issued in 2004 and 2009 were merged into one group and compared to sickness certificates in 2012. Logistic binomial regression analyses examined associations between patient-, sick leave-, and physician-related variables and GQS.

Results: The GQS demonstrated moderate to good inter-rater reliability (ICC= 0.79, 95% CI: 0.6-0.9) and good internal consistency. Certificate quality improved significantly (p < 0.001) from 3.6 (SD 1.5) in 2004/2009 to 4.7 (SD 1.2) in 2012. In 2004/2009, mental disorder or an extended length of sick leave was negatively associated with high quality. In 2012, only female sex of the patient was negatively associated with high certificate quality.

Conclusion: While sickness certificate quality was overall low, it improved significantly after the 2011 revision of the sickness certificate. Also, diagnosis, sick leave duration, and patient's sex were factors associated with the quality and varied over time, highlighting the need for further research regarding potential remaining differences in quality of sickness certificates.

Background: Effective collaboration between general practitioners (GPs) and specialized mental health services is essential to ensure high-quality care for patients with depression. However, achieving such collaboration remains a challenge across healthcare systems internationally. This study aimed to investigate Norwegian GPs' perceptions of their collaboration with the two main components of specialized mental health services - community mental health centers and psychiatric contract specialists. We further examined factors associated with GPs' perceptions of well-functioning collaboration and assessed how their knowledge of prioritization regulations was related to these perceptions.

Methods: A questionnaire among Norwegian GPs, part of a biennial survey among physicians working in Norway capturing information of different elements of collaboration between GPs and mental health specialists and knowledge about prioritization criteria.

Results: Half of the GPs reported collaboration be well-functioning, largely independent of organizational model. A shared understanding of the patient's problems and clear definition of roles had the highest association with well-functioning collaboration. Experiencing a clear distribution of responsibilities and tasks and active communication was associated with perceived well-functioning collaboration. GPs' knowledge about the prioritization criteria was positively associated with a perceived well-functioning collaboration.

Our findings reveal unclarities regarding the distribution of responsibilities and tasks and very little interactive communication between GPs and mental health specialists in both organizational models, which were affecting the GPs' perceptions of collaboration negatively.

Conclusions: Enhanced clarity regarding the roles and responsibilities, more communication about the patient during concurrent treatment, and improved knowledge about specialized mental health prioritization criteria could facilitate and improve the collaboration.

Background: Understanding patients' perspectives on their medications is important to facilitate collaborative deprescribing and shared decision-making.

Aim: To explore older patients' attitudes towards having their medications deprescribed and facilitators for deprescribing in Swedish primary care.

Methods: Swedish primary care patients (≥ 65 years and taking ≥5 medications) responded to an anonymous survey on their attitudes towards deprescribing (June 2022-December 2023).

Results: Out of 101 patients (45% women), 81% were satisfied with their medications (n = 82), 78% would be willing to stop or reduce ≥1 medication if their physician said it was possible (n = 79), and 27% (n = 27) wanted to deprescribe ≥1 medications from their medication lists (with 48 unique medications being mentioned). Side effects associated with the medication was the most commonly stated reason for wanting to deprescribe, mentioned by 52% (14/27 patients). Patients most often wanted to deprescribe blood glucose lowering medications, mentioned by 26% (7/27 patients). Most frequent patient-perceived facilitators for deprescribing were the support from their general practitioner (GP) (68%), a plan for deprescribing (38%), the possibility of restarting the medication if needed (23%), and having an alternative medication (22%).

Conclusions: While most older adults with polypharmacy in Swedish primary care would be willing to deprescribe if suggested by their physician, many did not want to have any medication deprescribed. This difference highlights the need to clarify patients' preferences when discussing medication changes. Support from the GP was identified as an important facilitator, demonstrating the importance of patient-GP communication and shared decision-making in deprescribing.

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.

Objective: In primary health care in southern Sweden, interprofessional medication reviews are conducted, to a limited extent, for patients living independently, with the purpose of optimising their pharmacological treatment. These medication reviews have identified and addressed many important issues regarding the patients' medication. However, there is limited knowledge regarding the participating physicians' perspectives on the work. Gaining a better understanding of the physicians' perspectives could contribute to the optimisation of the interprofessional medication review model used in primary health care. This study aimed to explore physicians' perceptions and experiences of interprofessional medication reviews in primary health care for patients who live independently.

Methods: We conducted a qualitative study based on semi-structured discussions in four focus groups with a total of 24 participating primary care physicians. The discussions were transcribed verbatim, condensed, coded and categorised using content analysis.

Results: Through our analysis, we identified four categories: obstacles and facilitators, interprofessional collaboration with the pharmacist, the physician's responsibility and value-adding aspects. An underlying theme, a value-creating intervention with logistical barriers, emerged from the latent material.

Conclusion: Physicians expressed a consistently positive view of medication reviews for independently living patients, highlighting their value for patient safety, clinical decision-making, and learning. However, practical barriers, such as time constraints and unclear routines, were seen as key obstacles to implementation. These findings reflect the dual nature of medication reviews as a value-creating intervention with logistical challenges, which need to be addressed to support broader integration in primary care.

Background: Burnout among General Practitioners (GPs) is a growing concern, with implications for physician well-being, patient care quality, and healthcare system sustainability. However, we lack studies of burnout among GPs in Norway.

Objective(s): To examine the prevalence of burnout among GPs in Norway in 2012, 2018 and 2024 and subsequently identify demographic, health-related, and work-related factors associated with burnout in 2024.

Methods: Data were drawn from the Norwegian Physician Panel, a nationally representative survey conducted in 2012, 2018, and 2024. Response rates exceeded 71% in all waves. Only respondents identifying as GPs were included. Burnout was assessed using the Maslach Burnout Index. Prevalence was reported descriptively. Logistic regression was employed to examine associations between overall burnout, emotional exhaustion, depersonalisation and personal accomplishment and the following independent variables: age, sex, weekly work hours, self-rated health, sick leave, presenteeism, job satisfaction and work-related stress.

Results: Overall burnout increased from 5.8% in 2012 to 17.1% in 2018, reaching 21.8% in 2024. The proportion of GPs with high emotional exhaustion rose from 19.1% to 47.2%, and the proportion with high depersonalization from 2% to 24% over the same period, whereas those reporting low personal accomplishment became relatively fewer, going from 16.4% to 6.3%. In 2024, burnout was significantly associated with low job satisfaction, high work-related stress, and frequent sickness presenteeism.

Conclusion: The prevalence of burnout among Norwegian GPs has increased markedly from 2012 to 2024. Addressing modifiable factors such as work-related stress, job satisfaction, and sickness presenteeism is essential for sustaining physician well-being and maintaining patient care quality.

Objective: To examine characteristics of primary healthcare patients with long-term impaired work ability, and to assess the correlation between sense of coherence and factors related to health, function, and work ability.

Design and setting: Cross-sectional study including patients from the LEARN-to-COPE cluster-randomized controlled trial, conducted across 40 primary care centers in Region Västra Götaland, Sweden.

Subjects: Primary healthcare patients with recurrent or long-term sick leave or health-related unemployment (n = 243).

Data collection: Sick leave data were collected from the Swedish Social Insurance Agency. Demographics and contextual data were patient-reported or retrieved from personal identity numbers. Symptoms, health-related quality of life, health literacy, sense of coherence, perceived work ability, and lifestyle were assessed using validated questionnaires.

Results: Mean age was 47.4 years. Most were women born in a Nordic country, had at least secondary education, and were gainfully employed. A third was unemployed. Mean number of sick days was 1,215 (SD 1,010), and 67.9% were on full-time sick leave. Perceived work ability was low. Participants reported severe anxiety and exhaustion, moderate depression, and a high risk of long-term sick leave due to pain. Health-related quality of life was extremely low. Half reported inadequate or problematic health literacy, and sense of coherence was low. Smoking and obesity were common, physical activity levels were average, and excessive alcohol consumption was below average. About half participated in any rehabilitation activities. Sense of coherence was significantly correlated with health literacy, health-related quality of life, symptoms of mental illness, perceived work ability, and pain (all p < 0.001); but not with sick leave duration or participation in rehabilitation.

Conclusion: Given participants' pronounced suffering, improving health-related quality of life among primary healthcare patients with long-term impaired work ability should be prioritized. Sense of coherence was associated with several determinants of sick leave, but not with its previous duration.

Trial registration number: clinicaltrials.gov NCT04254367.

Background: Post COVID-19 condition remains a complex and challenging issue, with diverse manifestations, despite accumulating research and clinical experience. Dyspnea is one of the most common symptoms reported in post COVID-19 condition. Cardiopulmonary exercise testing (CPET) offers a cohesive assessment of dyspnea and exercise limitations. The Nijmegen questionnaire is a form for assessment of dysfunctional breathing.

Aim: The aim was to explore relationships between self-reported post COVID-19 respiratory symptoms, assessed by Nijmegen questionnaire, and the results of a 6-minute walk test (6MWT) and CPET, in patients with mild primary infection of COVID-19, managed within primary healthcare.

Methods: A total of 15 participants with long-term dyspnea after a mild COVID-19 infection were prospectively included at primary healthcare facilities between July 2021 and April 2022. At inclusion, all subjects performed a 6MWT and answered the Nijmegen questionnaire. All subjects underwent CPET within 4 months of study inclusion. We estimated correlations between Nijmegen score (both total score and a subset of the questionnaire focusing on respiratory symptoms), and the 6MWT and CPET derived variables, respectively.

Results: Nijmegen scores (both total and particularly a respiratory subset) were inversely correlated to 6MWT walking distance, but not to spirometric parameters. Subjects with more self-reported symptoms had higher end-tidal O₂ and lower end-tidal CO₂, indicating mild hyperventilation. Nijmegen scores also correlated with CPET variables reflecting breathing pattern.

Conclusions: Nijmegen score was associated with CPET variables and walking distance at 6MWT. Post COVID-19 condition could be associated with mild hyperventilation, also in subjects without overt dysfunctional breathing pattern.