Scandinavian Journal of Primary Health Care最新文献

Background and purpose: Absence from work due to illness is common in many western countries and has many negative consequences for both the individual and society. Since 2020 Swedish healthcare regions are required to provide resources to coordinate the rehabilitation process, a complex system involving medical as well as work-related parties, where both the physician and the rehabilitation coordinator play a central role. The aim of this study was to describe how primary care physicians experience the role of and the collaboration with a rehabilitation coordinator.

Materials and methods: We used a qualitative design doing semi-structured interviews with primary care physicians (n= 9) in the Skåne healthcare region. The interviews were recorded, transcribed and analyzed using qualitative content analysis.

Results: One main category "An external and internal connecting point that has improved the sick-listing and rehabilitation process", and four subcategories: "Provides relief for the individual physician"; "Offers practical support at the clinic"; "Gives increased sense of security for the patients" and "Sufficiently trained, with potential to take further responsibility", were determined.

Conclusions: The study shows that primary care physicians experienced benefits from a close collaboration with a rehabilitation coordinator, feeling less lonely. The rehabilitation coordinator is often regarded as having a central role in insurance medicine related tasks, but an even more active role is desired.

Background: Disease prevention strategies during the COVID-19 pandemic could potentially disrupt the continuity of care. Aims: (1) describe changes in contacts with general practitioner (GP) before and during the pandemic, (2) compare consultation rates for common and at-risk diagnoses, and (3) examine the impact of COVID-19 restrictions on monthly consultation rates across patient subgroups.

Methods: Register study with data from the Norwegian Registry for Primary Health Care (NRPHC) for the period 1 April 2018 to 30 March 2021. Changes in consultation rate were the main outcome. Twenty-five diagnoses representing common and at-risk for mortality diagnoses were studied. Interrupted time series analyses were applied.

Results: Face-to-face consultations decreased from 2935 to 2304 per 1000 inhabitants per year from the pre-pandemic period to the first pandemic year, with an increase in e-consultations from 60 to 846 per 1000 inhabitants per year. Consultations for common diagnoses decreased by 25.6%, whereas those for high-risk diagnoses decreased by 10.7%. In the group of common diagnoses, the decrease in average monthly consultation rates was less among the eldest compared to the youngest age group. A similar decrease was found in the group with multiple morbid conditions compared to single or no morbidity.

Conclusions: The pandemic resulted in fewer face-to-face consultations, but there was a substantial rise in electronic consultations. Consultations for at-risk for mortality diagnoses decreased relatively less than for common diagnoses. Consultation rates for older adults and those with multiple decreased less, suggesting that sicker patients continued to visit their GP during the pandemic.

Background: The use of point-of-care ultrasound (POCUS) in general practice increases, but little is known about potential unintended findings and harms to patients. Information regarding such unwanted effects may be obtained by evaluating the medical records of patients who have been scanned by their general practitioner.

Objective: To identify and characterize re-consultations related to POCUS use in general practice, potential misdiagnosis, overdiagnosis, and incidental findings, and to compare potentially troublesome cases to GPs' scanning competence and type of ultrasound device.

Design and setting: Professors in general practice with extensive experience in both research and quality assurance in general practice did a blinded review of prospectively collected routine electronic medical record data combined with cross-sectional data collected in relation to POCUS examinations.

Subjects: Twenty general practitioners collected data on 564 patients examined with POCUS in primary care.

Main outcome measures: International standards for the classification of adverse events and incidental findings were used. First, research assistants identified all re-consultations described in the medical records that were related to the primary health complaint at the index consultation. Second, these re-consultations were classified by the medical experts in terms of seriousness and relation to the POCUS examination performed at the index consultation. In addition, the experts identified possible misdiagnosis, possible overdiagnosis, and incidental findings. Finally, identified cases were discussed in terms of appropriateness and described narratively.

Results: Medical records of 564 patients were reviewed. A low risk of possible misdiagnosis (5.3%), potential overdiagnosis (0.7%), and incidental findings (0.7%) were found. Eleven POCUS-related re-consultations were identified and described.

Conclusion: POCUS scanning performed by general practitioners was generally safe, but it can result in unnecessary examinations and potential harm in a few cases. Certain areas, e.g. pelvic scans that included the ovaries, may especially be prone to misdiagnosis.

Trial registration number: NCT03375333.

Objective: Early identification of persons at risk for sickness absence offers an opportunity to initiate preventive measures. The aim of this study was to examine whether perceived work-related stress, measured by The Work Stress Questionnaire (WSQ), predicted registered sickness absence up to 10 years later in a general working population of women.

Design: A survey-linkage study based on the 2004-2005 wave of the Swedish 'Population Study of Women in Gothenburg (PSWG)' and 10-year follow-up in the official MiDAS sickness absence register.

Subjects: A population-based cohort of women aged 38 and 50 in 2004/2005 were invited (participation rate 59%). Participants registered as employed or self-employed were included (n = 396).

Methods: Predictors were indicators of work-related stress (WSQ). Outcomes were number of sickness absence episodes in total (examined using negative binomial regression) and sickness absence during separate time periods of follow-up (examined in logistic regression models).

Results: High perceived stress due to poor organizational climate predicted sickness absence episodes (adjusted Incidence Risk Rate (IRR_adj): 1.99 [95% CI 1.19-3.34]). The combination of stress due to both poor organizational climate and high work commitment gave an IRR_adj of 2.32 [95% CI 1.26-4.26]. Examination of specific two-year time period indicated that the results were rather consistent for up to 8 years of follow-up. Additionally, low influence at work was associated sickness absence in some of the time periods examined.

Conclusion: The findings indicate that perceived stress due to organizational factors at work, alone and in combination with the individual factor high work commitment, are long-lasting risk factors for sickness absence. Aligning with previous studies, the findings further suggest that WSQ might successfully aid identifying women with such elevated risk and adds that this is even true in a general population context. These findings merit further investigation in larger samples.

Motivation: Primary care centres are the first line of mental health service in Sweden responsible for individuals with mild to moderate severe symptoms of common mental disorders (CMD). The aim was to evaluate impact of sick leave and sick leave duration in patients diagnosed with CMD in primary care centres with a care manager organisation during the first and second year after implementation compared to usual care.

Methods: Register data on sick leave (mean number of net and gross sick leave days) among patients with CMD was obtained per primary care centre from the national social insurance database MiDAS. Two measures of sick leave were used: impact of sick leave in total patient population with CMD, and sick leave duration among sick listed patients with CMD. Linear mixed-effects regression analysis was performed for cross-sectional differences and longitudinal changes between and within the two groups of primary care centres.

Results: Primary care centres with care as usual had a lower proportion of sick listed patients with CMD at both year 1 and 2. Primary care centres with a care manager organisation (CMO) had significantly fewer mean number of sick leave days (net and gross days) among patients with CMD compared to centres with care as usual, indicating a lower impact of sick leave. Sick leave duration among sick listed patients did not show statistically significant differences between the two groups of primary care centres. Both groups of primary care centres increased their sick leave duration significantly from year 1 to year 2, congruent to Sweden as a whole.

Conclusion: The aim of this study was to evaluate two measures of sick leave in primary care centres with a care manager organisation compared to care as usual. There were no differences in sick leave duration. Primary care centres with a care manager organisation, designed to increase accessibility and continuity for patients with CMD, seemed to facilitate the primary care centre's possibility to offer enhanced care taking to more patients with CMD with continued lower levels of impact of sick leave compared to care as usual.

Implementation: This study evaluated outcomes after implementation of CMO at primary care centres.

Background: Detection of colorectal cancer (CRC) is mainly achieved by clinical assessment. As new treatments become available for metastatic CRC (MCRC), it is important to accurately identify these patients.

Aim: To develop a predictive model for identifying MCRC in primary health care patients using diagnostic data analysed with machine learning.

Design and setting: A case-control study utilising data on primary health care visits for 146 patients >18 years old diagnosed with MCRC in the Västra Götaland Region, Sweden during 2011, and 577 sex-, age, and primary health care centre-matched controls.

Method: Stochastic gradient boosting was used to construct a model for predicting the presence of MCRC based on diagnostic codes from primary health care consultations during the year before index (diagnosis) date and number of consultations. Variable importance was estimated using the normalised relative influence (NRI) score. Risks of having MCRC were calculated using odds ratios of marginal effects (OR_ME).

Results: The optimal model included 76 variables with non-zero influence, had an area under the curve of 76.5%, a sensitivity of 77.8%, and a specificity of 69.2%. The 10 most important variables had a combined NRI of 61.0%. Number of consultations during the year before index date had the highest NRI at 19.2%, with an OR_ME of 3.3.

Conclusion: A machine learning method based on primary health care consultation frequency and diagnoses may be used to identify important variables for predicting presence of MCRC. Both primary health care consultations and associated diagnostic codes need to be taken into consideration.

Background: Sleep disorders such as insomnia may occur in old age, potentially leading to z-hypnotic use. However, few studies have explored older adults' self-reported sleep concerns in relation to z-hypnotic use. We aim to examine this relationship.

Methods: We conducted a cross-sectional study using a web-based questionnaire to assess sleep disturbances and medication use (z-hypnotics, benzodiazepines, and opioid analgesics) among 5,194 older adults through 21 GPs in southeast Norway. The main outcome, inappropriate z-hypnotic use, was defined as self-reported use for ≥4 weeks at ≥ three times per week. We used descriptive statistics and exploratory logistic regression mixed-effects models for data analysis.

Results: Among the 687 patients included in the study, 22% (N = 153) reported sleep disturbances. Of these, 84% (N = 575) did not use z-hypnotics, while 16% (N = 112) used z-hypnotics, 63% (N = 71) of these used them inappropriately. (≥4 weeks, ≥ three times per week). Patients with sleep disturbances (OR: 12.1, CI: 6.77 - 21.6, p < 0.001), trouble falling or staying asleep (OR: 14.6, CI: 5.04-42.0, p < 0.001), and multiple reasons for disturbances (pain, overthinking, or a family death) (OR: 3.58, CI: 1.85-6.93, p < 0.001) had higher odds of inappropriate z-hypnotic use compared to those with no or occasional disturbances. Men had lower odds (OR: 0.54, CI: 0.30-0.97, p = 0.039) than women. GP prescribing was not associated with inappropriate use, but men had lower odds (OR: 0.34, CI: 0.14-0.84, p = 0.020) when prescribed by male GPs compared to women prescribed by female GPs.

Conclusion: A high proportion of patients used z-hypnotics inappropriately. This inappropriate use was associated with experienced sleep disturbances, particularly trouble falling asleep, trouble staying asleep, and multiple reasons for sleep disturbances. The prescribing GP was not significantly associated with inappropriate use.

Objective: Many adolescent males report negative experiences of consultations with general practitioners (GPs), which contrasts with the importance of patient-centredness that GPs themselves emphasise. A better understanding of this discrepancy might facilitate improvements. The aim was to explore and describe adolescent males' encounters with GPs in Swedish primary healthcare centres using a lifeworld perspective.

Design: Qualitative lifeworld-based study. Video-recorded observations were analysed using a phenomenological-hermeneutical method.

Setting: Two primary healthcare centres in mid-Sweden.

Subjects: Nine males aged 15 to 19, video-recorded during their encounters with GPs in March through May 2022.

Findings: Adolescent males navigate between being children in need of parental support and men who can take initiative and responsibility. They face cognitive, emotional, and relational demands, the complexity of which renders them particularly vulnerable. When feeling exposed and not knowing what to expect, they struggle to make themselves understood, and to understand what the GP is saying and what is happening. The difficulties that they have disclosed to the GP in trust need to be recognised and carefully acted upon. Thus the GP must respond appropriately to this complex mix of vulnerabilities to prevent feelings of disappointment or of having exposed themselves in vain.

Conclusion: The complexity of encounters with adolescent males imposes great demands on GPs to identify and adapt to their individual needs. A proper ethical response involves helping them navigate the challenges of the consultation while also respecting them as persons and meeting their age-dependent needs.

Aims: General practitioners (GPs) need tools and working methods to deal with sick listed patients' multifaceted needs as well as to collaborate with stakeholders such as the employer or the social welfare counsellor. This study explored GPs' experiences when testing the mapping and dialogue tool ISIVET in sick leave follow-up.

Methods: Individual interviews with seven GPs in salaried positions testing ISIVET in sick leave follow-up in a Norwegian municipality. Data were transcribed verbatim and analysed using systematic text condensation.

Results: Five categories of experiences were identified: 1) positive perceptions of ISIVET in terms of visualizing the complexity of health and work conditions, 2) procedures and collection of research data made it difficult to test the tool, 3) unclear ownership and anchoring, 4) difficulties with experimentation in demanding working days and 5) close follow-up during training followed by a lack of sharing experiences.

Conclusions: Despite positive GP perceptions of ISIVET in sick leave follow-up, the testing 'failed' due to difficulties during the testing overshadowing the benefits. This was primarily due to poor technological and practical adaptions of the use of the tool in a busy GP's working day. Secondly, a weak local anchoring with lack of follow-up and sharing of experiences, influenced the use of ISIVET negatively. If further testing of ISIVET in primary care is carried out, it would be necessary to simplify and adapt the use of the tool extensively. Given the positive perceptions of ISIVET, one could consider new adaptions and further testing according to these experiences.

Aims: The aim of this study was to describe the prevalence, associations, and reasons for the use of complementary and alternative medicine (CAM) in Sweden, as well as to further explore possible self-perceived outcomes including adverse effects as well as the sources of information used.

Methods: Data were collected by a cross-sectional survey, administered by computer assisted telephone interviews, in June 2020 (n = 500), during the first three months of the COVID-19 pandemic. The survey was a modified version of the International Questionnaire to measure use of Complementary and Alternative Medicine (I-CAM-Q) instrument.

Results: 63.6% of respondents reported use of CAM. The most common reasons for use were to improve general well-being and/or to treat long-term illness or its symptoms. Very few used CAM to prevent or treat COVID-19. The most used CAMs were natural remedies and dietary supplements (50%), followed by self-help practices (33.2%) and consultation of CAM providers (13%). Women, those of older age (40+), and living in larger cities were more likely to use CAMs compared to the entire sample. Household income or level of education did not predict CAM use. Few adverse effects were reported. The main sources for information were media and the Internet followed by family and friends.

Conclusions: This study contributes with updated knowledge about Swedish citizens' use of CAM. The results are important to inform health care policy about patterns of CAM use among Swedish citizens.