wow-inequalities/02-data/intermediate/wos_sample/254123cebbabe2603981bf92ccae8462-anonymous/info.yaml

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2023-09-28 14:46:10 +00:00
abstract: 'Current primary care in Finland is based on the Primary Health Care Act
(1972), which addressed numerous new tasks to all municipalities. All of
them had to find a new health centre organization, which provides a wide
range of health services, including prevention and public health
promotion. Multiple tasks require multiprofessional staff, and thus, the
Finnish health centre personnel consisted not only of GPs but of public
health nurses, midwives, physiotherapists, psychologists, social
workers, dentists, etc. During the next decade, there have been some
changes but the idea of multiprofessional structure has remained.
According to the QUALICOPC study (2012) Finnish GPs are still co-located
with several other healthcare professionals compared to most of the
European countries; even compared to other Nordic countries which
otherwise have many similarities in their primary healthcare. During the
last 10 or 15 years, healthcare providers and researchers have
recognized a new challenge: our current systems do not meet the needs of
patients with multiple health and social problems-and the proportion of
these patients is increasing all the time as the population is getting
older. One could suppose that preconditions of handling multimorbidity
would be excellent in multiprofessional surroundings like ours, but
actually, a person with multiple problems is a challenge there, too.
Multiprofessional organization in primary care does not guarantee proper
care of patients with multiple diseases, if we do not acknowledge the
challenge and revise our systems. We have to develop new ways of
collaboration and new models of integrated care. The problematic part is
secondary care, which is organized with logic of one medical speciality
per visit. In Tampere University Hospital district, we have created a
care pathway model, which defines the roles of primary healthcare and
secondary care. Nationwide, we have recently started to prepare national
guidelines for the care of patients with multimorbidity. What we need
more in the future is more research on new practices and models.
Background: Most patients with antihypertensive medication do not
achieve their blood pressure (BP) target. Several barriers to successful
hypertension treatment are well identified but we need novel ways of
addressing them. Research question: Can using a checklist improve the
quality of care in the initiation of new antihypertensive medication?
Methods: This non-blinded, cluster-randomized, controlled study was
conducted in eight primary care study centres in central Finland,
randomized to function as either intervention (n = 4) or control sites
(n = 4). We included patients aged 30-75 years who were prescribed
antihypertensive medication for the first time. Initiation of medication
in the intervention group was carried out with a nine-item checklist,
filled in together by the treating physician and the patient. The
treating physician managed hypertension treatment in the control group
without a study-specific protocol. Results: In total, 119 patients were
included in the study, of which 118 were included in the analysis (n =
59 in the control group, n = 59 in the intervention group). When
initiating medication, an adequate BP target was set for 19\% of the
patients in the control group and for 68\% in the intervention group.
Shortly after the appointment, only 14\% of the patients in the control
group were able to remember the adequate BP target, compared with 32\%
in the intervention group. The use of the checklist was also related to
more regular agreement on the next follow-up appointment (64\% in the
control group vs 95\% in the intervention group). Conclusion: Even
highly motivated new hypertensive patients in Finnish primary care have
significant gaps in their treatment-related skills. The use of a
checklist for initiation of antihypertensive medication was related to
substantial improvement in these skills. Based on our findings, the use
of a checklist might be a practical tool for clinicians initiating new
antihypertensive medications.
Background: Immediate feedback is underused in the French medical
education curriculum, specifically with video-recorded consultation.
Research question: The objective of this study was to evaluate the
feasibility and the interest in this teaching method as a training and
assessment tool in the learning process of general practitioner (GP)
trainees. Methods: During the period November 2017 to October 2018,
trainees in ambulatory training courses collected quantitative data
about recording consultations with a video camera: numbers of
recordings, feedback, patients'' participation refusals, and information
about the learning process and competencies. The trainees'' level of
satisfaction was measured by means of a questionnaire at the end of
their traineeship. Results: Sixty-seven trainees were recruited and 44
of them 65.7\% actively participated in the study; 607 video recordings
and 243 feedback with trainers were performed. Few patients (18.5\%)
refused the video-recording. Most trainees considered video recording
with immediate feedback to be a relevant learning tool. It made it
possible for the participants to observe their difficulties and their
achievements. `Relation, communication, patient-centred care'' was the
most built competency, non-verbal communication, in particular. Time was
the main limiting factor of this teaching method. Most trainees were in
favour of its generalization in their university course. Conclusion:
Video recording with immediate feedback in real-time consultation needs
to be adapted to training areas and depends on time and logistics. This
teaching method seems to be useful in the development of communication
skills. It could lift the barriers of the trainer''s physical presence
near GP trainees during immediate feedback in real-time consultation. It
could help trainees to build their competencies while enhancing the
place of immediate feedback in the general practice curriculum. It could
also constitute an additional tool for the certification of GP trainees.
Background: Perinatal depression has been associated with psychiatric
morbidity in mothers and their offspring. This study assessed the
prevalence of perinatal depressive symptoms in a large population of
women and investigated associations of these symptoms with demographic
and clinical factors. Research question: Which factors (including
sociodemographic, medical, lifestyle, and laboratory test) are
associated with perinatal depression? Methods: All members of Maccabi
Health Services who completed the Edinburgh Postnatal Depression Scale
(EPDS) during 2015-2016 were included in the study. Odds ratios (ORs)
were calculated for associations of sociodemographic, medical,
lifestyle, and laboratory test factors with perinatal depressive
symptoms, according to a score >10 on the EPDS. Results: Of 27 912 women
who filled the EPDS, 2029 (7.3\%) were classified as having peripartum
depression. In a logistic regression analysis, the use of antidepressant
medications, particularly for a period greater than three months, Arab
background, current or past smoking, a diagnosis of chronic diabetes and
age under 25 years were all associated with increased ORs for perinatal
depression; while Orthodox Jewish affiliation, residence in the
periphery and higher haemoglobin level were associated with lower ORs.
Incidences of depression were 17.4\% in women with a history of
antidepressant medication, 16\% among women with diabetes, and 11.8\%
among current smokers. Conclusion: Several demographic, medical, and
lifetime factors were found to be substantially more prevalent among
women with symptoms of perinatal depression than those without.
Encouraging women to complete the EPDS during and following pregnancy
may help identify women in need of support.
Background: Regulating the quality and effectiveness of the work of
general practitioners is essential for a sound healthcare system. In the
Republic of Macedonia this is regulated by the Health Insurance Fund
through a system of penalties/sanctions. Research question: The goal of
this study is to evaluate the types and effectiveness of the sanctions
used on primary care practitioners. Methods: This is a quantitative
research study for which we used an anonymous survey with 18 questions.
This survey was distributed to 443 randomly selected general
practitioners from different parts of Macedonia and 438 of them
responded. For the quantitative data, we used the Pearson''s chi-squared
test, correlation and descriptive statistics. Part of the survey is
qualitative, consisting of comments and opinions of the general
practitioners. Results: From the participants, 336 were female and 102
were male. The doctors'' gender was not associated with sanctioning. Most
general practitioners were in the age categories of 30-39 and 40-49
years. The participants'' age had a significant influence on
sanctioning-older doctors were sanctioned more frequently. Out of 438
participants, 33.3\% were specialists in family medicine and 66.7\%
general practitioners. Specialists in family medicine were sanctioned
significantly more frequently than general practitioners. Doctors that
worked in the hospital or 19 km from the nearest hospital were
significantly more frequently sanctioned. The three most common reasons
for sanctions were financial consumption of prescriptions and referrals
above the agreed amount, higher rate of sick leaves and/or justification
of sick leaves and unrealized preventative goals or education.
`Financial sanction by scale'' was the most common type of sanction:
49.8\% of participants. Doctors who followed the guidelines, but who
were exposed to violence were sanctioned significantly more frequently.
Conclusion: We can observe that age, speciality, the distance of the
workplace from the nearest hospital and violence influence sanctioning.
Background: Biases are major barriers to external validity of studies,
reducing evidence. Among these biases, the definition and the reality of
the Hawthorne effect (HE) (or observation bias) remains controversial.
According to McCambridge in a review from 2013, the Hawthorne effect is
a behaviour change occurring when the subject is being observed during a
scientific study. This effect would be multifactorial, and he suggests
the term `effects of research participation.'' However, the reviewed
studies were conflicting and evidence is sparse. Research question: We
updated McCambridge''s review to actualize the definition of the HE.
Methods: McCambridge''s most recent article dated back to January 3,
2012. We focused on the articles published between January 1, 2012 and
August 10, 2018 searching Medline. We used the sole keyword `Hawthorne
Effect.'' The search was filtered based on the dates, the availability of
an abstract and the languages English and French. We included articles
defining or evaluating the HE. Articles citing the effect without
defining it or irrelevant to the topic were excluded. Two independent
readers searched and analysed the articles. Discrepancies were solved by
consensus. Results: Out of 106 articles, 42 articles were included. All
the articles acknowledged an observation bias, considered as significant
or not, depending on the population (education, literacy), the methods
and the variable of interest. It was a psychological change, limited in
time. The HE was defined as a change of behaviour related to direct or
indirect observation of the subjects or the investigators, to their
previous selection and commitment in the study (written agreement) and
to social desirability. Despite observations, articles were conflicting.
Some do confirm the existence of the HE, others deny it. Meta-analysis
is ongoing. Conclusion: No formal consensus regarding the definition of
the effect has been reached so far. However, the authors agree on its
implication as an experimental artefact.
Background: Polypharmacy and multimorbidity are on the rise.
Consequently, general practitioners (GPs) treat an increasing number of
multimorbid patients with polypharmacy. To limit negative health
outcomes, GPs should search for inappropriate medication intake in such
patients. However, systematic medication reviews are time-consuming.
Recent eHealth tools, such as the `systematic tool to reduce
inappropriate prescribing'' (STRIP) assistant, provide an opportunity for
GPs to get support when conducting such medication reviews. Research
question: Can the STRIP assistant as electronic decision support help
GPs to optimize medication appropriateness in older, multimorbid
patients with polypharmacy? Methods: This cluster randomized controlled
trial is conducted in 40 Swiss GP practices, each recruiting 8-10
patients aged >= 65 years, with >= 3 chronic conditions and >= 5 chronic
medications (320 patients in total). We compare the effectiveness of
using the STRIP assistant for optimizing medication appropriateness to
usual care. The STRIP assistant is based on the STOPP/START criteria
(version 2) and, for this trial, it is implemented in the Swiss eHealth
setting where some GPs already share routine medical data from their
electronic medical records in a research database (FIRE). Patients are
followed-up for 12 months and the change in medication appropriateness
is the primary outcome. Secondary outcomes are the numbers of falls and
fractures, quality of life, health economic parameters, patients''
willingness to deprescribe as well as implementation barriers and
enablers for GPs when using the STRIP assistant. Results: Patient
recruitment started in December 2018. This presentation focuses on the
study protocol and the challenges faced when testing this new software
in Swiss primary care. Conclusion: Finding out whether the STRIP
assistant is an effective tool and beneficial for older and multimorbid
patients, who are usually excluded from trials, will have an impact on
the coordination of chronic care for multimorbid patients in Swiss
primary care in this new eHealth environment.
Background: Workplace violence (WPV) towards healthcare staff is
becoming a common problem in different healthcare settings worldwide.
Moreover, the prevalence is 16 times higher than in other professions.
How often it happened towards young doctors working as general
practitioners (GPs) at the beginning of their careers has been rarely
studied. Research question: To investigate the frequency and forms of
WPV, experienced by the young Croatian GPs from their patients, and
violence reporting pattern to the competent institutions. Methods: The
cross-sectional study was carried out on 74 GP residents, during their
postgraduate study in family medicine in May 2018. A specially designed
anonymous questionnaire, developed by Association of Family Physicians
of South Eastern Europe, was used to investigate the prevalence and
forms of WPV, the narrative description of the traumatic event itself
and the process of reporting it. Results: The response rate was 91.9\%,
female 87\%, the median of years working as a GP was 3.5 years. Most of
the residents were working in an urban practice (63\%), others in the
rural and the suburban once (27\%, 10\%). All GP residents experienced
patients'' and caregivers'' violent behaviour directed towards them.
High-intensity violence (e.g. physical violence, sexual harassment) was
experienced by 44\%, middle intensity (e.g. intimidation, visual sexual
harassment) by 84\% while all residents experienced verbal violence.
Only 13.2\% residents reported WPV to the competent institutions. Most
of GP residents reported the appearance of the new form of violence: the
one over the internet. Conclusion: The high prevalence of all types of
violence towards young Croatian doctors is worrisome, as is the fact
that violent acts are seldom reported to the competent institutions.
Those alarming facts could become a threat to GPs career choosing.
Background: About 50\% of patients adhere to chronic therapy in France.
Improving adherence should improve their care. Identifying the patient''s
difficulties in taking medication is complex for the physician, because
there is no gold standard for measuring adherence to medications. How
can the general practitioner in his/her practice identify patient
compliance? Research question: Analyse studies that develop or validate
scales used to estimate adherence in primary care. Methods: A systematic
review of the literature from PubMed, the Cochrane Library and PsycINFO
databases. The search terms used were the MeSH terms (or adapted to the
database''s vocabulary): questionnaire, compliance and primary care. All
articles were retained whatever the language of writing. Selection
criteria were: assessment of the development, validation or reliability
of one or more compliance scales; taking place in primary care. One
reviewer screened titles, which included the term adherence then
abstracts and full text. Only articles evaluating the development,
validity or reliability of a primary care adherence rating scale were
included in analysis. Results: In total 1022 articles were selected and
18 articles were included. Seventeen adherence scales were identified in
primary care, most of which targeted a single pathology, especially
hypertension. The most cited scale is the MMAS Morisky medication
adherence scale. Three scales were developed for patients with multiple
chronic diseases. One scale was developed for patients older than 65
years-the Strathclyde compliance risk assessment tool (SCRAT)-and two
scales were developed for adult patients whatever their age-the
instrument developed by Sidorkiewicz et al., and the DAMS, diagnostic
adherence to medication scale. Conclusion: Two scales have been
developed and validated in primary care to assess patient adherence with
multiple chronic diseases: the DAMS and the instrument developed by
Sidorkiewicz et al. A simple, reliable, reproducible primary care scale
would assess the impact of actions developed to improve adherence:
motivational interviewing, patient therapeutic education, and the ASALeE
protocol.
Background: Multimorbidity prevalence increases with age while declining
quality of life (QoL) is one of its major consequences. Research
question: The study aims to: (1) Assess the relationship between
increasing number of diseases and QoL. (2) Identify the most frequently
occurring patterns of diseases and how they relate to QoL. (3) Observe
how these associations differ across different European countries and
regions. Methods: Cross-sectional data analysis performed on wave six of
the population-based survey of health, ageing and retirement in Europe
(SHARE) (n = 68 231). Data were collected in 2015 among population 50+
years old in 17 European countries and Israel. Multimorbidity is defined
as the co-occurrence of two or more chronic conditions. Conditions were
self-declared and identified through an open-end questionnaire
containing 17 prelisted conditions plus conditions added by
participants. Control, autonomy, self-realization and pleasure
questionnaire (CASP-12v) was used to evaluate QoL. Association between
increasing number of diseases and QoL was assessed with linear
regression. Factor analysis is being conducted to identify patterns of
diseases to evaluate their impact on QoL further. Multilevel analysis
will take into account differences between countries and regions.
Confounding was searched with directed acyclic graph (DAG) method and
included age, sex, education, socio-economic status, behavioural habits,
social support and healthcare parameters. Results: Participants
(49.09\%) had two or more diseases. Maximum number of diseases per
person was 13, mean number was 1.9. Unadjusted preliminary analysis
showed that on average QoL decreases by -1.27 (95\%CI: -1.29, -1.24)
with each added new condition across Europe. The decline appears to be
the steepest in Spain, -1.61 (95\%CI: -1.71, -1.51), and the least so in
Israel, -0.67 (95\%CI: -0.82, -0.52). Conclusion: Ongoing analysis will
identify disease patterns, which may have the highest impact on QoL, as
well as to elucidate the role of confounders in the relationship between
increasing number of diseases and disease patterns with QoL.
Background: The burden and preventive potential of disease is typically
estimated for each non-communicable disease (NCD) separately but NCDs
often co-occur, which hampers reliable quantification of their overall
burden and joint preventive potential in the population. Research
questions: What is the lifetime risk of developing any NCD? Which
multimorbidity clusters of NCDs cause the greatest burden? To what
extent do three key shared risk factors, namely smoking, hypertension
and being overweight, influence this risk, life-expectancy and
NCD-multimorbidity? Methods: Between 1990 and 2012 we followed NCD-free
participants aged >= 45 years at baseline from the Dutch prospective
Rotterdam study for incidents of stroke, heart disease, diabetes,
chronic respiratory disease, cancer, and neurodegenerative disease. We
quantified (co-)occurrence and remaining lifetime risk of NCDs in a
competing risk framework, and studied the effects of smoking,
hypertension, and being overweight on lifetime risk and life expectancy.
Results: During follow-up of 9061 participants, 814 participants were
diagnosed with stroke, 1571 with heart disease, 625 with diabetes, 1004
with chronic respiratory disease, 1538 with cancer, and 1065 with
neurodegenerative disease. Among those, 1563 participants (33.7\%) were
diagnosed with multiple diseases. The lifetime risk of any NCD from the
age of 45 onwards was 94.0\% (95\%CI: 92.9-95.1) for men and 92.8\%
(95\%CI: 91.8-93.8) for women. Absence of shared risk factors was
associated with a 9.0-year delay (95\%CI: 6.3-11.6) in the age at onset
of any NCD. Furthermore, overall life expectancy for participants
without risk factors was 6.0 years (95\%CI: 5.7-7.9) longer than those
with these risk factors. Participants without these risk factors spent
21.6\% of their remaining lifetime with NCDs, compared to 31.8\% for
those with risk factors. Conclusion: Nine out of 10 individuals aged 45
years and older will develop at least one NCD during their remaining
lifetime. A third was diagnosed with multiple NCDs during follow-up.
Absence of three common shared risk factors related to compression of
morbidity of NCDs.
Background: This study examined if using electronic reminders increases
the rate of diagnosis recordings in the patient chart system following
visits to a general practitioner (GP). The impact of electronic
reminders was studied in the primary care of a Finnish city. Research
question: How effective is the reminder of the information system in
improving the diagnostic level of primary care? Which is better and how:
financial incentives or reminders? Methods: This was an observational
retrospective study based on a before-and-after design and was carried
out by installing an electronic reminder in the computerized patient
chart system to improve the recording of diagnoses during GP visits. The
quality of the recorded diagnoses was observed before and after the
intervention. The effect of this intervention on the recording of
diagnoses was also studied. Results: Before intervention, the level of
recording diagnoses was about 40\% in the primary care units. After four
years, the recording rate had risen to 90\% (p < 0.001). The rate of
change in the recording of diagnoses was highest during the first year
of intervention. In the present study, most of the visits concerned mild
respiratory infections, elevated blood pressure, low back pain and type
II diabetes. Conclusion: An electronic reminder improved the recording
of diagnoses during the visits to GPs. The present intervention produced
data, which reflects the distribution of diagnoses in real clinical life
in primary care and thus provides valid data about the public.
Background: Child abuse is widespread, occurs in all cultures and
communities and remains undiscovered in 90\% of the cases. In total,
80\% of reported child abuse concerns emotional ill-treatment. In the
Netherlands, at least 3\% (118 000) of children are victims of child
abuse resulting in 50 deaths each year. Only 1-3\% of abuse cases are
reported by general practitioners (GPs) to the Child Protective Services
agency (CPS). To explain this low reporting rate, we examined GPs''
experiences with child abuse. Research question: How does the suspicion
of child abuse arise in GPs'' diagnostic reasoning? How do they act upon
their suspicion and what kind of barriers do they experience in their
management? Methods: In total 26 GPs (16 female) participated in four
focus groups. We used purposive sampling to include GPs with different
levels of experience in rural and urban areas spread over the
Netherlands. We used NVivo for thematic content analysis. Results:
Suspected child abuse arose based on common triggers and a gut feeling
that `something is wrong here''. GPs acted upon their suspicion by
gathering more data by history taking and physical examination. They
often found it challenging to decide whether a child was abused because
parents, despite their good intentions, may lack parenting skills and
differ in their norms and values. GPs reported clear signs of sexual
abuse and physical violence to CPS. However, in less clear-cut cases
they followed-up and built a supporting network around the family. Most
GPs highly valued the patient-doctor relationship while recognizing the
risk of pushing boundaries. Conclusion: A low child abuse reporting rate
by GPs to CPS does not mean a low detection rate. GPs use patients''
trust in their doctor to improve a child''s situation by involving other
professionals.
Background: The number of people suffering from multiple chronic
conditions, multimorbidity, is rising. For society, multimorbidity is
known to increase healthcare expenses through more frequent contacts,
especially with the primary sector. For the individual, an increasing
number of medical conditions are associated with lower quality of life
(QoL). However, there is no statistically validated condition-specific
patient-reported outcome measure (PROM) for the assessment of QoL among
patients with multimorbidity. A validated PROM is essential in order to
measure effect in intervention studies for this patient group. Research
question: (1) To identify items covering QoL among patients with
multimorbidity in a Danish context. (2) To develop and validate a PROM
for assessment of QoL among patients with multimorbidity. (3) To utilize
the final PROM in a large group of patients with multimorbidity to
measure their QoL when living with different combinations and severity
of multimorbidity. Methods: Phase 1: qualitative individual and focus
group interviews with patients with multimorbidity to identify relevant
QoL items. Phase 2: validation of the items through a draft
questionnaire sent by email to around 200-400 patients with
multimorbidity. Phase 3: psychometric validation of the draft
questionnaire securing items with the highest possible measurement
quality. Phase 4: assessment of QoL among approximately 2000 patients
with multimorbidity from the Danish Lolland-Falster study. Results:
There are no results yet. Currently, the interview guide is under
development. Conclusion: Despite the rising number of patients with
multimorbidity and the known inverse relationship between a patient''s
number of medical conditions and their quality of life, there is no
statistically validated condition-specific PROM for assessment of QoL
among this group. Our aim is that this project''s developed and validated
PROM will be used in future intervention studies as a valid measure of
QoL among patients with multimorbidity.
Background: Through a systematic review of the literature and
qualitative research across Europe, the European General Practitioners
Research Network (EGPRN) has designed and validated a comprehensive
definition of multimorbidity. It is a concept considering all the
biopsychosocial conditions of a patient. This concept encompasses more
than 50 variables and is consequently difficult to use in primary care.
Consideration of adverse outcomes (such as death or acute
hospitalization) could help to distinguish which variables could be risk
factors of decompensation within the definition of multimorbidity.
Research question: Which criteria in the EGPRN concept of multimorbidity
could detect outpatients at risk of death or acute hospitalization (i.e.
decompensation) in a primary care cohort at 24-months of follow-up?
Methods: Primary care outpatients (131) answering to EGPRN''s
multimorbidity definition were included by GPs, during two periods of
inclusion in 2014 and 2015. At 24 months follow-up, the status
`decompensation'' or `nothing to report'' was collected. A logistic
regression following a Cox model was performed to achieve the survival
analysis and to identify potential risk factors. Results: At 24 months
follow-up, 120 patients were analysed. Three different clusters were
identified. Forty-four patients, representing 36.6\% of the population,
had either died or been hospitalized more than seven consecutive days.
Two variables were significantly associated with decompensation: Number
of GPs encounters per year (HR: 1.06; 95\%CI: 1.03-1.10, p <0.001), and
total number of diseases (HR: 1.12; 95\%CI: 1.03-1.33; P = 0.039).
Conclusion: To prevent death or acute hospitalization in multimorbid
outpatients, GPs may be alert to those with high rates of GP encounters
or a high number of illnesses. These results are consistent with others
in medical literature.
Background: A study of casual versus causal comorbidity in family
medicine in three practice populations from the Netherlands, Malta and
Serbia. Research question: (1) What is the observed comorbidity of the
20 most common episodes of care in three countries? (2) How much of the
observed comorbidity is likely to be casual versus causal? Methods:
Participating family doctors (FDs) in the Netherlands, Malta and Serbia
recorded details of all patient contacts in an episode of care structure
using electronic medical records based on the International
Classification of Primary Care, collecting data on all elements of the
doctor-patient encounter, including the diagnostic labels (episode of
care labels, EoCs). Comorbidity was measured using the odds ratio of
both conditions being incident or rest-prevalent in the same patient in
one-year data frames, as against not. Results: Comorbidity in family
practice expressed as odds ratios between the 41 most prevalent (joint
top 20) episode titles in the three populations. Specific associations
were explored in different age groups to observe the changes in odds
ratios with increasing age as a surrogate for a temporal or biological
gradient. Conclusion: After applying accepted criteria for testing the
causality of associations, it is reasonable to conclude that most of the
observed primary care comorbidity is casual. It would be incorrect to
assume causal relationships between co-occurring diseases in family
medicine, even if such a relationship might be plausible or consistent
with current conceptualizations of the causation of disease. Most
observed comorbidity in primary care is the result of increasing illness
diversity.
Background: The concept of therapeutic alliance emerged in the beginning
of the twentieth century and came from psychoanalysis. This notion was
then extended to the somatic field and aims to replace the paternalistic
model in the doctor-patient relationship. The EGPRN TATA group selected
the WAI SR as the most reliable and reproducible scale to assess
therapeutic alliance. To use it within Europe, it was necessary to
translate it into most European languages. The following study aimed to
assess the linguistic homogeneity of five of these translations.
Research question: Are the translations of the WAI SR homogeneous
between Spain, Poland, Slovenia, France and Italy? Methods:
Forward-backward translations were achieved in five participating
countries (Spain, Poland, France, Slovenia and Italy). Using a Delphi
procedure, a global homogeneity check was then performed by comparing
the five backward translations during a physical meeting involving GP
teachers/researchers from many European countries; the heterogeneity of
the participants'' origins was a token of reliability. Results: In the
assessment of the five translations, 107 experts participated. A
consensus was obtained in one to two Delphi rounds for each. During the
`homogeneity check,'' some discrepancies were noted with the original
version and were discussed with the local teams. This last stage
permitted to highlight cultural discrepancies and real translation
issues and to correct if needed. Conclusion: Five homogeneous versions
of the WAI SR are now available in five European languages. They will be
helpful to evaluate therapeutic alliance at different levels: for GPs in
daily practice, for students during the initial and continuous training,
and for further research in these five countries.
Background: The patient enablement instrument (PEI) is an established
patient-reported outcome measure (PROM) that reflects the quality of a
GP appointment. It is a six-item questionnaire, addressed to the patient
immediately after a consultation. Research question: The study aimed to
evaluate whether a single-item measure (the Q1), based on the PEI, or a
single question extracted from the PEI itself (the Q2) could replace the
PEI when measuring patient enablement among Finnish healthcare centre
patients. Methods: The study design included (1) a pilot study with
brief interviews with the respondents, (2) a questionnaire study before
and after a single appointment with a GP, and (3) a telephone interview
two weeks after the appointment. The correlations between the measures
were examined. The sensitivity, specificity and both positive and
negative predictive values for the Q1 and the Q2 were calculated, with
different PEI score cut-off points. Results: Altogether 483 patients
with completed PEIs were included in the analyses. The correlations
between the PEI and the Q1 or the Q2 were 0.48 and 0.84, respectively.
Both the Q1 and the Q2 had high sensitivity and negative predictive
value in relation to patients with lower enablement scores. The
reliability coefficients were 0.24 for the Q1 and 0.76 for the Q2.
Conclusion: The Q2 seems to be a valid and reliable way to measure
patient enablement. The Q1 seems to be less correlated with the PEI, but
it also has high negative predictive value in relation to low enablement
scores.
Multimorbidity challenges existing healthcare organization and research,
which remains disease and single-condition focused. Basic science
approaches to multimorbidity have the potential to identify important
shared mechanisms by which diseases we currently think of as distinct
might arise, but there is a pressing need for more applied and health
services research to understand better and manage multimorbidity now.
There are several recent clinical guidelines, which make recommendations
for managing multimorbidity or related issues for patients such as
polypharmacy and frailty. However, the evidence base underpinning these
recommendations is often weak, and these guidelines, therefore, also
help define a research agenda. A key problem for researchers and health
services is that multimorbidity is very heterogeneous, in that
`intermittent low back pain plus mild eczema'' presents very different
challenges to researchers and health services compared to `active
psychosis plus severe heart failure''. Identifying important but
tractable research questions is therefore not always straightforward.
This presentation will identify important gaps in the evidence, and
illustrate how they might be filled. The focus will be on two areas
where there is consensus that better evidence is needed to inform care
design and delivery: (1) organizational interventions to implement more
coordinated and holistic care; and (2) interventions to improve
medicines management in people with multimorbidity and polypharmacy.
These illustrate both the potential for imaginative research, but also
the scale.
Background: The accumulation of multiple chronic diseases
(multimorbidity) and multiple prescribed medications (polypharmacy) over
time may influence the extent to which an individual maintains health
and well-being in later life. Research question: This research aims to
describe the patterns (sequence and timing) of multimorbidity and
polypharmacy that accumulate over time among primary healthcare patients
in Canada. Methods: Data are derived from the Canadian primary care
sentinel surveillance network (CPCSSN) electronic medical record (EMR)
database that holds >= 1 million longitudinal, de-identified records.
Multimorbidity will be identified with 20 categories, cut-off points of
>= 2 and >= 3 chronic conditions and the International Classification of
Disease (ICD) classification system. Polypharmacy will be identified
using the cut-off points of >= 5 and >= 10 medication classes and the
Anatomical Therapeutic Chemical (ATC) classification system. Analyses
will be conducted using Java and Stata 14.2 software. Results: The
prevalence of chronic diseases and prescribed medications will be
presented, as well as the patterns that are observed among adults and
older adults in Canada. The most frequent patterns (combinations and
permutations) of multimorbidity and polypharmacy will be presented,
stratified by sex and age category. The relationships with other
factors, such as the presence of frailty, disability or increased health
service use, will be examined. As well, the methodological challenges to
identifying the presence and sequence of multimorbidity and polypharmacy
in national, longitudinal data will be discussed. Conclusion: This
research will explore the profiles of multimorbidity and polypharmacy in
mid- and late-life using a national, longitudinal database. These
findings can be used strategically to inform healthcare delivery and to
contribute to the understanding of multimorbidity and polypharmacy in
the international literature. Reducing the burden of prescribed
medications and the harms of polypharmacy are key tasks within the
context of multimorbidity.
Background: Multimorbidity and polypharmacy have become the norm for
general practitioners (GPs). Ideally, GPs search for inappropriate
medication and, if necessary, deprescribe. However, it remains
challenging to deprescribe given time constraints and little backup from
guidelines. Furthermore, barriers and enablers to deprescribing among
patients have to be accounted for. Research question: To identify
barriers and enablers to deprescribing in older patients with
polypharmacy. Methods: We surveyed among patients >70 years with
multimorbidity (>2 chronic conditions) and polypharmacy (>4 regular
medicines). We invited Swiss GPs to recruit eligible patients, each of
whom completed a paper-based survey on demography, medications and
chronic conditions. We applied the revised patients'' attitudes towards
deprescribing (rPATD) questionnaire and added 12 additional questions
and two open questions to assess barriers and enablers towards
deprescribing. Results: We analysed the first 221 responses received so
far and full results will be presented at the conference. Participants
were 79.3 years in mean (SD 5.8) and 48\% female. Thirty-one percent
lived alone, and 85\% prepared their medication themselves, all others
required help. Seventy-six percent of participants took 5-9 regular
medicines and 24\% took >= 10 up to 22 medicines. Participants (76\%)
were willing to deprescribe one or more of their medicines and 78\% did
not have any negative experience with deprescribing. Age and gender were
not associated with their willingness to deprescribe. Important barriers
to deprescribing were satisfaction with drugs (96\%), long-term drugs
(56\%) and noticing positive effects when taking them (92\%). When it
comes to deprescribing, 89\% of participants wanted as much information
as possible on their medicines. Having a good relationship with their GP
was a further key factor to them (85\%). Conclusion: Most older adults
are willing to deprescribe. They would like to be informed about their
medicines and want to discuss deprescribing to achieve shared
decision-making with the GP they trust.
Background: With growing populations of patients with multimorbidity,
general practitioners need insight into which patients in their practice
are most in need for person-centred integrated care (''high-need''
patients). Using data from electronic primary care medical records to
automatically create a list of possible `high need'' patients could be a
quick and easy first step to assist GPs in identifying these patients.
Research question: Can `high need'' patients with multimorbidity be
identified automatically from their primary care medical records?
Methods: Pseudonymized medical records of patients with multimorbidity
(>= 2 chronic diseases) were analysed. Data was derived from the Nivel
primary care database, a large registry containing data routinely
recorded in electronic health records. This includes data on healthcare
use, health problems and treatment. Logistic regression analysis was
conducted to predict outcomes (frequent contact with the general
practice, ER visits and unplanned hospital admissions). Predictors were
age, sex, healthcare use in the previous year, morbidity and medication
use. Results: In total, 245 065 patients with multimorbidity were
identified, of which 48\% were above the age of 65 and 57\% female. More
than 42\% had five GP contacts in the previous year and 62\% used five
or more different medications. Frequent contact with the general
practice could be reliably predicted using only the number of contacts
in the previous year (AUC: 0.82). Adding all other predictors (including
specific chronic conditions) only improved the predictive value of the
model marginally (AUC: 0.84). Identifying patients with a high risk for
ER visits and unplanned hospital admissions proved more difficult (AUC:
0.67 and 0.70, respectively). Conclusion: `High need'' patients with
multimorbidity can be automatically selected from primary care medical
records using only the number of contacts with the general practice in
the previous year. Composing a list of these patients can help GPs to
identify those eligible for person-centred integrated care.
Background: Chronic diseases usually have a long duration and slow
progression and, as a result, they tend to aggregate in multimorbidity
patterns (MPs) during the life course and/or due to shared underlying
pathophysiological pathways. Knowledge of how MPs progress over time is
necessary to develop effective prevention management strategies.
Research question: What are the most likely MPs over time? Which
longitudinal shifts from one pattern to another occur during follow-up?
Methods: A prospective longitudinal study based on electronic health
records was conducted during 2012-2016 in Catalonia, Spain. For people
aged >= 65 years, we extracted data on demographics and diagnostic codes
for chronic diseases (ICD-10). Machine-learning techniques were applied
for the identification of disease clusters using fuzzy c-means analysis
to obtain initial clusters. To estimate longitudinal MPs and their
progression for each individual a hidden Markov model was fitted,
estimating: (1) the transition probability matrix between clusters; (2)
the initial cluster probability; (3) the most likely trajectory for each
individual. The prevalence of disease in each cluster, observed/expected
ratios (O/E ratios) and disease exclusivity was determined for each MP.
Criteria used to designate cluster: O/E ratio >= 2. Results: In total,
916 619 individuals were included. Ten MPs were identified. The cluster
including the most prevalent diseases was designated non-specific
(42.0\% of individuals). The remaining nine clusters included the
following anatomical systems: ophthalmologic and mental diseases
(19.3\%), osteometabolic (7.9\%), cardio-circulatory (6.6\%), and
others. Most patients, minimum 59.2\%, remained in the same cluster
during the study period. The highest transitions to the mortality state
were observed in the cardio-circulatory (37.1\%) and nervous (31.8\%)
MPs. Conclusion: Ten significant longitudinal MPs were found. The
application of sophisticated statistical techniques ideally suited the
study of the MPs and allowed for characterization over time. This method
is useful to establish a probabilistic evolution of MPs.
Background: Quality of life is an essential theme for quantitative
surveys in primary care. Treatments and procedures need to be assessed
on whether they change patients'' quality of life. This has led to the
creation of evaluation scales. The purpose of this study was to
determine reproducibility and efficiency of 11 previously selected
quality of life scales (selected with a systematic review) for the
general population. Research question: What is the best possible
reproducible and efficient quality of life scale for the general
population? Methods: The search was conducted from November 2017 to
April 2018 in PubMed and Cochrane databases, according to the PRISMA
(preferred reporting items for systematic reviews and meta-analyses)
protocol. The inclusion criteria were the psychometric qualities for
each of the 11 scales studied. Articles dealing with subpopulations or
those not written in IMRAD format were excluded. The collected values
were reproducibility and efficiency. Results: Out of 206, 46 selected
articles were included. Cronbach''s alpha by domain and Pearson''s
coefficient were the most analysed psychometrics. No valid efficiency
data was obtained. The internal consistency was over 0.7 for the SF-36,
SF12v2 and EQ-5D scales. The Pearson coefficient was over 0.4 for the
SF36v2, SF-12 and SF-12v2 scales. The Cohen''s kappa ranged from 0.4 to
0.80 for the EQ-5D questionnaire. Conclusion: No scale is fully
validated. Reproducibility values were incomplete (Cronbach''s alpha and
Pearson''s most expressed). No efficiency data was found. The most
validated scales are the SF family and the EQ-5D. Researchers and
clinicians should be aware of these limitations when choosing a quality
of life scale. They should return to the scales'' designs to choose the
one that underlines the type of quality of life they want to assess as
no external validity is available.
Background: Previous studies have shown an increased rate of infection
among patients with diabetes; however, it is unclear from these studies
if the level of HbA1c is correlated with infection. Research question:
This study aimed to examine the association between glycaemic control of
type 2 diabetes patients and the incidence of infections. Methods: An
HMO database was used to identify all DM patients. The first HbA1c test
during the period of the study was selected for each patient; then an
infection diagnosis was searched in the 60 days that followed the test.
We compared the HbA1c test results that were followed by an infection to
those that were not. After applying exclusion criteria: having cancer,
receiving immunosuppressive medication, undergoing dialysis treatment,
anaemia less than 9 mg\%, and G6PD deficiency, there remained 33 637
patients in the cohort. The study period was October 2014 to September
2017. The following information was collected: age, gender,
socio-economic index, BMI, use of hypoglycaemic and steroid medication
in the 90 days before infection, and comorbid conditions (IHD, PVD, CVA,
CCF, asthma, COPD, Parkinson''s disease, dementia, CRF). Results: In
total, 804 patients had an infection within 60 days following an HbA1c
test. For cellulitis, cholecystitis, herpes zoster, pneumonia and
sinusitis the HbA1c was higher than those patients that had no infection
(for cellulitis 7.603 vs 7.243). When factored into logistic regression
analysis, we found that other chronic diseases increased the risk of
infection between 29 and 60\%. Each increase of a gram of HbA1c
increased the risk by 8.5\%. Use of steroids in the 90 days before the
infection increases the chance of infection by 734\%. Conclusion:
Increasing HbA1c and comorbidity both increase the risk of infection
among type 2 diabetics but use of oral or injectable steroids is a much
more significant risk factor.'
author: '[Anonymous], '
author_list:
- family: '[Anonymous]'
given: ''
da: '2023-09-28'
doi: 10.1080/13814788.2019.1643166
eissn: 1751-1402
files: []
issn: 1381-4788
journal: EUROPEAN JOURNAL OF GENERAL PRACTICE
language: English
month: JUL 3
number: '3'
number-of-cited-references: '0'
orcid-numbers: hong, zhao/0000-0003-3528-6320
pages: 164-175
papis_id: 7fc5bd18a475fb2113b071e320e3421b
ref: Anonymous2019researchmultimorbidi
researcherid-numbers: 'Blondeel, Sofie/AAE-5307-2022
Fazli, Ghazal/AAE-8320-2022
DSILVA, BROOKE/HCI-4879-2022
Baldissera, Annalisa/AHD-6334-2022
'
times-cited: '1'
title: 'Research on multimorbidity in primary care. Selected abstracts from the EGPRN
meeting in Tampere, Finland, 9-12 May 2019 All abstracts of the conference can be
found at the EGPRN website: www.egprn.org/page/conference-abstracts'
2023-10-01 08:15:07 +00:00
type: techreport
2023-09-28 14:46:10 +00:00
unique-id: WOS:000481779500010
usage-count-last-180-days: '83'
usage-count-since-2013: '878'
volume: '25'
web-of-science-categories: Primary Health Care; Medicine, General \& Internal
year: '2019'