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'
type: techreport
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'