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This study examined associations between avoidance and approach coping and patient delay in cancer patients (N = 1024). Approach coping was associated with short appraisal intervals (time from symptom discovery to recognition of symptom seriousness). Avoidance coping was associated with long appraisal intervals when adjusting for covariates. Help-seeking intervals (time from recognition of symptom seriousness to contact to general practitioner) were only associated with approach coping and only when adjusting for the influence of covariates. The results revealed a complex relationship between coping and patient delay and supported that normal processing of health threats implies avoidance and approach coping strategies. [ABSTRACT FROM AUTHOR]

Background: People living with chronic disease currently account for the majority of the total healthcare costs. The Central Denmark Region implemented a disease management programme (DMP) for chronic obstructive pulmonary disease (COPD) in 2008. This presented an opportunity to examine the effect of an evidence-based, planned and proactive implementation of a DMP compared to the usual implementation strategy. Methods: We performed a block- and cluster-randomised controlled trial with two groups and an extra external control group. The primary outcome was patients' assessment of their care after using an active implementation model for a DMP for COPD measured with the Patient-Assessment-of-Chronic-Illness-Care (PACIC) instrument. At baseline, questionnaires were sent to 2,895 patients identified by an algorithm based on health registry data on lung-related contacts to the healthcare system. Patients were asked to confirm or refute their diagnosis of COPD. Of those who responded, 1,445 (72.8%) confirmed their diagnosis. PACIC data were collected at baseline and at a 12-month follow-up for 744 (51.1%) patients. Results: Comparing the three groups after the implementation of the DMP, we found a statistically significantly higher change in the PACIC score in the intervention group than in the control groups. No statistically significant differences were found between the control and the external control groups in any of the dimensions. Conclusions: Reinforcing the role of general practice as coordinator for care-and self-management-support with an active implementation of a DMP for COPD made patients score higher on the PACIC instrument, which indicates a better experience of the received healthcare. Trial registration: NCT01228708. [ABSTRACT FROM AUTHOR]

Objective. Approximately 98% of Danish citizens are listed with a general practice which they consult for medical advice. Although 85% of the population contact their general practitioner (GP) every year, little is known about these contacts. The aim of the present paper is to gain updated knowledge about patients' reasons for encounter and the GP activities and to make comparisons with a similar study from 1993. Methods. All GPs in the Central Denmark Region were invited to register all contacts during one randomly chosen day within a year. The registration included questions about patients' reasons for encounter, the types and contents of the contacts, referrals, and distribution between new episodes and follow-up contacts. Aggregated data were compared with the results from 1993. Results. A total of 404 (46%) GPs participated. The number of contacts per 1000 inhabitants had risen by 19.7%. The reasons for encounter and final diagnoses resembled those in 1993. Musculoskeletal, psychological, and respiratory problems were the most common reasons for encounter, psychological problems being the only type to increase over the period. Interestingly, the proportion of diagnoses within the ICPC 'A' chapter rose from 13.5 to 19.7%. The referral rate rose by 2% (relative: 18.7%) from 10.7% to 12.7% and the share of follow-up contacts rose from 45.9% to 50.4% (relative: 8.7%). Conclusion. Quite small changes were seen in the patterns of reasons for encounter and diagnoses from 1993 to 2009. However, an increase was found in contacts with general practice and referrals and in the proportion of follow-ups. [ABSTRACT FROM AUTHOR]

Background: Little is known about the existing barriers to cooperation among health professionals in basic level palliative care for terminally ill patients with cancer in primary health care. Objective: The aim of this study was to analyze health professionals' views on interprofessional cooperation in basic level palliative home care for terminally ill cancer patients. Method: This study was a qualitative, descriptive study based on 7 semistructured group interviews conducted in the former Aarhus County, Denmark. Forty-three health professionals (23 family physicians, 5 chief physicians, and 15 home care nurses) were interviewed. Results: Two main categories of problems were identified: (1) the organization of palliative home care (need for proactive planning from the start of the palliative trajectory, clear distribution of tasks, advancement of more efficient communication pathways, and improved accessibility to all health professionals) and (2) interaction between health professionals (increased knowledge of and respect for the competencies of other health occupations and individuals). Conclusion: The study indicates problems with respect to both the organization of the basic level palliative home care and the working culture among health professionals. The main issues: distribution of tasks, information exchange, availability, respect, and personal acquaintance are pivotal to improve the delivery of palliative home care, to training in palliative care and warrant future research. [ABSTRACT FROM AUTHOR]

Background: Spouses' involvement in palliative care is often a prerequisite for home death, but it is unclear whether active involvement of the spouse, e.g. administering and being in charge of oral or subcutaneous medication or taking care of the patient's personal hygiene, could be harmful or have negative effects on the spouse's experience of the palliative course of disease. The aim of this study was to explore the impact of bereaved spouses' active involvement in medical and physical care on their experience of the palliative course of disease. Methods: The study was a qualitative, descriptive study based on semi-structured individual interviews with seven bereaved spouses. Results: Four main categories were found: Degree of involvement, Positive and Negative impact and Prerequisites. The prerequisites found for a positive outcome were Safety (24-hour back-up), Confidence (Professionals' confidence in the spouses' abilities) and Dialog (Spouses' influence on decision-making and being asked). Conclusion: The results from this study identified important issues whenever spouses take an active part in medical treatment and physical care of critically ill patients in palliative care. The results question the previous research that active involvement of family care givers could be harmful and add preconditions to a positive outcome. More research into these preconditions is needed. [ABSTRACT FROM AUTHOR]

Background: Knowledge about the quality and organisation of care to terminally ill cancer patients with a relatives' view in a primary health care setting is limited. The aim of the study is to analyse experiences and preferences of bereaved relatives to terminally ill cancer patients in a primary care setting to explore barriers and facilitators for delivery of good palliative home care. Methods: Three focus group interviews with fourteen bereaved relatives in Aarhus County, Denmark. Results: Three main categories of experience were identified: 1) The health professionals' management, where a need to optimize was found. 2) Shared care, which was lacking. 3) The relatives' role, which needs an extra focus. Conclusion: Relatives experience insufficient palliative care mainly due to organizational and cultural problems among professionals. Palliative care in primary care in general needs improvement and attention should be drawn to the "professionalization" of the relatives and the need to strike a balance between their needs, wishes and resources in end-of-life care and bereavement. [ABSTRACT FROM AUTHOR]

Background: Delay in cancer diagnosis may be important for cancer prognosis. Large individual variations in the duration of delay have been observed. This study examines whether patients' socioeconomic characteristics are predictors of long patient-, doctor- and system-related delay in cancer diagnosis. Methods: Danish population-based cohort study. From September 2004 to September 2005, newly diagnosed cancer patients were enrolled from administrative registries. A total of 467 general practitioners in the County of Aarhus, Denmark, completed questionnaires on 2,212 cancer patients' diagnostic pathways. A total of 1,252 cancer patients filled in questionnaires on their socioeconomic characteristics (e.g. marital status, education, occupation, household income and fortune). Delay was categorised as short or long based on quartiles. Predictors of long delay were assessed in a logistic regression model using odds ratios (ORs) as a proxy of relative risks. Results: In regard to patient delay, retired female patients experienced shorter delays (OR 0.35, 95% confidence interval (95%CI) 0.13 to 0.98) than employed female patients, while female smokers experienced longer delays (OR 2.42, 95%CI 1.21 to 4.85) than female non-smokers. In regard to doctor delay, female patients with a large household fortune experienced shorter delays (OR 0.07, 95%CI 0.01 to 0.45) than economically less privileged female patients. Well-educated men experienced shorter delays (OR 0.40, 95%CI 0.16 to 1.00) than men with short education. Male patients experienced longer doctor delays (OR 2.11, 95%CI 1.11 to 4.02) than women when gender-specific cancers were excluded. In regard to system delay, female patients with a large household fortune experienced shorter delays (OR 0.46, 95%CI 0.21 to 0.99) than economically less privileged women, while female patients with a high alcohol intake experienced longer delays (OR 2.82, 95%CI 1.18 to 6.72) than women with an average intake. Conclusion: We found socioeconomic predictors of delay that allow us to hypothesize social inequalities in the distribution of delay, but, in general, only a few socioeconomic variables predicted delay in cancer diagnosis. Future research should examine a broader array of patients' personal characteristics. [ABSTRACT FROM AUTHOR]

Abstract: Objective: Our aim was to evaluate the effect of an educational program designed to improve care for somatizing patients in primary care. Method: Evaluation was performed during routine clinical care in a cluster randomized controlled trial. Patients were included consecutively, and those with a high score on rating scales for somatization were selected for follow-up (n=911). Follow-up was conducted 3 months (response rate=0.74) and 12 months (response rate=0.69) after inclusion using questionnaires measuring quality of life (Medical Outcomes Study 36-Item Short Form), disability days (WHO''s Disability Assessment Schedule), somatization (Whiteley-7 and Symptom Checklist Somatic Symptom Scale) and patient satisfaction (European Project on Patient Evaluation of General Practice Care). We analyzed differences from baseline to follow-up and compared these for intervention and control groups. Results: Self-reported health improved in both intervention and control groups during follow-up for patients with a high score for somatization, but changes were small. We could not demonstrate any difference between the control group and the intervention group with regard to our primary outcome ‘physical functioning.’ Patients in the intervention group tended to be more satisfied at 12-month follow-up than those in the control group, but this difference fell short of statistical significance. Conclusion: Training of primary care physicians showed no statistically significant effect on clinical outcome and showed nonsignificant improvement in patient satisfaction with care for patients with a high score for somatization. [Copyright &y& Elsevier]

The effect of 2 population-based outreach screening strategies that used in-home sampling was compared with usual care practices for Chlamydia trachomatis infection. All 30,439 persons 21-23 years old in Aarhus County, Denmark, were divided randomly into 3 groups: group 1 (n = 4500) had a home sampling kit mailed directly to their centrally registered home address; group 2 (n = 4500) had a reply card mailed to their home address with which a home sampling kit could be ordered; and group 3 (n = 21,439) had access to usual care. For women in groups 1 and 2, the relative risks of being tested were 4.1 (95% confidence interval [CI], 3.8-4.4) and 3.5 (95% CI, 3.2-3.9), respectively, compared with usual care. The corresponding figures for men were 19.1 (95% CI, 16.0-22.8) and 11.8 (95% CI, 9.8-14.2), respectively. Both screening strat-egies were highly effective, but men benefited the most from having the home sampling kit pro-vided directly. [ABSTRACT FROM AUTHOR]

Objective - The aim of the study was to describe the referral rates from general practice to physiotherapists and to investigate possible predictors for referral. Methods - Referral rates per 100 patients per year were obtained from the health insurance register of the county of Aarhus. General Practitioner (GP) characteristics were obtained via a questionnaire to all GPs in the county. Results - A total of 38 231 referred patients from 260 practices were included. Twice as many women as men were referred. Referral rates varied from 1.6% to 13.2% between practices. Of the explored predictors ''practice location'', ''female GP practices'' and ''GPs reporting frequent contact with physiotherapist regarding the treatment of individual patients'' were statistically significant, but ex plained little of the variance in referral rates. Conclusion – The examined practice and GP characteristics explain little of the substantial variation in referral rates. In view of increasing health care expenses and the need for quality assurance, the large variation in referral rates warrants reflection and further research on indications for and possible benefit from physiotherapy. [ABSTRACT FROM AUTHOR]

Talks about the creation of a definition for general practice of medicine for the 21st century. Old definitions of general practice; Criteria and content that must be considered when creating a definition of general practice; Importance of defining the discipline; Suggested definition of general practice.

The paper aims to describe the context for future continuing medical education (CME) in primary care. CME must develop the doctor's ability to look at diseases from a scientifically-based biomedical, psychological, and social perspective. It is a challenge for CME to bridge the gap between scientific evidence, and doctors' knowledge, attitude, and performance, but awareness on how to do this is scarce. CME must be better integrated with quality development, especially with the use of clinical guidelines. This is impeded by insufficient scientific evidence on the impact, advantages, and disadvantages of different CME methods, and by insufficient outcome measures of the effect of CME. Teaching the teachers should also be improved. It is concluded that the time is ripe for a scientific-based development in the conduction of CME. This may be done by establishing national research centres for CME, working together in an international network. [ABSTRACT FROM AUTHOR]

Evaluates the 1992 reform in the out of hours service by medical practioners in Denmark, five years after its introduction. Comparison between the before and after reform; Details on the three types of out of hours service; How data was collected; Information on the distribution of services.

Editorial. Comments on the concept of placebo and the general practice. Considerations on standards for evaluating specific effects of therapy; Implications of specific effects to counterbalance weaker initials on comparing treatment effects; Re-establishment of doctor-patient relationships for effective clinical practice.

Reports the provision of out of hours care by general practitioners in Denmark. Increase of demand for medical services by the public; Complaints of heavy workload and low remuneration by the rural doctors; Replacement of negotiated rota systems with county based services.

In this article the author discuses on a report entitled, Implementation of Medical Research in Clinical Practice, published by the European Medical Research Council and European Science Foundation. He states about the three main strength that are strategy for improving the quality of clinical research, imply good research and special attention should be given to the problems encountered in general practice.

The article focuses on the support of general practitioners (GPs) in identifying early clinical diagnosis of cancer. With the increasing number of cancer patients across the Nordic countries, immediate steps are need to be taken for prevention. The author reflects that general practice of health care research covers themes like knowledge of symptoms, role of GPs towards patients in personal consultations, and well-defined conclusion of disapprovement or confirmation of cancer.

Comments on techniques of managing medically unexplained symptoms, or, functional somatic symptoms, which lack an obvious organic basis. Reasons why medically unexplained symptoms represent a clinical problem that must be taken seriously; Significance of communication between doctors and patients, which may need to be adjusted in patients with medically unexplained symptoms; Consideration of research which determined the need for physicians to offer the same professional management and quality of care to the many patients with unexplained symptoms.

The article provides information about various researches on the concepts of patient-centered medicine. Researcher Daniel McWhinney and his team introduced the concept of patient-centered medicine. These concepts represent broader ways of thinking about the doctor-patient relationship. The article reveals that research aiming at improving patients' communication with doctors also showed ambiguous outcomes with regard to patient satisfaction. It also states that it is the responsibility of the doctors to see that the patients continuously feel that they meet a doctor in the consultation.

The authors comment a research by Van den Broek and colleagues to determine the effectiveness of population based screening for asymptomatic Chlamydia trachomatis infection. They found the study results disappointing, which indicated that screening strategy needs to be re-evaluated. They suggest that continuous efforts should be made to improve screening interventions and information about safe sex and the prevention of sexually transmitted diseases should be provided.

An obituary for professor Barbara Starfield is presented.

Editorial. Examines reports from the Medical Research Council and National Health Service working group on research in general practice. Focus of the reports; Implications of the reports.

Background: From 2008, Danish general practitioners could refer patients suspected of having cancer to standardised cancer patient pathways (CPPs). We aimed to compare the length of the diagnostic interval in 2010 with the length of the diagnostic interval before (2004/05) and during (2007/08) the implementation of CPPs in Denmark for all incident cancer patients who attended general practice prior to the cancer diagnosis. Methods: General practitioner questionnaires and register data on 12,558 patients were used to compare adjusted diagnostic interval across time by quantile regression. Results: The median diagnostic interval was 14 (95% CI: 11;16) days shorter during and 17 (95% CI: 15;19) days shorter after the implementation of CPPs than before. The diagnostic interval was 15 (95% CI: 12;17) days shorter for patients referred to a CPP in 2010 than during the implementation, whereas patients not referred to a CPP in 2010 had a 4 (95% CI: 1;7) days longer median diagnostic interval; the pattern was similar, but larger at the 75th and 90th percentiles. Conclusion: The diagnostic interval was significantly lower after CPP implementation. Yet, patients not referred to a CPP in 2010 tended to have a longer diagnostic interval compared to during the implementation. CPPs may thus only seem to expedite the diagnostic process for some cancer patients. [ABSTRACT FROM AUTHOR]

Background: Many countries have implemented standardised cancer patient pathways (CPPs) to ensure fast diagnosis of patients suspected of having cancer. Yet, studies are sparse on the impact of such CPPs, and few have distinguished between referral routes. For incident cancer patients, we aimed to determine how often GPs suspected cancer at the time of first presentation of symptoms in general practice and to describe the routes of referral for further investigation. In addition, we aimed to analyse if the GP's suspicion of cancer could predict the choice of referral to a CPP. Finally, we aimed to analyse associations between not only cancer suspicion and time to cancer diagnosis, but also between choice of referral route and time to cancer diagnosis. Methods: We conducted a population-based, cross-sectional study of incident cancer patients in Denmark who had attended general practice prior to their diagnosis of cancer. Data were collected from GP questionnaires and national registers. We estimated the patients' chance of being referred to a CPP (prevalence ratio (PR)) using Poisson regression. Associations between the GP's symptom interpretation, use of CPP and time to diagnosis were estimated using quantile regression. Results: 5,581 questionnaires were returned (response rate: 73.8%). A GP was involved in diagnosing the cancer in 4,101 (73.5%) cases (3,823 cases analysed). In 48.2% of these cases, the GP interpreted the patient's symptoms as 'alarm' symptoms suggestive of cancer. The GP used CPPs in 1,426 (37.3%) cases. Patients, who had symptoms interpreted as 'vague' had a lower chance of being referred to a CPP than when interpreted as 'alarm' symptoms (PR = 0.53 (95%CI: 0.48;0.60)). Patients with 'vague' symptoms had a 34 (95% CI: 28;41) days longer median time to diagnosis than patients with 'alarm' symptoms. Conclusions: GPs suspect cancer more often than they initiate a CPP, and patients were less likely to be referred to a CPP when their symptoms were not interpreted as alarm symptoms of cancer. The GP's choice of referral route was a strong predictor of the duration of the diagnostic interval, but the GP's symptom interpretation was approximately twice as strong an indicator of a longer diagnostic interval. [ABSTRACT FROM AUTHOR]

Highlights: [•] A CDSS could be reached directly from the GP's EMR via hyperlink. [•] The GP's visited the CDSS. [•] PSA-testing might not be the best case for evaluating the effect of an CDSS. [ABSTRACT FROM AUTHOR]

Background: Equal access to end-of-life care is important. However, social inequality has been found in relation to place-of-death. The question is whether social and economic factors play a role in access to specialist palliative care services. Objective: The study analyzed the association between access to outreach specialist palliative care teams (SPCTs) and socioeconomic characteristics of Danish cancer patients who died of their cancer. Methods: The study was a population-based, cross-sectional register study. We identified 599 adults who had died of cancer from March 1 to November 30, 2006, in Aarhus County, Denmark. Data from health registers were retrieved and linked based on the unique personal identifier number. Results: Multivariate analysis with adjustment for age, gender, and general practitioner (GP) involvement showed a higher probability of contact with an SPCT among immigrants and descendants of immigrants than among people of Danish origin (prevalence ratio [PR]: 1.55; 95% confidence interval (CI): 1.04;2.31) and among married compared to unmarried patients (PR: 1.25; 95% CI: 1.01;1.54). The trends were most marked among women. Conclusion: We found an association between females, married patients, and female immigrants and their descendants and access to an SPCT in Denmark. However, no association with the examined economic factor was found. Need for specialized health care, which is supposed to be the main reason for access to an SPCT, may be related to economic imbalance; and despite the relative equality found, SPCT access may not be equal for all Danish residents. Further research into social and economic consequences in palliative care services is warranted. [ABSTRACT FROM AUTHOR]

Background: Introduction and diffusion of new disease management programs in healthcare is usually slow, but active theory-driven implementation seems to outperform other implementation strategies. However, we have only scarce evidence on the feasibility and real effect of such strategies in complex primary care settings where municipalities, general practitioners and hospitals should work together. The Central Denmark Region recently implemented a disease management program for chronic obstructive pulmonary disease (COPD) which presented an opportunity to test an active implementation model against the usual implementation model. The aim of the present paper is to describe the development of an active implementation model using the Medical Research Council's model for complex interventions and the Chronic Care Model. Methods: We used the Medical Research Council's five-stage model for developing complex interventions to design an implementation model for a disease management program for COPD. First, literature on implementing change in general practice was scrutinised and empirical knowledge was assessed for suitability. In phase I, the intervention was developed; and in phases II and III, it was tested in a block- and cluster-randomised study. In phase IV, we evaluated the feasibility for others to use our active implementation model. Results: The Chronic Care Model was identified as a model for designing efficient implementation elements. These elements were combined into a multifaceted intervention, and a timeline for the trial in a randomised study was decided upon in accordance with the five stages in the Medical Research Council's model; this was captured in a PaTPlot, which allowed us to focus on the structure and the timing of the intervention. The implementation strategies identified as efficient were use of the Breakthrough Series, academic detailing, provision of patient material and meetings between providers. The active implementation model was tested in a randomised trial (results reported elsewhere). Conclusion: The combination of the theoretical model for complex interventions and the Chronic Care Model and the chosen specific implementation strategies proved feasible for a practice-based active implementation model for a chronic-disease-management-program for COPD. Using the Medical Research Council's model added transparency to the design phase which further facilitated the process of implementing the program. [ABSTRACT FROM AUTHOR]

Background. We assessed risk of burnout in GPs during a 7-year followup and examined whether (1) thoughts about changing medical specialty increased the risk of burnout and (2) burned out GPs had higher job turnover rates than burnout-free GPs. Methods. In 2004 and 2012, all GPs in the county of Aarhus, Denmark, were invited to participate in a survey. Retirement status of physicians who participated in 2004 was obtained through the Registry of Health Providers in 2012. Results. 216 GPs completed both surveys. The risk of developing burnout during the 7-year followup was 13.2% (8.2-19.6%). GPs who in 2004 were burnout-free and reported that they would not select general practice as medical specialty again had a statistically significant increased risk of burnout in 2012 (OR = 4.5; 95% CI = 1.2-16.5; P = 0.023). Among GPs with burnout in 2004, 25.0% had with drawn from general practice during followup compared to 28.8% of burnout-free GPs in 2004 (adj. OR = 0.99; 95% CI = 0.48-2.02; P = 0.975). Conclusion. The 7-year incidence of burnout was 13%.Thoughts about changing medical specialty were an important predictor of burnout. Burned out GPs had not higher job turnover rates than burnout-free GPs. [ABSTRACT FROM AUTHOR]

walk-in open access in general practice may influence the general practitioner's (GP's) work, but very little research has been done on the consequences. In this study from Danish general practice, we compare the prevalence of burnout between GPs with a walk-in open access and those without. In a questionnaire study (2004), we approached all 458 active GPs in the county of Aarhus, Denmark, and 376 (82.8%) GPs returned the questionnaire. walk-in open access was defined as at least 30 minutes every weekday where patients could attend practice without an appointment. Burnout was measured by the Maslach Burnout Inventory. Analyses using logistic regression were adjusted for gender, age, marital status, job satisfaction, minutes per consultation, practice organisation, working hours, number of listed patients per GP, number of contacts per GP, continuing medical education- (CME-) activities, and clusters of GPs. In all, 8% of GPs had open access and the prevalence of burnout was 24%. GPs with walk-in open access were more likely to suffer from burnout. Having open access was associated with a 3-fold increased likelihood of burnout (OR = 3.1 (95% CI: 1.1-8.8, p = 0.035)). Although the design cannot establish causality, it is recommended to closely monitor possible negative consequences of open access in general practice. [ABSTRACT FROM AUTHOR]

Background The purpose was to examine the prevalence of fear of recurrence (FoR) in long-term testicular cancer survivors (TCSs) and the association between FoR and causal attributions of cancer. Methods Testicular cancer survivors were sampled from a clinical register and were sent a questionnaire assessing FoR, depression using Beck Depression Inventory II (BDI-II), physical symptoms (ototoxicity, neuropathy, and Raynaud-like phenomena), and causal attributions of testicular cancer. Results There were 316 TCSs who completed the questionnaires (response rate, 65%). The mean age was 47.6 years (standard deviation ( SD) = 10.9), and the mean time since diagnosis was 12.0 years ( SD = 3.0). Among the TCSs, 27.9% reported FoR. Univariate analyses revealed that FoR was associated with a BDI-II sum score of ≥19 (odds ratio ( OR) = 7.07, p < 0.001) and attributing the cancer disease to psychological stress ( OR = 2.57, p = 0.002). A multivariate analysis revealed associations between FoR and attributing the cancer disease to psychological stress ( OR = 2.35, p = 0.010) and a BDI-II sum score ≥19 ( OR = 5.82, p = 0.002). Conclusions Fear of recurrence is prevalent in long-term TCSs. The observed relationship between FoR and a psychological causal attribution is probably complex and the direction of causality may be twofold: attributing the disease to a factor that is perceived as uncontrollable in nature could induce loss of control, and high levels of FoR may increase the need to gain control over the situation by pointing out factors that could be responsible for the disease such as psychological stress. Copyright © 2011 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Objective. The absence of a more significant improvement in cancer survival in countries such as the UK and Denmark may be partly rooted in delayed care-seeking among cancer patients. Past research on patient delay has mainly focused on patient characteristics (e.g. sociodemographic and psychological factors and symptom recognition) as causes of delayed care-seeking, while few studies have examined how the organizational structure of health care systems may influence patients' reflections on seeking care. The aim of this study was to explore this relationship. Design. The analysis presented is based on semi-structured interviews with 30 cancer patients and their families. Results. The article raises two hypotheses on the relationship between structural elements of a health care system and people's reflections on seeking health care: (1) Gatekeeping introduces an asymmetrical relationship between the patient and the GP which potentially results in self-restricting care-seeking, (2) Continuity in the doctor-patient relationship may negatively influence patient reflections on access to health care, as the focus shifts from the medical issues of the consultation to reflections on how to properly interact with the GP and the system in which she/he is situated. Conclusion. It is concluded that these hypotheses form a sound basis for further primary care research on how the organizational structure of health care systems influences patient reflections on access to medical care. [ABSTRACT FROM AUTHOR]

Objective. Central health organizations suggest routine screening for depression in high-risk categories of primary care patients. This study compares the effectiveness of high-risk screening versus case-finding in identifying depression in primary care. Design. Using an observational design, participating GPs included patients from 13 predefined risk groups and/or suspected of being depressed. Patients were assessed by the Major Depression Inventory (MDI) and ICD-10 criteria. Setting. Thirty-seven primary care practices in Mainland Denmark. Main outcome measures. Prevalence of depression, diagnostic agreement, effectiveness of screening methods, risk groups requiring special attention. Results. A total of 37 (8.4%) of 440 invited GP practices participated. We found high-risk prevalence of depression in 672 patients for the following traits: (1) previous history of depression, (2) familial predisposition to depression, (3) chronic pain, (4) other mental disorders, and (5) refugee or immigrant. In the total sample, GPs demonstrated a depression diagnostic sensitivity of 87% and a specificity of 67% using a case-finding strategy. GP diagnoses of depression agreed well with the MDI (AUC values of 0.91--0.99). The potential added value of high-risk screening was 4.6% (31/672). Patients with other mental disorders were at increased risk of having an unrecognized depression (PR 3.15, 95% CI 1.91--5.20). If patients with other mental disorders were routinely tested, then 42% more depressed patients (14/31) would be recognized. Conclusions. A broad case-finding approach including a short validation test can help GPs identify depressed patients, particularly by including patients with other mental disorders in this strategy. This exploratory study cannot support the screening strategy proposed by central health organizations. [ABSTRACT FROM AUTHOR]

Objective. General practitioner (GP) involvement may be instrumental in obtaining successful palliative cancer trajectories. The aim of the study was to examine associations between bereaved relatives’ evaluation of palliative cancer trajectories, place of death, and GP involvement. Design. Population-based, cross-sectional combined register and questionnaire study. Setting. The former Aarhus County, Denmark. Subjects. Questionnaire data on GPs’ palliative efforts and relatives’ evaluations of the palliative trajectories were obtained for 153 cases of deceased cancer patients. Main outcome measures. A successful palliative trajectory as evaluated retrospectively by the relatives. Results. Successful palliative trajectories were statistically significantly associated with home death (PR 1.48 (95% CI 1.04; 2.12)). No significant associations were identified between the evaluations of the palliative trajectory at home and GP involvement. “Relative living with patient” (PR 1.75 (95% CI: 0.87; 3.53)) and “GP having contact with relatives” (PR 1.69 (95% CI 0.55; 5.19)) were not significantly associated, but this may be due to the poor number of cases included in the final analysis. Conclusion. This study indicates that home death is positively associated with a higher likelihood that bereaved relatives will evaluate the palliative trajectory at home as successful. No specific GP services that were statistically significantly associated with higher satisfaction among relatives could be identified, but contact between GPs and relatives seems important and the impact needs further investigation. [ABSTRACT FROM AUTHOR]

Objective . To investigate GPs’ attitudes to and willingness to report and learn from adverse events and to study how a reporting system should function. Design . Survey. Setting . General practice in Denmark. Main outcome measures . GPs’ attitudes to exchange of experience with colleagues and others, and circumstances under which such exchange is accepted. Subjects . A structured questionnaire sent to 1198 GPs of whom 61% responded. Results . GPs had a positive attitude towards discussing adverse events in the clinic with colleagues and staff and in their continuing medical education groups. The GPs had a positive attitude to reporting adverse events to a database if the system granted legal and administrative immunity to reporters. The majority preferred a reporting system located at a research institute. Conclusion . GPs have a very positive attitude towards discussing and reporting adverse events. This project encourages further research and pilot projects testing concrete reporting systems. [ABSTRACT FROM AUTHOR]

Objective: A substantial proportion of patients found in primary care complain of physical symptoms not attributable to any known conventionally defined disorder, that is, medically unexplained or functional somatic symptoms. The objective of this paper is to outline the problems with the current classification and propose a classification more suitable for primary health care. Method: We refer to and discuss relevant literature including papers on our own research on the topic in the light of our experiences from major projects on somatizing patients in primary health care. Results: Functional somatic symptoms may impose severe suffering on the patient and are costly for society because of high health-care utilization, lost working years and social expenses. At present, studies on functional somatic symptoms and disorders and their treatment are hampered by lack of a valid and reliable diagnostic classification. The diagnostic categories of somatoform disorders are overlapping. Thus, the present situation is that patients with identical symptoms and clinical pictures may receive different diagnostic labels depending on the focus of interests of the assessing physician. A particular problem in primary care is that the somatoform diagnostic categories only include persistent cases and do not offer the opportunity for classification of the patients with short-symptom duration found in this setting. We present a framework for a new descriptive classification of functional somatic symptoms and unfounded illness worrying, and outline a new classification that covers the whole spectrum of severity seen in clinical practice. Conclusion: A precondition for an appropriate management of patients with functional somatic symptoms is a valid taxonomy common for all medical specialties facilitating cooperative care. Classification systems as outlined in this paper may be a candidate for such a system, but it should be subject to further evaluation in research. [ABSTRACT FROM AUTHOR]

Cross-sectional studies have suggested an association between rumination and subjective health. The aim of the present study was to investigate in a longitudinal design whether rumination was related to self-reported physical health. A total of 96 young (age range 20–35) and 110 elderly (age range 70–85) participants completed questionnaires measuring rumination, negative affect, life events, and self-reported physical health at baseline and at 1-year follow-up. Multiple linear regressions showed a significant association between self-reported physical health at time 1 only for the elderly and negative affect mediated the association. At follow-up, rumination was significantly associated with self-reported physical health only for the young and the association was only partly mediated by negative affect. In conclusion, rumination is associated with poorer self-reported physical health, but the association depends on the age of the individual as well as time span studied. [ABSTRACT FROM AUTHOR]

Abstract Objective To identify associations between various cultural and demographic factors and patients’ primary health care preferences. Search strategy Searches were performed in MEDLINE (1966–December 2000), PsycINFO (1977–May 2001) and Sociological Abstracts (1963–December 2000). Identified papers were checked for more papers. Inclusion criteria Studies with a focus on primary health care or health care in general, asking patients about preferences with regard to health care, reporting quantitative results and examining the relations between specific patient characteristics and patient preferences. Data extraction and synthesis Data were extracted from studies using a scoring form to register what methods were used, which patient characteristics were analysed and which patient characteristics significantly influenced patients’ preferences with regard to different aspects of health care (P < 0.05). Main results A total of 145 studies were included with 2276 comparisons between subgroups of patients. Of all the comparisons, 607 (27%) showed a significant association between patient characteristics and preferences with regard to primary health care. Age and economic status significantly related to patient preferences in 38 and 33% of the comparisons, respectively. Education, health status, family situation, sex, and utilization of health care related significantly to patient preferences in less than 25% of the comparisons. Conclusions This review of the literature showed patient characteristics to be an important determinant of preferences regarding many aspects of primary health care defined as general practice care or health care, in general. All of the patient characteristics examined here showed at least some significant associations with preferences for primary health care. [ABSTRACT FROM AUTHOR]

Scand J Prim Health Care 2003;21:00-00. ISSN 0281-3432 Objective - To investigate general practitioner (GP) assessment of a structured oncology information pack sent to GPs when newly referred patients had visited a department of oncology for the first time, and to compare their assessment of this material with their assessment of traditional information provided by the department. Design - Randomised, unblinded clinical trial. Setting - Patients and GPs in the catchment area of a regional oncology department. Subjects / patients - 248 cancer patients and their 199 GPs. Main outcome measures - GP assessment of the quality of the information material received for each patient. Results - 88.3% of the 248 questionnaires were returned. The structured information pack improved GP knowledge of oncology; GPs found themselves better equipped to support and counsel patients during the course of their illness, and practitioner satisfaction with the department rose. Conclusion - Intervention, though reasonably simple, inexpensive and not particularly time-consuming, improved cooperation between the specialist department and the GP. While this is a small step in the right direction, the need remains for new initiatives and further studies into how to improve cooperation and communication between the primary and secondary healthcare sectors. [ABSTRACT FROM AUTHOR]

Submission of samples from the home allows screening for Chlamydia trachomatis without preceding professional assessment of clinical risk factors. Therefore, a validation of self-reportable information for use as selective screening criteria is needed. We asked a total of 1175 women and 1033 men who participated in an in-home sampling screening study to provide information on behavior and sociodemographic characteristics. In a multivariate model, selective screening criteria were developed on the basis of information from a random part of the tested population (development group), and the validity was assessed for the remaining part of the tested population (validation group). To find all infections, 95% of the subjects had to be screened, and screening 63% of them would have detected 86% of infections. Low predictive values were found when selective screening criteria from other studies were assessed. Selective screening by means of in-home sampling strategies among men and women aged 21-23 years cannot be recommended in the area studied. [ABSTRACT FROM AUTHOR]

Objective: To investigate the diagnostic activity in general practice and the cumulative incidence of colorectal cancer (CRC) in individuals invited to the Danish national screening programme for CRC. Design: A historical population-based cohort study. Setting: The Danish CRC screening programme and general practice. Subjects: The 376,198 individuals invited to the Danish CRC screening programme from 1 March to 31 December 2014. Main outcome Measures: The diagnostic activity (consultations and haemoglobin measures) in general practice in the year preceding the screening invitation and the cumulated incidence of CRC in the year following the screening invitation. Results: Screening participants had significantly higher diagnostic activity than non-participants. Individuals with a positive faecal immunochemical test (FIT) had higher diagnostic activity compared to individuals with a negative FIT, and a small increase in the months leading up to the invitation. Individuals with a screen-detected CRC had lower diagnostic activity than individuals with no CRC. In total, 308 (25.3%) of CRCs diagnosed in the invited population were diagnosed outside the screening programme. Non-participants with CRC more often had low socio-economic status, high comorbidity and stage IV CRC than participants with CRC. Conclusions: There was a tendency that participants and those with a positive FIT had a higher diagnostic activity the year before the screening. This was not seen for those with CRC detected through screening. CRC must still be diagnosed in general practice in the invited population and non-participants are of special interest as they have higher risk of late stage CRC. Key Points: Current awareness:Individuals with colorectal cancer (CRC) in screening may be symptomatic and CRC may still occur outside screening in the invited population. Most important points:The majority of individuals with CRC in screening cannot be expected to be diagnosed on symptomatic presentation in general practice GPs have to be aware that CRC still occurs outside screening in the invited population Non-participants with CRC are often deprived and have late stage CRC [ABSTRACT FROM AUTHOR]

Background: Around 50% of individuals with colorectal cancer (CRC) initially present with non-alarm symptoms.Methods: We investigated the value of using the faecal immunochemical test (FIT) in the diagnostic process of CRC and other serious bowel disease in individuals presenting with non-alarm symptoms in general practice. The study was conducted in the Central Denmark Region from 1 September 2015 to 30 August 2016. The FIT was used as a rule-in test on patients aged ≥30 years with non-alarm symptoms of CRC. The cut-off value was set to 10 µg Hb/g faeces.Results: A total of 3462 valid FITs were performed. Of these, 540 (15.6%) were positive. Three months after FIT performance, 51 (PPV: 9.4% (95% CI: 7.0;11.9)) individuals with a positive FIT were diagnosed with CRC and 73 (PPV: 13.5% (95%CI: 10.6;16.4)) with other serious bowel disease. Of CRCs, 66.7% were diagnosed in UICC stage I & II and 19.6% in stage IV. The false negative rate for CRC was <0.1% for the initial 3 months after FIT performance.Conclusion: The FIT may be used as a supplementary diagnostic test in the diagnostic process of CRC and other serious bowel disease in individuals with non-alarm symptoms of CRC in general practice. [ABSTRACT FROM AUTHOR]

Background: The Relationship Scale Questionnaire (RSQ) is a widely-used measure of adult attachment, but whether the results obtained by the RSQ fit the attachment construct has only been examined to a limited extent. Objective: The objectives of this study were to investigate the psychometric properties of the Danish translation of the RSQ and to test whether the results are consistent with the hypothesized model of attachment. Methods: The study included two samples: 602 general practitioners and 611 cancer patients. The two samples were analyzed separately. Data quality was assessed by mean, median and missing values for each item, floor and ceiling effects, average inter-item correlations and Cronbach’s α for each subscale. Test-retest was assessed by intra-class correlations among 76 general practitioners. A confirmatory factor analysis was conducted to establish evidence of the four proposed subscales. Due to an inadequate fit of the model, data was randomly split into two equally sized subsamples and an exploratory factor analysis was conducted for all 30 items in the first subsample comprised of 286 cancer patients and 285 general practitioners. The EFA yielded a three-factor structure which was validated through a confirmatory factor analyses in a second subsample comprised of 278 cancer patients and 289 general practitioners. Results: The data quality of the RSQ was generally good, except low internal consistency and low to moderate test-retest reliability. The four subscales of the RSQ were not confirmed by the confirmatory factor analysis. An exploratory factor analysis suggested a three-factor solution for both general practitioners and patients, which accounted for 61.1% of the variance among general practitioners and 62.5% among patients. The new three-factor solution was verified in a confirmatory factor analyses. Conclusion: The proposed four-factor model of the RSQ could not be confirmed in this study. Similar challenges have been found by other studies validating the RSQ. An alternative three-factor structure was found for the RSQ. [ABSTRACT FROM AUTHOR]

Objective:The objective of this study is to identify points of agreement and disagreements among general practitioners (GPs) in Denmark concerning how the existential dimension is understood, and when and how it is integrated in the GP–patient encounter. Design:A qualitative methodology with semi-structured focus group interviews was employed. Setting:General practice setting in Denmark. Subjects:Thirty-one GPs from two Danish regions between 38 and 68 years of age participated in seven focus group interviews. Results:Although understood to involve broad life conditions such as present and future being and identity, connectedness to a society and to other people, the existential dimension was primarily reported integrated in connection with life-threatening diseases and death. Furthermore, integration of the existential dimension was characterized as unsystematic and intuitive. Communication about religious or spiritual questions was mostly avoided by GPs due to shyness and perceived lack of expertise. GPs also reported infrequent referrals of patients to chaplains. Conclusion:GPs integrate issues related to the existential dimension in implicit and non-standardized ways and are hindered by cultural barriers. As a way to enhance a practice culture in which GPs pay more explicit attention to the patients’ multidimensional concerns, opportunities for professional development could be offered (courses or seminars) that focus on mutual sharing of existential reflections, ideas and communication competencies. Key pointsAlthough integration of the existential dimension is recommended for patient care in general practice, little is known about GPs’ understanding and integration of this dimension in the GP–patient encounter.The existential dimension is understood to involve broad and universal life conditions having no explicit reference to spiritual or religious aspects.The integration of the existential dimension is delimited to patient cases where life-threatening diseases, life crises and unexplainable patient symptoms occur. Integration of the existential dimension happens in unsystematic and intuitive ways.Cultural barriers such as shyness and lack of existential self-awareness seem to hinder GPs in communicating about issues related to the existential dimension. Educational initiatives might be needed in order to lessen barriers and enhance a more natural integration of communication about existential issues. [ABSTRACT FROM PUBLISHER]

Background: Colorectal cancer is a common malignancy and a leading cause of cancer-related death. Half of patients with colorectal cancer initially present with non-specific or vague symptoms. In the need for a safe low-cost test, the immunochemical faecal occult blood test (iFOBT) may be part of the evaluation of such patients in primary care. Currently, Danish general practitioners have limited access to this test. The aim of this article is to describe a study that will assess the uptake and clinical use of iFOBT in general practice. Furthermore, it will investigate the diagnostic value and the clinical implications of using iFOBT in general practice on patients presenting with non-alarm symptoms of colorectal cancer.Methods/design: The study uses a cluster-randomised stepped-wedge design and is conducted in the Central Denmark Region among 836 GPs in 381 general practices. The municipalities of the Region and their appertaining general practitioners will be included sequentially in the study during the first 7 months of the 1-year study period. The following intervention has been developed for the study: a mandatory intervention providing all general practitioners with a starting package of 10 iFOBTs, a clinical instruction on iFOBT use in general practice and online information material from the date of inclusion, and an optional intervention consisting of a continuous medical education on colorectal cancer diagnostics and use of iFOBT.Discussion: This study is among the first and largest trials to investigate the diagnostic use and the clinical value of iFOBT on patients presenting with non-alarm symptoms of colorectal cancer. The findings will be of national and international importance for the future planning of colorectal cancer diagnostics, particularly for 'low-risk-but-not-no-risk' patients with non-alarm symptoms of colorectal cancer.Trial Registration: A Trial of the Implementation of iFOBT in General Practice NCT02308384 . Date of registration: 26 November 2014. [ABSTRACT FROM AUTHOR]

Background:Sexually transmitted infections (STIs) continue to be highly prevalent in young people. New understanding of sexual risk behaviour is essential for future preventive initiatives. Studies based on self-reported STI history indicate that gap length between sexual partnerships is an important determinant in STI transmission, but little is known about the impact of concurrent partnerships and short gap length. This study aimed to examine the significance of concurrent partnerships and short gap length between serially monogamous partnerships inChlamydia trachomatis-infected individuals compared to the general population.Methods:A Danish cross-sectional study was conducted among individuals aged 15–29 years with a verifiedC. trachomatisinfection and a sample of the background population. Participants answered a web-based questionnaire on sexual behaviour. Associations were identified in multivariate analyses.Results:In total, 36% of the included young adults reported that they had two or more partners within the last year. Concurrent partnerships were frequent (46%), and the gap length between serially monogamous partnerships tended to be short (median gap length, 64 days, interquartile interval (IQI) = 31, 122). A strong association was found between concurrent partnerships (odds ratio (OR) = 12.5, 95% confidence interval (CI) = 7.7–20.4), short gap length between serially monogamous partnerships (OR = 10.0, 95% CI = 5.7–17.4) and having a verifiedC. trachomatisinfection.Conclusions: C. trachomatisinfection was strongly associated with concurrent partnerships or short gap length between serially monogamous partnerships. These findings have considerable implications for public health policy. Both types of risk factors should be considered in future preventive interventions aiming to reduce the spread ofC. trachomatisinfections. [ABSTRACT FROM AUTHOR]

Objectives Sexually transmitted infections and unwanted pregnancies occur at high rates among youth. Understanding sexual behaviour is essential for planning and implementing future effective preventive interventions. The present study examines the sexual behaviour in the general Danish population aged 15-29 years using the core indicators recommended by the European Centre for Disease Prevention and Control. Methods A nationwide cross-sectional study was conducted in Denmark among a random sample of 20 000 men and women in 2012. Respondents completed a web-based sexual behaviour questionnaire and data were linked to a nationally held demographic database. Core indicators for sexual behaviour frequency stratified by gender are presented as unweighted and weighted data after consideration of sociodemographic differences between respondents and non-respondents. Results Response rate was 20.4%. Condoms were used at sexual debut by 69.9% of women and 62.3% of men, while 14.3% of women and 15.1% of men used no contraceptives at sexual debut. Half of the respondents used condom alone at the latest sexual encounter with a steady partner (women 51.8%, men 55.2%), while 10% used no contraceptives. Having a sexual encounter with a casual partner decreased the likelihood of using condoms (women 43.7%, men 49.5%) and increased the likelihood of using no contraceptives (women 14.8%, men 20.9%). Data on sexual behaviour characteristics showed only minor changes when weighted for non-response. Conclusions The findings call for interventions addressing the use of appropriate contraception at sexual debut and at last sexual encounter; this seems particularly important when the sexual partner is a casual partner. [ABSTRACT FROM AUTHOR]

Objective. Little is known about the prognosis of patients with chronic disease who contact the out-of-hours (OOH) service in primary care. The characteristics of contacts with the Danish out-of-hours service and daytime general practice, hospitalization, and death were studied during a 30-day follow-up period in patients with chronic heart diseases. Design. Cohort study. Setting and subjects. The study was based on data from 11 897 adults aged 18 + years from a Danish survey of OOH contacts, including information on consultation type. Reason for encounter (RFE) was categorized by OOH GPs at triage as either 'exacerbation' or 'new health problem'. Registry data were used to identify eligible patients, and the cohort was followed for 30 days after OOH contact through nationwide registries on healthcare use and mortality. Main outcome measures. The 30-day prognosis of chronic-disease patients after OOH contact. Results. Included patients with chronic disease had a higher risk of new OOH contact, daytime GP contact, and hospitalization than other patients during the 30-day follow-up period. OOH use was particularly high among patients with severe mental illness. A strong association was seen between chronic disease and risk of dying during follow-up. Conclusion. Patients with chronic disease used both daytime general practice and the out-of-hours service more often than others during the 30-day follow-up period; they were more often hospitalized and had higher risk of dying. The findings call for a proactive approach to future preventive day care and closer follow-up of this group, especially patients with psychiatric disease. [ABSTRACT FROM AUTHOR]

Presents information on a study conducted to assess the workability of home sampling for the screening of Chlamydia trachomatis, aimed at improving screening rates. Effects of Chlamdia trachomatis; Benefits of screening; Methods of the study; Results of the study.

Background: Many countries have implemented standardised cancer patient pathways (CPPs) to ensure fast diagnosis of patients suspected of having cancer. Yet, studies are sparse on the impact of such CPPs, and few have distinguished between referral routes. For incident cancer patients, we aimed to determine how often GPs suspected cancer at the time of first presentation of symptoms in general practice and to describe the routes of referral for further investigation. In addition, we aimed to analyse if the GP's suspicion of cancer could predict the choice of referral to a CPP. Finally, we aimed to analyse associations between not only cancer suspicion and time to cancer diagnosis, but also between choice of referral route and time to cancer diagnosis.Methods: We conducted a population-based, cross-sectional study of incident cancer patients in Denmark who had attended general practice prior to their diagnosis of cancer. Data were collected from GP questionnaires and national registers. We estimated the patients' chance of being referred to a CPP (prevalence ratio (PR)) using Poisson regression. Associations between the GP's symptom interpretation, use of CPP and time to diagnosis were estimated using quantile regression.Results: 5,581 questionnaires were returned (response rate: 73.8%). A GP was involved in diagnosing the cancer in 4,101 (73.5%) cases (3,823 cases analysed). In 48.2% of these cases, the GP interpreted the patient's symptoms as 'alarm' symptoms suggestive of cancer. The GP used CPPs in 1,426 (37.3%) cases. Patients, who had symptoms interpreted as 'vague' had a lower chance of being referred to a CPP than when interpreted as 'alarm' symptoms (PR = 0.53 (95%CI: 0.48;0.60)). Patients with 'vague' symptoms had a 34 (95% CI: 28;41) days longer median time to diagnosis than patients with 'alarm' symptoms.Conclusions: GPs suspect cancer more often than they initiate a CPP, and patients were less likely to be referred to a CPP when their symptoms were not interpreted as alarm symptoms of cancer. The GP's choice of referral route was a strong predictor of the duration of the diagnostic interval, but the GP's symptom interpretation was approximately twice as strong an indicator of a longer diagnostic interval. [ABSTRACT FROM AUTHOR]