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BACKGROUND: The choice of antidepressants for initial pharmacological treatment of depression in older adults and associated patients' characteristics are understudied. We aimed to describe the first selected antidepressant (first-choice) for depression in older adults (≥65 years) and whether patients' sociodemographic and clinical characteristics influence selecting an alternative first-choice (any other antidepressant than the nationally recommended first-choice sertraline) in Denmark.METHODS: Register-based cross-sectional study including all older adults who redeemed their first antidepressant prescription for depression at community pharmacies in Denmark in 2015-2019. We analyzed the effect of patients' characteristics on the first-choice antidepressant selection using multinomial logistic regression.RESULTS: Among 34,337 older adults with a first antidepressant-prescription, over two-thirds filled alternative first-choice antidepressants than sertraline (28.9 %): escitalopram or citalopram (30.3 %) or mirtazapine (34.4 %). Socially disadvantaged older adults (e.g., with short educational attainment, being single, or of non-western ethnicity) and clinically vulnerable older adults (e.g., having somatic diagnoses and hospital contacts) were more likely to use alternative first-choice antidepressants.LIMITATIONS: Information on prescribers and in-hospital medications was not included in this study.CONCLUSIONS: Further investigation of the first antidepressant selection and its impact on depression treatment outcomes in older adults is necessary. Moreover, for older patients, national guidelines on depression treatment should be more specific.ARTICLE SUMMARY: Antidepressant selection for initial pharmacological treatment of depression in older adults can be difficult due to comorbidity, polypharmacy, and age-related changes in pharmacokinetics and pharmacodynamics. Real-world evidence/knowledge on first-choice antidepressant selection and associated user characteristics are rare. This Danish register-based cross-sectional study found over two-thirds of older adults filled alternative antidepressants (primarily escitalopram/citalopram or mirtazapine) than nationally recommended first-choice sertraline for depression treatment and identified wide-ranging sociodemographic and clinical factors influencing the first antidepressant selection.

Background eHealth provides a viable option to facilitate type-2 diabetes mellitus self-management and adherence. To this end, a web-based computer-tailored eHealth programme, My Diabetes Profile (MDP), was developed and implemented in Dutch diabetes care. To fully utilize the potential of eHealth, the reach of effective programmes like MDP should be maximized. Therefore, it is vital to explore perceptions of general practitioners (GPs) regarding eHealth and factors that influence GPs’ decision to adopt eHealth programmes. Objective To shed light on Dutch GPs’ perceptions towards eHealth in general and specifically, the adoption of MDP. Methods Interviews were conducted among a heterogeneous sample of 16 Dutch GPs. The interview guide, based on the Diffusion of Innovations Theory, addressed perceptions about eHealth in general, characteristics of MDP, organizational characteristics, and external influences on adoption. Audio-recordings were transcribed and analysed using deductive coding in NVivo. Results Nearly all GPs used some form of eHealth and listed many benefits and few drawbacks about eHealth. Sometimes, GPs were unaware of what eHealth encompassed; programmes resembling MDP were not mentioned. COVID-19 immensely increased eHealth uptake, especially for remote communication. Regarding MDP, the organizational and external influences on adoption were limited, while characteristics of the innovation were deemed more important. GPs expressed benefits of MDP (e.g. uncomplex, user-friendly, tailored) other than attributed to eHealth in general and fewer drawbacks. Conclusion While GPs’ opinions about eHealth and MDP were positive, the concept of MDP was relatively unfamiliar. Future research should focus on targeting GPs’ awareness of eHealth possibilities.

Introduction: As the therapeutic options in the management of type 2 diabetes increase, there is an increase confusion among health care professionals, thus leading to the phenomenon of therapeutic inertia. This is the failure to escalate or de-escalate treatment when the clinical need for this is required. It has been studied extensively in various settings, however, it has never been reported in any studies focusing solely on primary care physicians with an interest in diabetes. This group is increasingly becoming the focus of managing complex diabetes care in the community, albeit with the support from specialists. Methods: In this retrospective audit, we assessed the prevalence of the phenomenon of therapeutic inertia amongst primary care physicians with an interest in diabetes in UK. We also assessed the predictive abilities of various patient level characteristics on therapeutic inertia amongst this group of clinicians. Results: Out of the 240 patients reported on, therapeutic inertia was judged to have occurred in 53 (22.1%) of patients. The full model containing all the selected variables was not statistically significant, p = 0.59. So the model was not able to distinguish between situations in which therapeutic inertia occurred and when it did not occur. None of the patient level characteristics on its own was predictive of therapeutic inertia. Conclusion: Therapeutic inertia was present only in about a fifth of patient patients with diabetes being managed by primary care physicians with an interest in diabetes.

Objective: To evaluate a newly developed blended learning programme for general practitioners (GPs) and nurses in supporting shared decision making (SDM) about palliative cancer treatment in a simulated setting. Methods: In a pre-posttest study, healthcare professionals (HCPs) participated in the blended learning (i.e. e-learning and (online) training session). HCPs filled out surveys (T0 (baseline), T1 (after e-learning) and T2 (after full blended learning)) and engaged in simulated consultations at T0 and T2. The primary outcome was observed SDM support (Triple-S; DSAT-10 for validation). Secondary outcomes included satisfaction, knowledge about and attitude towards SDM support. Repeated measures General Linear Models were conducted. Results: 33 HCPs (17 GPs and 16 nurses) participated. SDM support significantly improved after training (Triple-S; medium effect). Observers’ overall rating of SDM support (medium effect) as well as HCPs’ knowledge (large effect) and beliefs about their capabilities (medium effect) improved after training. There was no difference in decision support skills (DSAT-10), HCPs’ other clinical behavioural intentions and satisfaction. HCPs evaluated the training positively. Conclusion: Blended learning for HCPs on supporting SDM in palliative cancer care improved their skills, knowledge and confidence in simulated consultations. Practice implications: These first findings are promising for evaluating interprofessional SDM in clinical practice.

The clinical working hours of early-career general practitioners (GPs) are an important factor in Australian GP workforce planning. This study aimed to establish the prevalence and associations of early-career GPs working full time (nine or more sessions per week) in clinical practice.This was a cross-sectional questionnaire-based study of alumni (from six months to two years post-Fellowship) from three regional training organisations. Multivariable logistic regression was used to establish factors associated with alumni working full time.Of 356 currently practising early-career alumni participants, 30% worked full time. Factors associated with working full time included spouse/partner employment and family structure and any examination failure. Factors associated with working less than full time included female gender, being an Australian medical graduate, provision of other medical work and having taken additional leave during training.A high proportion of early-career GPs working part time in clinical general practice has implications for workplace planning, as GPs seek workload diversity and flexibility across their career stages.

To explore the acceptability, barriers and enablers of NICE guidelines for osteoarthritis in the Scottish primary care setting using the Joint Implementation of Guidelines for Osteoarthritis in Western Europe (JIGSAW-E) model and investigate the role of Advanced Physiotherapy Practitioners (APPs) in providing evidence-based care.A qualitative case study comprised of semi-structured interviews followed by a workshop with participants.10 Scottish primary care practices.Six general practitioners (GPs) and eight APPs were interviewed. Twenty-three practitioners attended the workshop including 22 physiotherapists and one GP.While both GPs and APPs recognised the need to improve and standardise osteoarthritis care delivery, this study found that APPs were better situated to implement the evidence-based model. Barriers to implementation included lack of time for training, limited appointment time for GPs to consult and discuss medication use with patients, limitation of disease specific guidelines for patients with complex multimorbidity, and system-based barriers such as electronic data collection and high staff turnover. The key enabler was practitioners' motivation to provide optimal, standardised quality care for osteoarthritis. To increase acceptance, ownership and usability for both practitioners and patients, the JIGSAW-E model materials required adaptation to the local context.This study provides evidence that the JIGSAW-E model is acceptable in Scottish primary care. Furthermore, the evolving roles of GPs and APPs within multidisciplinary primary care teams provides a platform to implement the JIGSAW-E model, where APPs are well placed to provide leadership and training in the delivery of evidence-based care for osteoarthritis.

Acute rheumatic fever (ARF) and rheumatic heart disease (RHD) disproportionately affect Aboriginal and Torres Strait Islander people in Australia, with devastating impacts on morbidity, mortality and community wellbeing. Research suggests that general practitioners and primary care staff perceive insurmountable barriers to improving clinical outcomes, including the need for systemic change outside their scope of practice.The aim of this article is to identify constructive, micro-level strategies that primary healthcare clinicians can consider, adopt and sustainably use to improve care for people with ARF and RHD in their routine clinical practice.Through skilled clinical care, reflection and culturally safe practices, individual primary healthcare clinicians have substantial capacity to improve care experiences and outcomes for Aboriginal and Torres Strait Islander people and communities affected by ARF and RHD.

This study aimed to explore factors across the environment, organisation and care team levels of the health care system that influence the engagement of primary healthcare workers (PHCWs) in Australia's national cancer screening programs.A cross-sectional qualitative study involving semi-structured interviews with PHCWs - general practitioners (n=10), practices nurses (n=10), and practice managers (n=10) from settings across Australia. Transcripts were analysed using the Framework Method.Two environment-level factors were found to influence several organisation and care team level factors. Firstly, the financial structure of primary health care, impacting on practitioner: time, practice culture, screening knowledge and opportunistic conversations. Secondly, the structure of screening programs had flow-on effects for: access to patient screening records, recall and reminder systems, and sense of program ownership.Encouraging more effective PHCW engagement in the screening programs requires the consideration and mitigation of overarching financial and structural barriers. Up-to-date and easy-to-use recall and reminder systems, whole-of-practice approaches which optimise the role of each PHCW and the identification of a 'champion' to drive implementation should be considered.This study offers insights into what elements practice and practitioner targeted initiatives in Australia should incorporate, potentially leading to improved engagement of PHCWs and increased cancer screening participation rates.

The COVID-19 pandemic was a catalyst for the introduction of additional telehealth funding (telehealth item numbers) for general practitioner (GP) consultations through the Medicare Benefits Schedule (MBS) in Australia. This study evaluated the impact of telehealth funding on costs to the MBS for GP consultations from January 2017 to December 2021. An interrupted time series analysis assessed MBS costs (initial and monthly growth) for GP consultations (in-person, videoconference, telephone) before and after additional telehealth item numbers were introduced. From January 2017 to February 2020, total MBS costs for GP consultations were, on average, $545 million per month compared to $592 million per month from March 2020 to December 2021. There was an initial cost increase of approximately $39 million in the first month after additional telehealth funding was introduced ( p = 0.0001). Afterwards, there was no significant change in monthly costs ( p = 0.539). The introduction of additional MBS telehealth funding increased overall MBS costs for GP consultations. This increased cost for GP telehealth services could save costs to society if it translates into improved continuity of care, decreased hospitalisations, reduced productivity losses and improved patient outcomes. Future policy reform should incorporate a cost–benefit analysis to determine if increased MBS costs for GP consultations are a good investment.

Locus of control (LoC) is a social cognition, that relates to the level of self-control that people have over their personal environment that influences their life. In this context, LoC is frequently associated with work-related behavioral outcomes, ranging from job attitudes, career behaviors, stress, and burnout.To investigate the association between LoC, and work-related behavioral factors, socio-cultural factors, and personal factors among Australian General Practitioners (GPs).This study utilized data from the 2010 Medicine in Australia: Balancing Employment and Life (MABEL) survey of doctors. Locus of control (LoC) was measured by a 7-point Likert scale based on Pearlin-Schooler Mastery/Self-efficacy 7-item Scale. Higher score indicated lower internal LoC. Multivariate linear regression model was performed to determine the independent predictors of LoC.Of 3,664 GP participants, LoC did not differ by gender. Poor/fair self-rated health, working in urban location, running a stressful practice, poor balance of professional and personal commitments, poor support network, financial circumstances after retirement, and perception of unrealistic expectation by patients were significant predictors for a lower Internal LoC in a multivariate linear regression model. Adjusted RLoC of Australian GPs is negatively affected by poor work-life balance, inadequate support, and unrealistic patient expectation. These work-place specific factors could be targeted by interventions to improve GPs wellbeing.

Domestic and family violence (DFV) is often difficult to recognise despite its high prevalence in the community. General practitioners require specialised skills to elicit a history of DFV, remain aware of the complex patterns of DFV, respond to potential risk and maintain engagement as part of a team involved in ongoing care.The aim of this article is to outline the principles of recognising, responding, referring, recording and reflecting on care for those who may be experiencing DFV.GPs have unique opportunities to identify, assess and respond to DFV because of the trusting therapeutic relationships they develop with patients. Managing DFV requires a safe place to disclose, skilled risk assessment, careful documentation, safety planning and ongoing therapeutic processes that soothe, validate, empower and connect to wider social supports. Trauma-informed general practice is a key element of integrated systems responses to DFV in our community.

Background General practitioners (GPs) have recognized the presence of gut feelings in their diagnostic process. However, little is known about the frequency or determinants of gut feelings or the diagnostic value of gut feelings for cancer and other serious diseases. Objective To assess the prevalence of gut feelings in general practice, examine their determinants and impact on patient management, and measure their diagnostic value for cancer and other serious diseases. Design This prospective observational study was performed using the Gut Feelings Questionnaire (GFQ). Participants Participants included 155 GPs and 1487 of their patients, from four Spanish provinces. Main Measures Sociodemographic data from patients and GPs; the reasoning style of GPs; the characteristics of the consultation; the presence and kind of gut feeling; the patient’s subsequent contacts with the health system; and new cancer and serious disease diagnoses reported at 2 and 6 months post-consultation. Key Results GPs experienced a gut feeling during 97% of the consultations: a sense of reassurance in 75% of consultations and a sense of alarm in 22% of consultations. A sense of alarm was felt at higher frequency given an older patient, the presence of at least one cancer-associated symptom, or a non-urban setting. GPs took diagnostic action more frequently after a sense of alarm. After 2 months, the sense of alarm had a sensitivity of 59% for cancer and other serious diseases (95% CI 47–71), a specificity of 79% (95% CI 77–82), a positive predictive value of 12% (95% CI 9–16), and a negative predictive value of 98% (95% CI 86–98). Conclusions Gut feelings are consistently present in primary care medicine, and they play a substantial role in a GP’s clinical reasoning and timely diagnosis of serious disease. The sense of alarm must be taken seriously and used to support diagnostic evaluation in patients with a new reason for encounter.

We explored whether having a variety of work roles and extra support during the first 2 years after qualifying would retain general practitioners (GPs) in London. Newly qualified GPs were offered a Fellowship comprising permanent salaried positions, part-time (portfolio) roles outside general practice and peer support for 1-2 years.We surveyed newly qualified GPs taking part in the Fellowship near the beginning of their Fellowship (91) and again after 8-10 months (93). We interviewed 34 newly qualified GPs taking part in the Fellowship and 20 who were not. We surveyed and interviewed representatives from employing practices (171), organisations hosting portfolio roles (20), those facilitating the Fellowship (10) and other stakeholders (43).Over a 2.5-year period, employers recruited and retained 425 newly qualified GPs to salaried posts using the Fellowship. Eighty-eight per cent of the newly qualified GPs taking part said they intended to stay working in local practices. They said that undertaking a portfolio role helped them feel valued, had more variety and integration with the wider professional community. Those with two or more portfolio sessions per week were the most positive.Portfolio roles and peer support may increase newly qualified GPs intention to stay working in salaried posts, however it is too early to say whether these intentions will translate into behaviour.Portfolio roles and monthly peer support helped newly qualified GPs feel supported and valued, which may influence their intention to stay working in general practice locally.

This survey aimed to determine the consensus amongst endodontic specialists in North America and practitioners worldwide to diagnose the pulp and periapical conditions of selected case scenarios encountered in daily practice using the American Association of Endodontists (AAE) pulpal and periapical diagnostic terms. Secondly, an attempt was made to suggest modifications in terms accordingly.A survey designed by two endodontic educators was sent to endodontists in North America and clinicians worldwide through an electronic database. The survey included socio-demographic questions followed by the clinical and radiographic presentations of four clinical scenarios. The participants were then requested to provide the pulpal and the periapical diagnosis of 11 teeth presented in these cases (22 answers in total/participant) using the AAE diagnostic terminology. Cases were designed to include 12 pulpal/periapical conditions as control (non-controversial conditions) and ten so-called controversial conditions. A proportion threshold of 10% was required for any diagnostic term to be reported in this survey. The participants were divided into two groups based on the region of endodontic training and/or practice to 'Specialised North American' or 'International Practitioners,' and their results were statistically compared using chi-squared tests (p .05).The survey included 421 participants. 74% were endodontists, and 46.1% were amongst the 'Specialised North American' group and 53.9% amongst the 'International Practitioners'. Eleven of 12 control conditions had an almost complete agreement amongst the participants regarding the diagnostic terms selected, ranging between 82% and 96%, with no other diagnostic term exceeding the 10% threshold. All the controversial conditions yielded more than one diagnostic term selected/condition that exceeded the 10% threshold for groups ('Specialised North American' and 'International practitioners'). There were no differences in the diagnostic terms selected between the two groups; however, the weight for each term varied between the groups in some cases.There is a lack of consensus amongst clinicians, regardless of their training and region of practice, on the appropriate diagnostic terms to be used in particular clinical conditions. More diagnostic terms and modifications in the current terms may be required to establish a more reliable diagnostic terminology.

As yet, the benefit of the Fit Note has not been convincingly demonstrated, although a limited body of research suggests that provision of fitness for work advice and sickness absence certification may be improved with training and case-specific direction. The role of certifying sickness absence in the UK has traditionally been conducted by General Practitioners, but this role has now been extended to First Contact Practitioner (FCP) Physiotherapists in primary care. Therefore, FCPs may offer an ideal solution to the current challenges faced within primary care for those with a musculoskeletal (MSK) condition at risk of sickness absence from their work environment.The main aim of this study was to identify the challenges and key learning and development needs of FCPs in response to providing Occupational Health (OH) information in the form of fitness for work advice and sickness certification for patients with MSK conditions within primary care.Consensus was generated using an online modified version of the Nominal Group Technique (NGT) method. A priori consensus threshold of 60% was used in the voting stage.NGT participants included clinicians with experience in managing MSK conditions in primary care within the FCP model of care. All participants generated, voted, and ranked the items using an online platform.This research adds new evidence regarding the challenges and learning and development needs identified by a group of FCPs working within primary care in consideration of sickness absence certification and fitness for work advice. The items highlighted provide evidence to complement Health Education England's FCP A Roadmap to Practice educational pathway and informs on professional development needs in this area.

General practitioners (GPs) play a central role in healthcare, serving as the first point of contact, making appropriate referrals and coordinating care for chronic conditions such as heart failure (HF). We sought to determine healthcare use by people with HF in primary care.In this Study of Heart failure in the Australian Primary carE setting (SHAPE), we analysed records of 1.93 million adult patients who attended a total of 43 practices between 1 July 2013 and 30 June 2018. We identified and examined the data of 20,219 patients with HF to describe the frequency of visits and use of Medicare Benefits Schedule items.Patients with HF saw GPs 14.4 times per annum on average; 59.5% had a General Practice Management Plan (GPMP), 2.9% of GPMPs were reviewed annually or more frequently, and 46.8% of patients had been referred to a cardiologist. A total of 3761 had coexisting anxiety or depression, and of these 37.1% had a mental health plan.Patients with HF visit their GP frequently, with many not reaching guideline therapy nor referred to cardiologists. Low use of care planning and reviews presents an opportunity for GPs to improve care.

The literature around co-payment shows evidence of increasing consumption following reduced co-payment. We apply difference-in-difference methods to assess the effect of abolishing the co-payment on psychologist treatment of anxiety and depression in 18 to 21-year olds. We apply nationwide individual level data with individuals close to this age interval as control group. The population amounts to approximately 1.2 million individuals and a total of 51 million patient months of observations. We show that after removing co-payment, the use of psychologist treatment almost doubles. We find that this increase involves moderately positive spill over effects on outpatient psychiatric care and on prescriptions of antidepressants. In the heterogeneity analysis we find evidence of higher effects on adolescents from families with lower income, indicating that reduced co-payments may increase equality in access. We also see that effects are higher for individuals listed with general practitioners (GPs) with a reluctant referral style; indicating that these GPs' behavior is affected by patient co-payment rates. Interestingly, we find evidence of significant reductions in suicide attempts - primarily among high-income women and low-income men. This indicates that better access to mental health care for adolescents may have a positive impact on their mental health and well-being.

Objective To examine the impact of telehealth policy changes on general practitioner (GP) consultation activity in Australia, during the coronavirus disease 2019 (COVID-19) pandemic, from January 2019 to December 2021. Methods An interrupted time-series analysis was conducted to analyse the impact of two major policy changes, introduced through the Medicare Benefits Schedule (MBS), on GP consultation (in-person, videoconference, telephone) activity. The first policy change was the introduction of additional COVID-19 telehealth funding through the MBS on 30 March 2020. The second policy change was the limitation on telephone consultation length to under 20 min on 1 July 2021. The rate of GP telehealth provision and activity was compared between pre-and post-intervention periods, separated by these MBS policy changes. Results After the first policy change, there was a significant increase in telehealth provision, with a simultaneous decrease in in-person consultations (P

Background Accelerated by the coronavirus disease 2019 (COVID-19) pandemic, Australia has shifted towards greater use of telehealth to deliver care for rural and remote communities. This policy direction might risk a shift away from the traditional model of informed person-centred care built around care relationships to a technology-mediated health transaction. Potential opportunity costs of widespread telehealth services on the quality of care for rural and remote communities remain understudied. Methods A qualitative study was conducted in three local health districts of rural New South Wales, Australia. Data were collected through in-depth interviews. A total of 13 participants was interviewed. Data were analysed using thematic analysis. Results Patient participants perceived telehealth as an alternative when specialist care was limited or absent. Both patients and clinicians perceived that the deeper caring relationship, enabled through face-to-face interactions, could not be achieved through telehealth services alone, and that telehealth services are often superficial and fragmented in nature. Patients in this study contended that virtual consultations can be distant and lacking in personal touch, and risk losing sight of social circumstances related to patients’ health, thereby affecting the trust placed in healthcare systems. Conclusions Simply replacing face-to-face interactions with telehealth services has the potential to reduce trust, continuity of care, and effectiveness of rural health services. Telehealth must be used to assist local clinicians in providing the best possible care to rural and remote patients within an integrated service delivery model across diverse rural contexts in Australia.

Background: Telemedicine was implemented in Brazil as a way to support primary health care (PHC). Orthopedic complaints are common in PHC, and, because musculoskeletal diseases are the most frequent causes of chronic pain, it is important to explore knowledge gaps of PHC as well as to understand the teleconsultations' impact on reducing referrals to secondary care. Materials and Methods: Observational, retrospective study that analyzed consecutive orthopedic asynchronous teleconsultations from the Telehealth Network of Minas Gerais, a large-scale public telehealth service, performed from September 17, 2013 to June 18, 2020. Teleconsultations were analyzed based on the type of query. Results: Throughout the study, 1,174 teleconsultations from 254 municipalities were analyzed. Most requests for teleconsultations were from nurses (37.8%) and physicians (48.7%). In 58.3%, challenges could be solved by a general practitioner, meanwhile 38.4% needed referral to an orthopedic specialist. Most queries related to a specific case (assistencial teleconsultation, 66.0%), and the others were classified as educational (34%). With regard to the motivation for the assistencial teleconsultations, 72% approached treatment options, 49.5% surrounded possible diagnosis, and 20.1% discussed patient's rehabilitation. In addition, 95.5% of requests could be solved by teleconsultation, without the need for referral to in-person consultation with the specialist. Conclusions: Teleconsultations can help investigate the most frequent queries in PHC. Most of them were solved without the need for referral, showing the potential of teleconsultations in daily practice as a way to manage patients and guarantee better access to first-rate health care. As for the public health system, teleconsultations represent a way to overcome the distance barrier to health care access.

Increasing numbers of women are experiencing age-related infertility. General practitioners (GPs) are ideally placed to provide initial age-related fertility counselling and fertility specialist referral. The aim of this pilot study was to document doctors' knowledge, attitudes and practices relating to proactive fertility counselling, ovarian reserve testing and oocyte cryopreservation.Seventy-two GPs and general practice registrars were recruited through social media and completed an online survey.Knowledge gaps were shown relating to age-related female fertility decline, ovarian reserve testing and elective oocyte cryopreservation. GPs were more likely to discuss reproductive planning with women aged 35-44 years, compared with younger women. The majority of participants agreed fertility counselling should be provided by GPs; however, barriers identified include limited time, knowledge and concern for causing patient distress.Providing GPs with fertility-focused education and resources may enable sensitive, accurate and timely counselling to improve reproductive outcomes.

Women living in rural Australia have worse survival rates for breast cancer compared with their urban counterparts. Identifying factors that contribute to delayed presentation could help to reduce this disparity. This study aimed to identify and explore the differences in help-seeking behaviours between rural and urban women with non-screen-detected breast cancer.We conducted a qualitative study consisting of semi-structured interviews with 20 women from New South Wales with non-screen detected breast cancer that was diagnosed within the past five years.There was little difference between rural and urban groups in terms of symptom appraisal and monitoring, social interactions, and personal and environmental factors. However, the presence of stoicism as a barrier was unique to rural women. Rural women also faced significant barriers in accessing general practice services that pertained to availability, cost and distance.GPs play a critical role in facilitating earlier presentation, and more research into rural stoicism is required. Continued investment in the rural primary care workforce will be key to improving access issues.

To assess the effectiveness of a brief educational intervention on prescribing first-line antibiotics in acute cystitis.This quasi-experimental before-after study was conducted over a period of eight months. We collected prescribing data related to urinary tract infections four months before the educational intervention and four months after it. Aggregate data on office visits, diagnoses, and issued prescriptions were collected from each practice's electronic medical records based on monthly reports.Overall, 3581 prescriptions were issued: 1717 before and 1864 after the intervention. The total number of prescriptions increased by 8.5%. The use of first-line antibiotics increased by 21.2%, the use of fluoroquinolones decreased by 6.6%, while the use of beta-lactams remained unchanged. After the intervention, nitrofurantoin was the most prescribed first-line antibiotic. The proportion of women who were prescribed first-line antibiotic did not reach the acceptable range (80%-100%) according to the European Surveillance of Antimicrobial Consumption quality indicators. The proportion of fluoroquinolones (17.9%) use was well above the acceptable range (0%-5%).A brief educational intervention proved to be a useful method in adopting better prescribing habits. Of particular importance is the considerable increase in the use of nitrofurantoin due to its reliable efficacy against multidrug-resistant urinary pathogens.

BackgroundFollow-up for cancer typically occurs in secondary care, and improved survival has increased demands on these services. Other care models may alleviate this burden, such as moving (parts of) follow-up care for curatively treated patients from secondary to primary care (care substitution).AimTo explore the opinions of GPs regarding the potential benefits, barriers, and requirements of care substitution for breast and colorectal cancer.Design and settingA qualitative study of the opinions of purposively sampled GPs in Dutch primary care.MethodFocus group sessions and individual semi-structured interviews were recorded and transcribed verbatim. Data were analysed by two independent researchers using thematic analysis.ResultsTwo focus groups (n = 14) were conducted followed by nine individual interviews. Three main themes were identified: perceived benefits, perceived barriers, and perceived requirements. Perceived benefits included better accessibility and continuity of care, and care closer to patients’ homes. Uncertainty about cancer-related competences and practical objections were perceived as barriers. Requirements included close specialist collaboration, support from patients for this change, and stepwise implementation to avoid loss of existing care quality.ConclusionMost GPs reported that they were not in favour of complete care substitution, but that primary care could have greater formal involvement in oncological follow-up if there is close collaboration with secondary care (that is, shared care), support from patients, sufficient resource allocation, stepwise implementation with clear guidelines, and monitoring of quality. Clear and broadly supported protocols need to be developed and tested before implementing follow-up in primary care.

Introduction General practitioners (GP) are key in the delivery of primary palliative care in the community, so appropriate knowledge and skills are needed. Previous research has suggested there may be gaps in training opportunities. Aims To develop and evaluate a Master Class series presented by a hospice palliative care service to their local GPs and other health-care professionals. A secondary aim was to measure the lasting impacts of the educational intervention. Methods The study setting was the Canterbury region of Aotearoa New Zealand (NZ). GPs and other health-care professionals were surveyed using a research team-designed questionnaire rating self confidence in the nominated learning objectives before and after the Master Classes. The participants were also asked to self-rate the application of the knowledge to their practice 3 years after the Master Class sessions were attended. Results There were 56 sets of questionnaires completed. The participants tended to be experienced female GPs with a range of palliative care patients in their practice. There was significant improvement in most learning outcomes across the Master Classes series. The attendees reported the Master Classes were relevant and clear, with useful resources. The improvements in the learning outcomes were largely sustained over 3 years. Discussion The provision of palliative care education that aligns with clinical practice improves knowledge, skills and confidence in GPs who provide most of the end-of-life care in New Zealand.

Contains fulltext : 252138.pdf (Publisher’s version ) (Open Access) BACKGROUND: Patients with severe mental illness (SMI) or receiving treatment with antipsychotics (APs) have an increased risk of cardiovascular disease. Cardiovascular risk management (CVRM) increasingly depends on general practitioners (GPs) because of the shift of mental healthcare from secondary to primary care and the surge of off-label AP prescriptions. Nevertheless, the uptake of patients with SMI/APs in CVRM programmes in Dutch primary care is low. OBJECTIVES: To explore which barriers and facilitators GPs foresee when including and treating patients with SMI or using APs in an existing CVRM programme. METHODS: In 2019, we conducted a qualitative study among 13 Dutch GPs. During individual in-depth, semi-structured interviews a computer-generated list of eligible patients who lacked annual cardiovascular risk (CVR) screening guided the interview. Data was analysed thematically. RESULTS: The main barriers identified were: (i) underestimation of patient CVR and ambivalence to apply risk-lowering strategies such as smoking cessation, (ii) disproportionate burden on GPs in deprived areas, (iii) poor information exchange between GPs and psychiatrists, and (iv) scepticism about patient compliance, especially those with more complex conditions. The main facilitators included: (i) support of GPs through a computer-generated list of eligible patients and (ii) involvement of family or carers. CONCLUSION: This study displays a range of barriers and facilitators anticipated by GPs. These indicate the preconditions required to remove barriers and facilitate GPs, namely adequate recommendations in practice guidelines, improved consultation opportunities with psychiatrists, practical advice to support patient adherence and incentives for practices in deprived areas.

Screening of colorectal cancer (CRC) can reduce incidence and mortality. First-degree relatives (FDRs) of patients with CRC or advanced adenoma before the age of 65 (index patients) are at increased risk of CRC; however, the guidelines for screening of FDRs by colonoscopy are poorly followed.The present study, conducted in the context of the COLOR3 interventional study project, aimed to explore the positioning of general practitioners (GPs) in familial CRC screening in France.From February 2020 to April 2021, 35 semi-structured interviews with GPs of index patients and/or their FDRs were conducted by telephone. The full-data transcribed corpus was subjected to horizontal thematic analysis.Knowledge and compliance with the guidelines vary greatly between GPs. Although initiating the diagnostic process, GPs do not consider themselves as actors in the flow of information concerning familial risk. Their accompaniment of index patients in this role varies. GPs should overcome barriers to implementing colonoscopic screening for FDRs. They underline the importance of exploring family history, but they lack the time and doubt the reliability of the information given by FDRs.Challenges include circumventing gaps in knowledge, adherence to guidelines and improving family history updates. The GPs interviewed suggested personalised guidelines in specialists' reports to initiate information campaigns raising awareness of familial risk, and to enhance coordination between organised screening and familial screening.

This study aims to examine whether participating in the contracted family doctor system increases patients' utilisation of primary care general practitioner for multiple disease outcomes in China.Binary logistic regression models were estimated using data collected from 372 community residents in nine selected districts of Hangzhou, China.Findings revealed that (1) for patients with influenza, diabetes, upper respiratory infection, and gingivitis, those who participated in the contracted family doctor system were approximately 4.3 times, 98.4%, 92.5%, and 52.8% more likely to choose primary care general practitioners (GP) for their initial diagnosis, respectively, as compared with their counterparts who did not have contracted family doctors; (2) For patients with stroke or cerebrovascular disease and cholecystitis or cholelithiasis, those who had contracted family doctors were 1.111 times and 80.6% more likely to choose primary care GP for their subsequent disease maintenance, respectively, as compared to their counterparts without contracted family doctors.Our findings indicate that the contracted family doctor system not only increases the utilisation of primary care GP for patients with many chronic conditions but also promotes the overall completion of China's hierarchical medical system in the long run. Policy implications were provided to help policymakers actively construct and develop the contracted family doctor system to promote the hierarchical medical system in China.

ObjectiveTo examine trends in end-of-life communication with people with cancer in general practice.MethodsMortality follow-back survey among general practitioners (GPs) in representative epidemiological surveillance networks in Belgium (BE), the Netherlands (NL) and Spain (ES) in 2009–2010 (ES: 2010–2011) and 2013–2014. Using a standardised form, GPs registered all deceased adult patients in their practice and reported for five end-of-life care topics whether they had been discussed with the patient. Non-sudden cancer deaths were included (n=2306; BE: 1233; NL: 729; ES: 344).ResultsA statistically significant increase was found between 2009/2010 and 2014 in the prevalence of communication about diagnosis (from 84% to 94%) and options for end-of-life care (from 73% to 90%) in BE, and in GPs’ awareness of patients’ preferences for medical treatment and a proxy decision-maker in BE (from 41% and 20% up to 53% and 28%) and the NL (from 62% and 32% up to 70% and 52%). Communication about options for end-of-life care and psychosocial problems decreased in the NL (from 88% and 91% down to 73%) and ES (from 76% and 77% down to 26% and 39%).ConclusionConsiderable change in GP–patient communication seems possible in a relatively short time span, but communication cannot be assumed to increase over time. Increasing specialisation of care and task differentiation may lead to new roles in communication for healthcare providers in primary and secondary care. Improved information sharing between GPs and other healthcare providers may be necessary to ensure that patients have the chance to discuss important end-of-life topics.

Live attenuated herpes zoster vaccine (Zostavax [CSL/Merck]) was included on the Australian National Immunisation Program from 1 November 2016 for adults aged 70 years, with a catch-up program for adults aged 71-79 years. The aim of this study was to assess the knowledge of Australian general practitioners (GPs) regarding Zostavax.A national cross-sectional online survey was distributed to GPs by Healthed, a private health education provider.Of 605 GPs, 502 responded to the survey (response rate 83%). Eighty-nine per cent were aware that Zostavax is funded and recommended for adults aged 70-79 years. Approximately 10% incorrectly responded that immunocompromise is not a contraindication to Zostavax, and 8% were unsure. For five clinical scenarios assessing knowledge of Zostavax contraindications, the proportion of correct responses ranged 25-82%.While most GPs surveyed had good knowledge, notable gaps were identified. Further efforts are needed to promote awareness of recommendations, particularly for immunocompromised individuals. The availability of Shingrix, a non-live recombinant subunit zoster vaccine, in the private market provides an alternative, especially for immuncompromised patients.

General practitioners (GPs) played a vital role during the COVID-19 pandemic. Little is known about GPs’ view of their role, leadership, participation in regional services and preferences for future pandemic preparedness. This representative study of German GPs comprised a web-based survey and computer-assisted telephone interviewing (CATI). It addressed GPs’ satisfaction with their role, self-perceived leadership (validated C-LEAD scale), participation in newly established health services, and preferences for future pandemic preparedness (net promotor score; NPS; range −100 to +100%). Statistical analyses were conducted using Spearman’s correlation and Kruskal–Wallis tests. In total, 630 GPs completed the questionnaire and 102 GPs the CATI. In addition to their practice duties, most GPs (72.5%) participated in at least one regional health service, mainly vaccination centres/teams (52.7%). Self-perceived leadership was high with a C-LEAD score of 47.4 (max. 63; SD ± 8.5). Overall, 58.8% were not satisfied with their role which correlated with the feeling of being left alone (r = −0.349, p < 0.001). 77.5 % of respondents believed that political leaders underestimated GPs’ potential contribution to pandemic control. Regarding regional pandemic services, GPs preferred COVID-19 focus practices (NPS +43.7) over diagnostic centres (NPS −31). Many GPs, though highly engaged regionally, were dissatisfied with their role but had clear preferences for future regional services. Future pandemic planning should integrate GPs’ perspectives.

Dairy and probiotics are examples of products that contain ingredients that provide health benefits beyond the basic nutritional components of the food itself. However, strong evidence based on randomised controlled trials is generally lacking, which in turn leads to weak guidelines and recommendations for clinical practice. Interestingly, despite the limited regulation of probiotics, for example, a significant proportion of healthcare professionals still recommend these products. We set out studying the advising behaviour of general practitioners (GPs) and dieticians and their underlying motivations whether to advise probiotics, a relatively new intervention, and dairy, an older intervention by conducting interviews and setting out a questionnaire. This study found that the vast majority of GPs and dieticians recommended dairy and probiotics. The proportion of dieticians that do not advise both dairy and probiotics was too small for statistical analysis, therefore, the results are mainly focused on GPs. Considerations that appeared to be associated with GP advising behaviour were related to compliance with protocols and guidelines in regard to both dairy and probiotics. For probiotics in particular, GPs' knowledge and patients' interest in using probiotics was related to advising behaviour of GPs. Considerations solely related to recommending dairy were related to GPs' perceptions about the amount of evidence of dairy efficacy and the recommendation of dairy in scientific journals. The study highlights the influence of authority-driven, expertise-driven and patient-driven considerations on whether or not to proceed with recommending an intervention. Insights into the drivers of GPs to advise, gives input to stakeholders in the nutrition innovation system to understand and allow to use appropriate tools to support GPs in making an informed decision to increase the quality of care provided.

BackgroundPractice-based pharmacists (PBPs) have been introduced into general practice across the UK to relieve some of the pressures within primary care. However, there is little existing UK literature that has explored healthcare professionals’ (HCPs’) views about PBP integration and how this role has evolved.AimTo explore the views and experiences of GPs, PBPs, and community pharmacists (CPs) about PBPs’ integration into general practice and their impact on primary healthcare delivery.Design and settingA qualitative interview study in primary care in Northern Ireland.MethodPurposive and snowball sampling were used to recruit triads (a GP, a PBP, and a CP) from across five administrative healthcare areas in Northern Ireland. Sampling of practices to recruit GPs and PBPs commenced in August 2020. These HCPs identified the CPs who had most contact with the general practices in which the recruited GPs and PBPs were working. Semi-structured interviews were recorded, transcribed verbatim, and analysed using thematic analysis.ResultsEleven triads were recruited from across the five administrative areas. Four main themes in relation to PBPs’ integration into general practices were revealed: evolution of the role; PBP attributes; collaboration and communication; and impact on care. Areas for development were identified such as patient awareness of the PBP role. Many saw PBPs as a ‘central hub–middleman’ between general practice and community pharmacies.ConclusionParticipants reported that PBPs had integrated well and perceived a positive impact on primary healthcare delivery. Further work is needed to increase patient awareness of the PBP role.

The development of multi-professional teamwork in primary care is one solution adopted to meet the needs of care coordination and comprehensive patient management. This article describes the composition of primary care practices in terms of professionals other than general practitioners. It highlights the fact that Western countries are at quite different stages of development in this field.

International audience; In many countries, policies have explicitly encouraged primary care teams and inter-professional cooperation and skill mix, as a way to improve both productive efficiency gains and quality improvement. France faces barriers to developing team working as well as new and more advanced roles for health care professionals including nurses. We aim to estimate the impact of a national pilot experiment of teamwork between general practitioners (GPs) and advance practitioners nurses (APN)-who substitute and complement GPs-on yearly quality of care process indicators for type two diabetes patients (T2DP). Implemented by a not-for-profit meso-tier organisation and supported by the Ministry of Health, the pilot relied on the voluntary enrolment of newly GPs from 2012 to 2015; the staffing and training of APNs; skill mixing and new remuneration schemes. We use latent-response formulation models, control for endogeneity and selection bias by using controlled before-after and quasi-experimental design combining coarsened exact matching-prior to the treatment, at both GPs (435 treated vs 973 control) and T2DP levels -, with intention to treat (ITT; 18,310 in each group) and per protocol (PP, 2943 in each group) perspectives, as well as difference-in-differences estimates on balanced panel claims data from the National Health Insurance Fund linked to clinical data over the period 2010-2017. We show evidence of a positive and significant positive impact for T2DP followed-up by newly enrolled GPs in the pilot compared to the pretreatment period and the control group. The effect magnitudes were larger for PP than for ITT subsamples.

The impact of the COVID-19 pandemic on general practitioners’ (GP) care for patients with asthma and/or COPD is largely unknown. To describe the impact of the pandemic on asthma or COPD-related GP care, we analysed routinely recorded electronic health records data from Dutch general practices and out-of-hours (OOH) services. During the COVID-19 pandemic (2020), the contact rates for asthma and/or COPD were significantly lower in GP practices and OOH services compared with the pre-pandemic period (2019) (respectively, 15% lower and 28% lower). The proportion of telephone contacts increased significantly with 13%-point in GP practices and 12%-point at OOH services, while the proportion of face-to-face contacts decreased. Furthermore, the proportion of high urgent contacts with OOH services decreased by 8.5%-point. To conclude, the overall contact rates in GP practices and OOH services decreased, while more contacts were remote. Lower contact rates have, after a short follow-up, not resulted in more patients with exacerbations in OOH care. However, this might still be expected after a longer follow-up.

Aim: Using the Theoretical Domains Framework (TDF) and COM-B model, this study aimed to determine the facilitators to a support tool for adolescent non-traumatic knee pain in general practice.Background: Many children and adolescents with non-traumatic knee pain consult their general practice. Currently, there are no tools to support general practitioners in the diagnosis and management of this group. There is a need to identify behavioural targets that would facilitate further development and implementation of such a tool.Methods: This study was designed as a qualitative study using focus group interviews with 12 medical doctors working in general practice. The semi-structured focus group interviews conducted online and followed an interview guide based on the TDF and COM-B model. Data were analysed via thematic text analysis.Findings: One of the biggest challenges from the general practitioner's perspective was how to manage and guide adolescents with non-traumatic knee pain. The doctors had doubts in their capability to diagnose knee pain and saw opportunity to help structure the consultation. The doctors felt motivated to use a tool but considered access a potential barrier. Increasing opportunity and motivation by creating access in the community among general practitioners was considered important. We identified several barriers and facilitators for a support tool for the management of adolescent non-traumatic knee pain in general practice. To align with user needs, future tools should support diagnostic workup, structure the consultation and be easily available among doctors working in general practice. Aim: Using the Theoretical Domains Framework (TDF) and COM-B model, this study aimed to determine the facilitators to a support tool for adolescent non-traumatic knee pain in general practice.Background: Many children and adolescents with non-traumatic knee pain consult their general practice. Currently, there are no tools to support general practitioners in the diagnosis and management of this group. There is a need to identify behavioural targets that would facilitate further development and implementation of such a tool.Methods: This study was designed as a qualitative study using focus group interviews with 12 medical doctors working in general practice. The semi-structured focus group interviews conducted online and followed an interview guide based on the TDF and COM-B model. Data were analysed via thematic text analysis.Findings: One of the biggest challenges from the general practitioner's perspective was how to manage and guide adolescents with non-traumatic knee pain. The doctors had doubts in their capability to diagnose knee pain and saw opportunity to help structure the consultation. The doctors felt motivated to use a tool but considered access a potential barrier. Increasing opportunity and motivation by creating access in the community among general practitioners was considered important. We identified several barriers and facilitators for a support tool for the management of adolescent non-traumatic knee pain in general practice. To align with user needs, future tools should support diagnostic workup, structure the consultation and be easily available among doctors working in general practice.

Background Falls in older people are common and morbid. Prediction models can help identifying individuals at higher fall risk. Electronic health records (EHR) offer an opportunity to develop automated prediction tools that may help to identify fall-prone individuals and lower clinical workload. However, existing models primarily utilise structured EHR data and neglect information in unstructured data. Using machine learning and natural language processing (NLP), we aimed to examine the predictive performance provided by unstructured clinical notes, and their incremental performance over structured data to predict falls. Methods We used primary care EHR data of people aged 65 or over. We developed three logistic regression models using the least absolute shrinkage and selection operator: one using structured clinical variables (Baseline), one with topics extracted from unstructured clinical notes (Topic-based) and one by adding clinical variables to the extracted topics (Combi). Model performance was assessed in terms of discrimination using the area under the receiver operating characteristic curve (AUC), and calibration by calibration plots. We used 10-fold cross-validation to validate the approach. Results Data of 35,357 individuals were analysed, of which 4,734 experienced falls. Our NLP topic modelling technique discovered 151 topics from the unstructured clinical notes. AUCs and 95% confidence intervals of the Baseline, Topic-based and Combi models were 0.709 (0.700–0.719), 0.685 (0.676–0.694) and 0.718 (0.708–0.727), respectively. All the models showed good calibration. Conclusions Unstructured clinical notes are an additional viable data source to develop and improve prediction models for falls compared to traditional prediction models, but the clinical relevance remains limited.

BACKGROUND: Many patients with ongoing complaints after a SARS-CoV-2 infection are treated in primary care. Existing medical guidelines on how to diagnose and treat Long-/Post-COVID are far from being comprehensive. This study aims to describe how German general practitioners (GPs) deal with this situation, what problems they experience when managing such patients, and how they solve problems associated with the diagnosis and treatment of Long-/Post-COVID. METHODS AND FINDINGS: We conducted a qualitative study and interviewed 11 GPs. The most commonly described symptoms were ongoing fatigue, dyspnea, chest tightness and a decrease in physical capacity. The most common way to identify Long-/Post-COVID was by exclusion. Patients suffering from Long-/Post-COVID were generally treated by their GPs and rarely referred. A very common non-pharmacological intervention was to take a wait-and-see approach and grant sick leave. Other non-pharmacological interventions included lifestyle advices, physical exercise, acupuncture and exercises with intense aromas. Pharmacological treatments focused on symptoms, like respiratory symptoms or headaches. Our study's main limitations are the small sample size and therefore limited generalizability of results. CONCLUSIONS: Further research is required to develop and test pharmaceutical and non-pharmaceutical interventions for patients with Long-/Post-COVID. In addition, strategies to prevent the occurrence of Long-/Post-COVID after an acute infection with SARS-CoV-2 have to be developed. The routine collection of data on the diagnosis and management of Long-/Post-COVID may help in the formulation of best practices. It is up to policymakers to facilitate the necessary implementation of effective interventions in order to limit the huge societal consequences of large groups of patients suffering from Long-/Post-COVID. ispartof: VIRUSES-BASEL vol:15 issue:4 ispartof: location:Switzerland status: published

Objective To explore health-care use in the 12 months preceding a diagnosis of RA in Denmark. Methods We conducted a population-based cohort study using data from national registries. Every patient diagnosed with RA in 2014–18 was matched to 10 reference individuals without RA from the Danish background population. Health-care use was defined as contacts to general practitioners, contacts to private practicing physiotherapists, and X-rays of hands and/or feet performed in primary or secondary care. We estimated the monthly contact rates for patients and references in the 12 months preceding the diagnosis, and we compared incidence rates for health-care use in each month between the two groups while adjusting for sociodemographic characteristics and comorbidity. Results We included 7427 patients with RA and 74 270 references. Patients with RA had increasing contact rates with general practitioners and physiotherapists from 6 to 8 months before the diagnosis. Compared with references, women with RA had statistically significantly more contacts to general practitioners and physiotherapists during all 12 months. A similar contact pattern was seen in men, albeit less distinct. The number of X-rays increased slightly from 8 months before the diagnosis, with a steep increase in the last 3 months. Conclusion Increased contacts to general practitioners and physiotherapists were seen in all 12 months preceding the RA diagnosis, intensifying in the last 6 to 8 months. Imaging increased from 3 months before the diagnosis. This indicates an opportunity to expedite referral to specialist care and ensure earlier diagnosis of RA.

Health care professionals face greater uncertainty in their careers as traditional jobs wither and new, organizationally controlled jobs proliferate, reducing economic security and professional autonomy.We apply psychological contract and self-efficacy theory to examine the career agency of early-career physicians. We ask the following: (a) What are the unfulfilled expectations and emotions experienced by young physicians at the training and early career stages? (b) What are the forms of career agency exhibited by young physicians in response to unfulfillment?We conducted a study on 48 U.K. early-career primary care physicians, known as general practitioners. The sample comprised both trainees as well as newly qualified physicians. Data were collected through in-depth interviews and focus group discussions.Physicians interpreted their early-career experiences based on predominantly ideological expectations around what it means to be a successful professional. However, the realities of practice resulted in highly emotional experiences of violation that were associated with a "reactive" agency and job behaviors that were more transactional and less relational.This study identifies the expectations of early career professionals, which helps understand how and why psychological contract violations occur. It also expands the conceptualization of career agency from a positively framed aspect of professional behavior to one that includes haphazard and self-serving elements.Our study highlights several implications of the shifts in physician career agency for primary care practice. It discusses the potential effects of the purposeful self-interest among doctors on professional identity and power, as well as patient care.

The relationship between the white-coat effect (WCE), defined as white-coat hypertension under treatment, and the frequency of orthostatic hypotension (OH) is not known. We conducted an orthostatic test in patients with WCE to determine the frequency of OH.This was a cross-sectional study of 5631 patients with hypertension visiting general practitioners nationwide, in which 4305 patients with hypertension recorded their home blood pressure (BP) and consented to the orthostatic test. Patients with hypertension were divided into four groups: controlled hypertension (CHT), masked hypertension (MHT), sustained hypertension (SHT), and WCE. The orthostatic test was performed, and BP and pulse rate were measured immediately and 1 min after orthostasis.The OH frequencies immediately after standing in CHT, WCE, SHT, and MHT patients were 7, 11.7, 12.1, and 6.6%, respectively, and those at 1 min after standing were 7.1, 13.1, 11.6 and 6.9%, respectively (Chi-square test, P0.01, respectively). Logistic regression analysis was performed to examine the relationship between WCE and the frequency of OH. The frequency of OH immediately after standing was significantly increased [adjusted odds ratio (AOR), 1.702; 95% confidence interval (CI), 1.246-2.326; P0.01]. The frequency of OH at 1 min after standing was also significantly higher (AOR, 1.897; 95% CI, 1.396-2.578; P0.01).When the standing test was performed for patients with WCE, the frequency of OH increased. Thus, it is important to recognize the possibility of OH in patients with WCE to avoid adverse events associated with excessive hypotension.

The aim of this study was to evaluate the concordance of the diagnoses made by senior rheumatologists and those made by residents in rheumatology and by general practitioners (GPs).In this cohort, 497 patients referred by GPs from August 1, 2018 to December 16, 2019 were evaluated first by a second-year resident in rheumatology. After clinical rounds, the diagnoses by senior rheumatologists were assumed as the criterion standard and defined the prevalence of the rheumatic diseases, divided into 5 groups: rheumatoid arthritis, spondyloarthritis, other connective tissue diseases and vasculitis, nonautoimmune rheumatic diseases, and nonrheumatic diseases. The follow-up ended on November 30, 2020. We calculated sensibility, specificity, positive predictive value, negative predictive value, and κ coefficient of the diagnosis by GPs and residents.The diagnoses were changed for 58% of the referral letters. Diseases of low complexity, such as fibromyalgia and osteoarthritis, accounted for 50% of the diagnoses. Compared with senior rheumatologists, residents in rheumatology had κ0.6 for all the groups, whereas GPs had κ0.5, with the worst performance for nonautoimmune rheumatic disease (κ = -0.18) and nonrheumatic disease (κ = 0.15). In terms of level of complexity, 46% of the letters were inappropriate.We found a poor level of diagnostic agreement between GPs and the rheumatology team. General practitioners had difficulties diagnosing and treating rheumatic diseases, referring patients that should be treated in the primary level of health care. One year of training in rheumatology made residents' skills comparable to those of senior rheumatologists.