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Background: Effective transitions of patients from Secondary Care Services (SCSs) to primary care are necessary for optimization of resources and care. Factors that enable or restrict smooth transitions of individuals with Serious Mental Illness (SMI) to primary care from SCSs have not been comprehensively synthesized. Methods: A scoping review was conducted to answer the questions (1) "What are the barriers and facilitators to discharge from SCSs to primary care for adults with SMI?" and (2) "What programs have been developed to support these transitions?". Results: Barriers and facilitators of discharge included patient-, primary care capacity-, and transition Process/Support-related factors. Patient-related barriers and facilitators were most frequently reported. 11 discharge programs were reported across the evidence sources. The most frequently reported program components were the provision of additional mental health supports for the transition and development of care plans with relapse signatures and intervention plans. Conclusions: Established discharge programs should be comprehensively evaluated to determine their relative benefits. Furthermore, research should be expanded to evaluate barriers and facilitators to discharge and discharge programs in different national contexts and models of care. Trial Registration: The protocol for this scoping review is registered with the Open Science Framework (https://doi.org/10.17605/OSF.IO/NBTMZ). [ABSTRACT FROM AUTHOR]

AbstractBackgroundMethodsResultsConclusions\nKEY POINTSAccording to the UN Committee Against Torture, all state parties to the Torture Convention have a responsibility to meet the rehabilitation needs of torture victims who have sought asylum within their borders. General practitioners (GPs) can play a crucial role in identifying torture victims and securing rehabilitation when needed. There is a pressing knowledge gap on the knowledge and practices of GPs vis-à-vis potentially tortured patients, and an urgent need for research that investigates GPs’ practices of identification, referral, and rehabilitation – in Norway and beyond. This article presents an exploratory qualitative pilot study that investigates the experiences of GPs in Oslo vis-à-vis this patient group.Semi-structured interviews with five experienced GPs in the greater Oslo area. Interview data was analyzed through thematic analysis and discussed within a theoretical framework seeing GPs as street-level bureaucrats.Issues that emerged in the pilot involve a consistent professional confidence and a particular concern for victims of sexual violence and sexualized torture. The pilot also found a troubling commonsensical reasoning about identification in the asylum process. The GPs asked for the re-establishment of specialist rehabilitation centers for refugees and torture victims to consult in case of need. Alas, the study also confirmed that GPs are a difficult profession to recruit for research.This study indicates that GPs are important actors in terms of identifying torture victims after resettlement, but that there are shortcomings in their training and knowledge, in the overall organization of the healthcare system, and in specialized healthcare, that limit prospects for rehabilitation.To what extent are torture victims met or identified by GPs in resettling contexts? This paper presents a pilot study designed to address this knowledge gap and prepare future studies. We found:GPs were confident in their abilities to identify and meet torture victims in a good way – and in the value that is patient-doctor continuity in general medicine.Troubling commonsensical reasoning about identification in the asylum process and in consultations.A lack of and need for qualified and available expertise to consult with and/or refer tortured patients to.GPs were confident in their abilities to identify and meet torture victims in a good way – and in the value that is patient-doctor continuity in general medicine.Troubling commonsensical reasoning about identification in the asylum process and in consultations.A lack of and need for qualified and available expertise to consult with and/or refer tortured patients to. [ABSTRACT FROM AUTHOR]

Background: Exposure to domestic and family violence is a pervasive form of complex trauma and a major global public health problem. At the frontline of the health system, primary healthcare practitioners are uniquely placed to support individuals with experiences of trauma, yet their views on trauma-informed primary care are not well understood. This systematic review of qualitative literature sought to explore primary healthcare practitioners' perspectives on trauma-informed primary care. Methods: Eight databases were searched up to July 2023. Studies were included if they consisted of empirical qualitative data, were conducted in general practice or equivalent generalist primary healthcare settings, and included the perspectives of primary healthcare practitioners where they could be distinguished from other participants in the analysis. Thematic synthesis was used for analysis. Results: 13 papers met inclusion criteria, representing primary care settings from the United States, Canada, Australia, and Norway. Three key themes were developed: Changing the paradigm, Building trust, and Navigating the emotional load. Findings shed light on how primary healthcare practitioners perceive and strive to practise trauma-informed primary healthcare and the challenges of navigating complex, trauma-related work in the primary care environment. Conclusions: This review supports the need for recognition of the value of primary care in supporting patients with histories of trauma and violence, the development of interventions to mitigate the emotional load worn by primary healthcare practitioners, and further work to develop a deep and consistent understanding of what trauma-informed primary care encompasses. [ABSTRACT FROM AUTHOR]

Background: Increasing numbers of patients treated in the emergency departments pose challenges to delivering timely and high-quality care. Particularly, the presentation of patients with low-urgency complaints consumes resources needed for patients with higher urgency. In this context, patients with non-specific back pain (NSBP) often present to emergency departments instead of primary care providers. While patient perspectives are well understood, this study aims to add a provider perspective on the diagnostic and therapeutic approach for NSBP in emergency and primary care settings. Methods: In a qualitative content analysis, we interviewed seven Emergency Physicians (EP) and nine General Practitioners (GP) using a semi-structured interview to assess the diagnostic and therapeutic approach to patients with NSBP in emergency departments and primary care practices. A hypothetical case of NSBP was presented to the interviewees, followed by questions on their diagnostic and therapeutic approaches. Recruitment was stopped after reaching saturation of the qualitative content analysis. Reporting this work follows the consolidated criteria for reporting qualitative research (COREQ) checklist. Results: EPs applied two different strategies for the workup of NSBP. A subset pursued a guideline-compliant diagnostic approach, ruling out critical conditions and managing pain without extensive diagnostics. Another group of EPs applied a more extensive approach, including extensive diagnostic resources and specialist consultations. GPs emphasized physical examinations and stepwise treatment, including scheduled follow-ups and a better knowledge of the patient history to guide diagnostics and therapy. Both groups attribute ED visits for NSBP to patient related and healthcare system related factors: lack of understanding of healthcare structures, convenience, demand for immediate diagnostics, and fear of serious conditions. Furthermore, both groups reported an ill-suited healthcare infrastructure with insufficiently available primary care services as a contributing factor. Conclusions: The study highlights a need for improving guideline adherence in younger EPs and better patient education on the healthcare infrastructure. Furthermore, improving access and availability of primary care services could reduce ED visits of patients with NSBP. Trial registration: No trial registration needed. [ABSTRACT FROM AUTHOR]

Introduction: Falls are a serious health problem in long-term care facilities (LTCFs), affecting more than 50% of residents. A key role of LTCF staff is to assess fall risks and implement fall prevention activities. Understanding the barriers and facilitators is key to successful implementation. Methods: This descriptive qualitative study involving four LTCF facilities (varied provider types and sizes) in southwest Ireland. We recruited a convenience sample of 17 LTCF staff, who participated in semi-structured online 1:1 interviews (n = 7) or small group interviews (n = 10). The data were analysed using Braun and Clarke's reflective thematic analysis. Results: The participants included two directors of nursing, three therapists, one ward manager, one general practitioner, five nurses and five healthcare assistants. Six main themes were identified, reflecting factors that influenced fall prevention: a need for sufficient staff and appropriate skill mix; fall policy, documentation and leadership; equipment and safe environments; person-centred care; staff knowledge, skills and awareness in falls prevention; and staff communication and collaborative working. A wide range of approaches that supported LTCF staff to overcome barriers were identified, including audits and feedback, falls champions, fall prevention leaders, daily communication (e.g., safety pauses) and staff collaboration. Formal multidisciplinary meetings and identification systems to highlight residents at high risk of falling were not considered helpful. Staff suggested that education should be briefer, ongoing and practice-based ("brief but often") to promote ownership and responsibility. Conclusion: LTCF staff identified several approaches to prevent falls in LTCFs as part of usual care, rather than lengthy, formal meetings and training. The potential role of families in fall prevention was under-appreciated and should be investigated further. [ABSTRACT FROM AUTHOR]

Background: Although the number of point-of-care ultrasound devices available in Hungarian primary care practices are increasing due to government funding, their use in day-to-day patient care is limited and unregulated. Our study aimed to evaluate the attitudes and needs of general practitioners (GPs) and patients in Hungary regarding the introduction of bedside ultrasonography in primary care practices. Methods: As a part of a cross-sectional study, an anonymous, self-administered questionnaire was distributed to GPs and patients on a social media platform. Data collection was carried out from August 2023 to October 2023. Chi-square test was used to determine the associations between categorical variables. Results: The survey was completed by 415 GPs (mean age 53.8 ± 11.1 years, 54.9% female, mean 19.5 ± 11.9 years of practice) and 693 patients (mean age 45.5 ± 12.3 years, 95.2% female). There was a statistically significant increase in interest in PoCUS among young and middle-aged GPs (age 28–59; p = 0.02). In addition, this population of GPs was also more likely to undertake training in PoCUS than their older colleagues (p < 0.0001). An inverse relationship was found between the duration of practice and training willingness (p = 0.0011). Even with the government's financial support, only 8.2% of GPs currently use PoCUS in a daily basis, and 59.5% of GPs are unfamiliar with the indications and the ways of using it. Patients would even pay to have the examination done in a primary care setting, even though only 45.9% of patients would pay a GP who is not certified in PoCUS, but the willingness to pay increased to 99.4% for those with formal training (p = 0.024). Conclusion: Our findings indicate a significant interest in adapting PoCUS in primary care from both GPs and patients. Based on the fact that a significant proportion of Hungarian GPs are unaware of PoCUS and its indications, it is particularly important to develop educational frameworks, and practical guidelines for the effective incorporation of PoCUS in Hungary. [ABSTRACT FROM AUTHOR]

Background: Women with breast cancer face many barriers to return to work (RTW) after their cancer. The main objective of the FASTRACS-RCT is to evaluate the impact of the FASTRACS (Facilitate and Sustain Return to Work after Breast Cancer) intervention on the sustainable RTW of breast cancer patients, 12 months after the end of active treatment. Methods: FASTRACS-RCT is a prospective, national, multicentre, randomized, controlled and open-label study. A total of 420 patients with early breast cancer scheduled for surgery and (neo)adjuvant chemotherapy, will be randomly assigned (1:1 ratio) to: (i) the intervention arm comprising four steps over 6 months : Handing over the intervention tools; transitional medical consultation with the general practitioner (GP); pre-RTW visit with the company's occupational physician (OP); catch-up visit with a hospital-based RTW expert (if sick leave > 10 months) (ii) the control arm to receive usual care. The design of the FASTRACS intervention was informed by intervention mapping for complex interventions in health promotion planning, and involved patients and representatives of relevant stakeholders. Specific tools were developed to bridge the gap between the hospital, the GP, the OP and the workplace: a toolkit for breast cancer patients comprising a theory-based guide; specific checklists for the GP and the OP, respectively; and a theory-based guide for workplace actors (employer, manager, colleagues). The primary endpoint will associate sustainable RTW (full-time or part-time work at 50% or more of working time, for at least 28 consecutive days) and days off work. It will be assessed at 4, 8 and 12 months after the end of active oncological treatment. Secondary endpoints will include quality of life, anxiety, depression, RTW self-efficacy, physical activity, social support, job accommodations, work productivity, job status, and the usefulness and acceptability of the intervention's tools. Discussion: FASTRACS-RCT will be supplemented by a realist evaluation approach aimed at understanding the influence of context in activating the intervention's mechanisms and effects. If the expected impact of the intervention is confirmed, the intervention will be adapted and scaled-up for other cancers and chronic diseases to better integrate healthcare and work disability prevention. Trial registration: NCT04846972 ; April 15, 2021. [ABSTRACT FROM AUTHOR]

Background: Telemedicine allows delivery of healthcare to occur between parties that are not in the same location. As telemedicine users are not co-present, effective communication methods are crucial to the delivery and reception of information. The aim of this study was to explore perspectives of general practitioners (GPs) and patients on the interactional components of telemedicine consultations. Methods: Semi-structured qualitative interviews were held with telemedicine users; 15 GPs and nine patients self-selected from a larger telemedicine study. Participants were asked about their preparation for telemedicine consultations, conducting telemedicine consultations and post-consultation activities. Deidentified transcripts from the interviews were analysed thematically. Results: GPs and patients discussed factors they used to decide whether a consultation would be best conducted by telemedicine or in-person; the condition to be discussed, the existing doctor-patient relationship and whether physical examination was required. Participants also described how they prepared for their telemedicine consultations, gathering relevant documents, and reading previous notes. Participants described strategies they employed to optimise the telemedicine interaction; improving conversational flow and building rapport, as well as difficulties they experienced when trying to provide and receive care via telemedicine. Conclusions: Patient factors including health literacy and familiarity with technology affect the transfer of information shared during telemedicine consultations and consideration of these factors when choosing patients for telemedicine is required. Many GPs and patients have innate communication skills to effectively deliver and receive care through telemedicine. However, they may not be aware of these subconscious techniques to use to optimise telemedicine consultations. Communication training could be delivered to increase conversational flow, build rapport, and establish safety netting. [ABSTRACT FROM AUTHOR]

Background: The effectiveness of the NSW Health "Get Healthy Information and Coaching Service®"(Get Healthy) to facilitate weight loss on a population scale has been documented, but this was based on self-reported measures. Our study aims to test the effectiveness of the Get Healthy Service on objectively measured weight, BMI, waist circumference, and changes in other health behaviours, including nutrition, physical activity and alcohol intake. Methods: Men and women aged 40–70 years (n = 154) with pre-diabetes (5.7% < HbA1c < 6.5%) were referred from GP Practices to the Get Healthy Service, NSW Health. A subset (n = 98) participated in the "Zinc In Preventing the Progression of pre-Diabetes" (ZIPPeD) trial (ACTRN12618001120268). Results: The self-reported outcomes showed a statistically significant improvement from baseline to 12 months in weight (mean 2.7 kg loss, p < 0.001), BMI (mean 1 unit reduction, p < 0.001), and waist circumference (mean 4.3 cm reduction, p < 0.001). However, in the objectively measured outcomes from ZIPPeD, the differences were more modest, with point estimates of 0.8 kg mean weight loss (p = 0.1), 0.4 unit reduction in BMI (p = 0.03), and 1.8 cm reduction in waist circumference (p = 0.04). Bland-Altman plots indicated that discrepancies were due to a small number of participants who dramatically underestimated their weight or BMI. There were minimal changes in nutrition, physical activity, and alcohol. Conclusions: The potential benefits of Get Healthy should be interpreted with caution as we have shown significant differences between self-reported and objectively measured values. More valid and objective evidence is needed to determine the program's effectiveness and cost-effectiveness. [ABSTRACT FROM AUTHOR]

Objective: Many countries experience challenges in recruiting and retaining general practitioners (GPs) as supervisors for medical students in clinical placements. We aimed to investigate the opportunities, capacities and limitations of Norwegian GPs to become supervisors. Design: Web-based cross-sectional questionnaire study. Setting: Norwegian general practice. Subjects: All GPs in Norway, including locums and those on leave, both active supervisors, and GPs who are not presently supervising medical students. Main outcome measures: GPs' terms of salary, office facilities, limiting factors, capacity and needs for becoming or continuing as supervisors. Results: Among 5145 GPs, 1466 responded (29%), of whom 498 (34%) were active supervisors. Lack of a dedicated student office was the most reported limitation for both active supervisors (75%) and other GPs (81%). A high proportion (67%) of active supervisors reported that they could host more students per year, given financial support for equipped offices and higher salaries. With this kind of support, 48% (n = 461) of the GPs who were not supervisors for medical students were positive about a future supervisor role. By adjusted regression analysis, female GPs had lower likelihood of being supervisors, OR (95% CI) 0.75 (0.59–0.95) than male colleagues. GPs in the North, Mid and West regions had higher odds (OR 3.89, 3.10 and 2.42, respectively) than those in the South-East region. Teaching experience also increased the odds (2.31 (1.74–3.05). Conclusions: There seems to be capacity among both active and potential supervisors if increased salaries and financial support for office facilities are made available. KEY POINTS: Undergraduate training by clinical placements is important for the recruitment of doctors to general practice, and depends on a sufficient number of GPs as supervisors. The study shows that there is sufficient capacity among Norwegian GPs to host medical students in clinical placements. Many potential supervisors among Norwegian GPs report that they have not been approached by a university to supervise medical students. Many supervisors state that they need increased salaries and financial support for facilities and expenses in order to supervise medical students. [ABSTRACT FROM AUTHOR]

Background: There has been a notable decrease in antibiotic prescribing in the last thirty years in Sweden. Little is known about factors influencing antibiotic prescribing over several years. Objective: To compare primary care physicians who, over time, reduced their antibiotic prescribing for respiratory tract infections with those who remained either high or low prescribers regarding potentially influencing factors. Design and setting: A register-based study including all RTI visits in primary care in Region Kronoberg, Sweden 2006–2014. The data were divided into three 3-year periods. Subjects: The data comprised all physicians who had diagnosed at least one RTI for each of the three-year periods. The antibiotic prescribing rate adjusted for the patients' sex and age group was calculated for each physician and period, and based on the change between the first and the third period, the physicians were divided into three prescriber groups: The High Prescribing Group, the Decreasing Prescribing Group, and the Low Prescribing Group. Main outcome measures: For the three prescriber groups, we compared factors influencing antibiotic prescribing such as the characteristics of the physicians, their use of point-of-care tests, their choice of diagnoses, and whether the patients returned and received antibiotics. Results: The High Prescribing Group ordered more point-of-care tests, registered more potential bacterial diagnoses, prescribed antibiotics at lower C-reactive protein levels, and prescribed antibiotics more often despite negative group A Streptococci test than in the Low Prescribing Group. The Decreasing Prescribing Group was between the High Prescribing Group and the Low Prescribing Group regarding these variables. The lower prescription rate in the Low Prescribing Group did not result in more return visits or new antibiotic prescriptions within 30 days. Conclusion: Point-of-care testing and its interpretation differed between the prescriber groups. Focus on interpreting point-of-care test results could be a way forward in antibiotic stewardship. KEY POINTS: High prescribers used antibiotics at lower CRP levels and were more likely to identify a potential bacterial diagnosis. Many physicians reduced their antibiotic prescribing during the study period. Nine out of ten low prescribers remained low prescribers. Seeing a low-prescribing physician did not lead to more return visits or antibiotic changes. [ABSTRACT FROM AUTHOR]

Background and objective: Previous research identified numerous barriers to general practitioner (GP) use of cardiovascular disease (CVD) risk guidelines, and it is unclear whether these issues have been resolved. This study explored recent GP experiences. Methods: Interviews with 18 GPs in an Australian state with relatively few COVID-19 cases in 2021 were transcribed and coded using a framework analysis approach, with data mapped to five previously identified CVD risk assessment strategies: absolute risk focused, absolute risk adjusted, clinical judgement, passive disregard and active disregard. Results: GPs used various CVD risk calculators to inform clinical decision making, but there were concerns about accuracy, the role of extra risk factors and less 'personalised' assessment. GPs addressed these concerns by requesting additional tests, subjectively adjusting the CVD risk assessment to account for extra risk factors and focusing on individual risk factors. Discussion: Many barriers to CVD risk assessment guidelines remain. GP support is needed to implement revised guidelines. [ABSTRACT FROM AUTHOR]

Background: Low back pain is one of the most common presentations in general practice. Although there is excellent evidence regarding best management of the condition, in primary care there is often overuse of less effective and expensive options, whereas effective, inexpensive options are underused. After broad consultation and evidence review, the Australian Commission on Safety and Quality in Health Care has developed a clinical care standard in response to this identified gap between best and actual practice. A clinical care standard focuses only on key areas of care where the need for quality improvement is greatest. Objective: We explore the new standard using a typical patient scenario in primary care to highlight evidence-based approaches for challenging aspects of management, such as imaging and pain management. Discussion: General practitioners (GPs) might find the practical GP 'quick guide' resource from the standard useful to support their care of patients with low back pain. [ABSTRACT FROM AUTHOR]

Background: Buruli ulcer (BU) is caused by Mycobacterium ulcerans, an environmental pathogen that causes severe skin and soft-tissue necrosis. In Australia, cases of BU are acquired in endemic regions, which include Victoria and Far North Queensland, but those who have visited these regions can present to health practitioners anywhere. Objective: This article provides Australian general practitioners with an overview of BU, including its epidemiology, transmission, clinical features, diagnosis and management. Discussion: BU can manifest as an ulcer or as a nonulcerated skin lesion, such as a plaque, nodule or oedema. Diagnosis can be achieved with a dedicated Mycobacterium ulcerans polymerase chain reaction (PCR) test performed on a wound swab. Swabs on non-ulcerated disease have a high false negative rate, and a PCR test should be performed on a tissue biopsy to confirm disease. Most cases are managed with prolonged antibiotic therapy - commonly a combination of oral rifampicin and clarithromycin or fluroquinolone (moxifloxacin or ciprofloxac. [ABSTRACT FROM AUTHOR]

Background: Keratinocyte cancer (KC) in Australia poses a unique healthcare challenge due to its high prevalence and the requirement for multidisciplinary management of many cases. Advances in radiation therapy (RT) have increased its use in treating different keratinocyte cancer presentations. Understanding the indications for RT and the role that general practitioners (GPs) play in the treatment pathway are imperative to ensure best patient outcomes. Objective: This review examined the efficacy, advances and treatment considerations of RT for the management of keratinocyte cancer, and role of the GP in the treatment pathway. Discussion: Radiation therapy offers effective alternatives to, or adjuvants for, surgery in existing keratinocyte cancer treatments in appropriate cases. The evolving RT landscape necessitates GPs to be well-informed for effective case identification, referral and management. This includes understanding RT advances, protocols, treatment reactions and managing patient expectations. Continuing education in this space is important for GPs to understand the suitability of RT for their patients. [ABSTRACT FROM AUTHOR]

The article presents a case study of a fair-skinned, elderly woman experiencing a sudden increase in skin malignancies after a long period of stability. Topics discussed include the management of skin lesions through shave and curettage, the impact of ruxolitinib on skin cancer progression, and factors contributing to the rapid rise in skin malignancies.

Background: Following major achievements seen with drug therapies for the treatment of advanced melanoma in the last decade, they now also have an ever-increasing role for the treatment of earlier stage disease. This review outlines the current drugs used to treat melanoma, and how general practitioners (GPs) can assist in the management of patients with melanoma and the associated toxicities with treatment. Objective: This review summarises the evolving status of melanoma care, emphasising when to refer patients to medical oncologists as part of the multidisciplinary team. It provides guidance into recognising and managing immune-related adverse events (irAEs) associated with immunotherapy, and provides insights into the future changes in clinical practice. Discussion: Drug therapies are increasingly used for the treatment of many patients with melanoma. Early referral is crucial, and clinical trials remain the best choice for most patients. Recognition and prompt management of irAEs is vital, and collaboration between GPs and oncologists is essential for best care. [ABSTRACT FROM AUTHOR]

Health care challenges in remote rural municipalities (RRMs) emphasize the importance of primary health care (PHC) and require an expanded scope of practice. Doctors are key actors in this context. The aim of this study was to explore the level of integration of doctors in RRMs and working practices. We conducted a qualitative study involving semi-structured interviews with 46 PHC doctors working in 27 RRMs in Brazil. Content analysis was performed, resulting in the identification of categories of analysis grouped under three core dimensions: doctor training and experience; comprehensive care and timely access; and the community-based approach. Doctors working in RRMs were mainly recent graduates with limited experience who had undertaken their degree outside Brazil, and care was focused on the individual. The findings also revealed weak sociocultural adaptation and a harsh working environment and issues related to social status that reinforced prejudice against rurality and poverty. Practice was limited in scope and care tended to be oriented towards acute problems, disease-centered and focused on the biomedical model of medicine. Barriers to the delivery of comprehensive care include both structural constraints, such as poor facilities and centralization of services in administrative centers, and the lack of professional competencies necessary for PHC in these areas. The findings point to the need to promote an expanded scope of practice in PHC delivery in RRMs, with major public investment in the promotion of training and strengthening career pathways in these areas. [ABSTRACT FROM AUTHOR]

Background: Moral distress in and ethical climate of health care institutions are highly intertwined subjects and have been linked to various quality of care indicators as well as job turnover intentions among health care professionals. Predominantly, both phenomena have been studied in intensive care, palliative and in-hospital settings. We aimed to explore the experience of moral distress by general practitioners (GPs), the role of ethical climate in GP moral distress and how ethical climate and moral distress can result in moral resilience in general practice. Methods and findings: Between April and October 2021, we interviewed 13 doctors active in general practice in Flanders, Belgium, through semi-structured interviews. Data were processed and analysed using the Qualitative Analysis Guide of Leuven (QUAGOL). Most GPs had ample experience with morally distressing situations. Causes, determinants, and consequences do not differ significantly from other care settings. Moral distress can arise from conflicting views of good care, communication problems, and impending harm to third parties. We detected determinants of moral distress on micro-, meso- and macrolevels. GPs associate moral distress with job turnover and emotional, physical, existential, and quality of care effects. Several malleable factors can contribute to resilient ethical climates. This requires acquisition of vocabulary, skills, and knowledge. Conclusions: Moral distress and ethical climate are important emerging themes for GPs. This research identifies determinants and effects of moral distress and ethical climate in primary care and could help GPs leverage moral distress experiences into morally resilient primary care through multiple suggested strategies. [ABSTRACT FROM AUTHOR]

Background: This study aimed to explore the influence of patient-, general practitioners (GP)-, and GP practice-level predictor variables on patient-experienced accessibility to GPs and GP practices. Additionally, we aimed to enhance our understanding of patient-experienced accessibility by analysing the free-text comments from patients who reported lowest accessibility scores to GPs and GP practices. Methods: We performed a secondary analysis of data from a 2021-2022 national Norwegian survey on patient experiences with their GP and GP practice. We identified seven accessibility-related items including experience and acceptance of regular waiting time and for urgent appointments, time spent with the GP, waiting time in the wating-room, and getting in touch with the GP practice by telephone. A composite accessibility score was computed. Predictor variables consisted of patient's self-reported characteristics, as well as background data about the GP and GP practice from National GP registry. The analysis included multiple linear regression of the composite accessibility score and seven accessibility items. Finally, a qualitative analysis was conducted of free-text survey comments among patients that had a score of 0 (unfavourable) on all the seven accessibility items. Results: The key factor for patient-experienced accessibility to general practice was seeing their own GP, showing a statistically significant positive correlation (p<0.001) across all seven accessibility items and the composite accessibility score in regression analyses. Other associations with positive experience included better self-reported health, and at the GP-level, a specialization in general medicine. Conversely, a negative experience was associated with longer time since the last GP consultation, female patients, and a higher number of GPs at the practice. Qualitative data confirmed accessibility challenges, detailing quantitative scores and highlighted that low accessibility scores were related to difficulties in seeing one's own GP. Conclusions: This study highlights the importance of continuity between patient and their GP in improving patients' experiences of accessibility to general practice. Several GP and GP practice-level factors were related to patient-reported accessibility. These results can be used to inform initiatives aimed at improving accessibility to general practice. [ABSTRACT FROM AUTHOR]

Background: Healthcare systems around the globe are facing challenges. There are increasing demands and costs at the same time as a diminishing health workforce. Without change, healthcare will become unsustainable. The Dutch government is searching for solutions, one of which is relocating healthcare. Relocating healthcare from expensive institutions to sites closer to patients' homes is an important part of this. This relocation is expected to reduce costs and lessen shortages of personnel. However, although citizens have an important stake in this, little is known about how they think about this topic. This research aims at investigating citizens' perspectives on relocating care. Methods: In December 2021, three open-ended questions were sent to 1,500 members of Nivel's Dutch Healthcare Consumer Panel, 796 respondents responded. In addition, two citizen platforms were organised in March and April 2022. A total of 23 citizens participated. Results: Our results indicated that the following aspects are important for citizens in healthcare delivery: being treated by someone with expertise in the area of their need, familiarity with the healthcare provider and the treatment of less complex care close to home. When certain conditions are met, citizens prefer treatment for less complex care from their general practitioner rather than in a hospital. The most important condition is that the general practitioner has the right expertise regarding their health question. The willingness to relocate care from the general practitioner to other healthcare providers or to self-care is also present. One of the problems, however, is that citizens often do not know to which healthcare provider they should go or what they should do to increase self-care. Conclusion: From a citizens' perspective, relocating care is an acceptable solution for keeping healthcare sustainable in the future, provided that certain conditions are met. [ABSTRACT FROM AUTHOR]

Objectives: Chronic kidney disease (CKD) affects up to 11% of the population. General practice is at the forefront of the identification of patients with declining kidney function, and appropriate monitoring and management of patients with CKD. An individualized and patient-centred approach is currently recommended in guidelines, but would be enhanced by more detailed guidance on how this should be applied to different age groups, such as use of a kidney trajectory chart. We explored the opinion of general practitioners (GPs) about the potential utility of kidney trajectory charts. Methods: Qualitative study interviewing 27 Australian GPs about their management of chronic kidney disease. GPs were presented with charts that plotted percentiles of kidney function (eGFR) with age and discussed how they would use the charts manage to patients with declining kidney function. GPs' opinion was sought as to how useful these charts might be in clinical practice. Results: Most GPs were positive about the use of kidney trajectory charts to assist them with recognition and management of declining kidney function in general practice: e.g, comments included a "valuable tool", "a bit of an eye opener"," will help me explain to the patients", "I'll stick it on my wall.". GPs responded that the charts could help monitor patients, trigger early recognition of a younger patient at risk, and assist with older patients to determine when treatment may not be warranted. GPs also thought that charts could also be useful to motivate patients and help them monitor their own condition. Conclusions: Use of percentile charts in conjunction with the current CKD guidelines help support a patient-centred model of care. Kidney trajectory charts can help patients to understand their risk of further kidney damage or decline. Research on the use of these charts in clinical practice should be undertaken to further develop their use. [ABSTRACT FROM AUTHOR]

Bed bug infestations have been increasing worldwide since the 2000s. Their consequences for health range from skin reactions to major psychological distress. However, epidemiological data is still lacking. This study estimated the incidence of general practice consultations related to bed bugs in France and evaluated factors associated with repercussions on everyday life. We conducted a prospective observational study from March 2019 to April 2020 among 217 GPs in France. Annual and monthly GP consultations related to bed bugs were estimated from the reported cases. Descriptive analyses were performed, and factors associated with repercussions on everyday life were assessed using a logistic regression model. The annual incidence rate of GP consultations related to bed bugs was estimated at 109 per 100,000 inhabitants [95%CI: 92–126]. Bed bug-related consultations occurred in all regions, peaking in the summer. Moderate-to-severe repercussions on everyday life were reported by 39% of the patients. The associated factors with this level of repercussions were: having seen bed bugs (OR = 4.02 [95%CI: 1.6–10.73]), having lesions from scratching (OR = 5.25 [1.65–19.92]), having lesions on the head and the neck (OR = 3.97 [1.52–10.95]) and reporting psychological distress (OR = 6.79 [2.47–20.42]). This study provides new knowledge on GP consultations related to bed bugs in France. These data will help tailor public health programs to the population's needs, including information and training for primary healthcare professionals. [ABSTRACT FROM AUTHOR]

Background: A type 3 medication review (MR3) is a patient-centred medication service primarily provided by pharmacists and is presently employed routinely in several countries. In this process, pharmacists interview patients and collaborate with the treating physician to optimize the patient's pharmacotherapy, taking into account the patient's medication history and other medical data including laboratory values. The need to maintain the quality of such interventions during and after their initial implementation cannot be overstated. Aim: The objective of this study was to refine and assess a scoring table to evaluate the quality of MR3 conducted in Belgian community pharmacies. Methods: The comprehensive quality of MR3s was assessed by scoring its various components using a previously developed scoring table, called BRANT-MERQS, Brussels Antwerp Medication Review Quality Score. MR3s were analysed from an implementation study with patients suffering from rheumatoid arthritis (RA, subproject 1) and type 2 diabetes mellitus (T2DM, subproject 2). Additional information was obtained during a telephone call with a subset of participating pharmacists of subproject 1 who finalized their first MR3. Results: In subproject 1, a total of 21 MR3s of patients with RA were examined. The assessment showed favourable scores for elements such as a well-organized medication schedule, treatment adherence, and the elaboration of specific interventions. However, certain other quality criteria posed challenges in the evaluation, for example, the use of simple and understandable language. Pharmacists faced time constraints, and elderly general practitioners (GPs) displayed limited enthusiasm, which were notable barriers observed for this subproject. In the context of subproject 2 that investigated 41 MR3s in patients with T2DM, the quality criteria of interaction between pharmacist and GP, and used sources and tools received high scores. However, there was still room for improvement, especially in areas such as accurate dosing, handling kidney function, QT prolongation, correctly associating laboratory values with relevant drugs and medical conditions, and optimisation of medication schedules for patients. Conclusion: This study demonstrated the feasibility of MR3 quality assessment through a scoring system. However, it also unveiled the tool's current imperfections and highlighted the ongoing need for refinement, something expected of a new service in an implementation phase. [ABSTRACT FROM AUTHOR]

Background: Digital therapeutic Sleepio has proven effective in improving sleep quality and decreasing symptoms of anxiety. The National Institute for Health and Care Excellence (NICE) guidance recommends Sleepio as an alternative treatment to usual sleep hygiene education and hypnotic medications. General practitioners (GPs) play a critical role in the adoption of digital therapeutics in patient care. Previous interventions did not adopt theoretical frameworks to systematically understand GPs behaviour toward referring patients to digital therapeutics. Objectives: This study aimed to report the systematic and comprehensive development of an intervention to encourage GPs to refer insomnia patients to Sleepio, using the Behaviour Change Wheel (BCW). Methods: The eight steps outlined in the BCW were followed to develop an intervention. The Capability Opportunity Motivation-Behaviour Self-Evaluation Questionnaire (COM-B-Qv1) was adopted to understand GPs perceived facilitators and barriers to refer insomnia patients to Sleepio. The Behaviour Change Technique Taxonomy Version 1 (BCTv1) was thereafter used to identify possible strategies that could be used to facilitate changes in GPs' behaviour in relation to Sleepio. Results: The BCW design process resulted in the identification of five intervention functions, three policy categories and five behaviour change techniques (BCTs) as potential active components for an intervention. The intervention includes providing GPs with an orientation about using Sleepio to improve their knowledge and confidence, sending visual reminders to GPs to recommend Sleepio to their patients, providing ongoing technical support. Conclusion: The BCW can be successfully applied through a systematic process to understand the drivers of GPs' behaviour and to develop an intervention that can encourage them to refer insomnia patients to Sleepio. [ABSTRACT FROM AUTHOR]

AbstractIntroductionMaterial and methodsResultsConclusionUrinary symptoms constitute the primary reason for female patients to consult their general practitioner. The urinary dipstick test serves as a cornerstone for diagnosing urinary tract infections (UTIs), yet traditional visual interpretation may be subject to variability. Automated devices for dipstick urinalysis are routinely used as alternatives, yet the evidence regarding their accuracy remains limited. Therefore we aimed to compare concordance between visual and automated urinary dipstick interpretation and determine their test characteristics for the prediction of bacteriuria.We conducted a prospective validation study including urine samples originating from adult patients in general practice that were sent to the Maastricht Medical Centre + for urinary culture. Urinary dipstick tests were performed on each sample, which were interpreted visually and automatically. We calculated Cohen’s κ and percentage agreement and used 2 × 2 tables to calculate test characteristics.We included 302 urine samples. Visual and automated analysis showed almost perfect agreement (κ = 0.82 and κ = 0.86, respectively) for both nitrite and leukocyte esterase, but moderate agreement for erythrocytes (κ = 0.51). Interpretation of clinically relevant (nitrite and/or leukocyte esterase positive) samples showed almost perfect agreement (κ = 0.88). Urinary dipsticks show similar test characteristics with urinary culture as gold standard, with sensitivities of 0.92 and 0.91 and specificities of 0.37 and 0.41 for visual and automated interpretation respectively.Automated and visual dipstick analysis show near perfect agreement and perform similarly in predicting bacteriuria. However, automated analysis requires maintenance and occasionally measurement errors can occur. [ABSTRACT FROM AUTHOR]

AbstractBackgroundObjectiveDesign and settingSubjectsMain outcome measureResultsConclusionsIncreases in opioid prescriptions have been described; however, recent trends and prescribing patterns of analgesics in Dutch general practice are largely unknown.To investigate recent changes in the number of analgesic prescriptions, and the indications for prescribing strong opioids. Furthermore, we aim to identify risk factors for chronic opioid use in Dutch general practice.A retrospective cohort study from 1 July 2013 to 31 June 2022, using a primary care practice based research network.Patients with ≥1 prescription for analgesics during the study period were included.Changes in the number of prescriptions for paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs) and opioids in Dutch general practice during the 9-year study period. Moreover, we analyzed indications for prescribing strong opioids by the general practitioner (GP).A total of 18,433 analgesic users were identified. Over time, prescriptions for paracetamol, NSAIDs and weak opioids decreased, while the number of strong opioid prescriptions increased. General practitioners prescribed more strong opioids for non-malignant pain, whereas prescriptions for malignant pain remained stable over time. Risk factors for chronic opioid use (≥90 days) included older age, lower educational level, smoking status and having a history of a musculoskeletal or psychological disorder, a malignancy or sexual, physical or psychological abuse.Considering the increase in strong opioid prescriptions for benign conditions, GPs need to be vigilant for patients who are at risk for chronic use. Regular monitoring and awareness for psychosocial factors in treatment of chronic pain may be key in preventing harms associated with persistent opioid use. [ABSTRACT FROM AUTHOR]

Background: Seasonal influenza vaccination coverage in Italian older adults is insufficient and well below the minimum target of 75%. In Italy, most influenza vaccine doses are administered by general practitioners (GPs), whose number has been declining. In parallel, the number of patients per GP and GP workload increased dramatically, which theoretically may impair vaccination counselling. In this ecological study, we aimed to assess whether influenza vaccination coverage in older adults is associated with the density of GPs having high number of patients. Methods: The study outcome was the influenza vaccination coverage rate in adults aged ≥ 65 years and registered in 20 Italian regions over the last 23 years. The independent variable of interest was the proportion of GPs with more than 1,500 adult patients, which is an imposed normative ceiling. This latter variable was considered as a proxy of GP overload. By adopting a panel regression approach, different specifications of fixed- and random-effects models were run to assess the association of interest, when adjusted for several social structural, economic and healthcare-related variables. Results: Over the last two decades, most regions showed a negative association between influenza vaccination coverage rates and the density of GPs with a high number of patients. This latter negative association was confirmed (P < 0.05) in different panel model specifications. In particular, in the fully adjusted two-way fixed-effects model, each 10% increase in the number of GPs with more than 1,500 patients was associated with a 1.7% decrease in influenza vaccination coverage. However, this association was present only in region-years where at least 18% of GPs were deemed overloaded. Conclusions: In the upcoming years, the number of Italian GPs is projected to decline further. At the same time, the aging Italian population will determine an even greater workload for GPs. This study demonstrated that increased GP workload may partially explain the spatiotemporal variation in influenza vaccination uptake in the Italian elderly. With the imperative of increasing or at least maintaining influenza vaccination coverage rates, several short- and mid-term initiatives should be implemented in order to optimize GP workload during seasonal immunization campaigns. [ABSTRACT FROM AUTHOR]

Background: Having knowledge of the dental procedures that necessitate endocarditis prophylaxis is of high importance. Therefore, the aim of the present study was to determine the knowledge level and attitudes of general medical and dental practitioners, dental specialists, and cardiologists in Tehran and Hamadan about endocarditis. Methods: This cross-sectional study was carried out on 420 general medical and dental practitioners, dental specialists, and cardiologists in Tehran and Hamadan provinces in 2015. The questionnaire used in this research consisted of three parts as follows: part one: information on cardiac diseases; part two: dental procedures requiring endocarditis prophylaxis; part three: antibiotic diet in endocarditis prophylaxis. Independent t-test, one-way ANOVA, and chi-square tests were conducted to analyze the data. All the analyses were performed in SPSS version 16. Results: The results showed that 86.7 had a relatively favorable and 10.5% of subjects had a favorable level of knowledge about endocarditis. Also, 58.6% of subjects had a poor attitude toward endocarditis prophylaxis. There was a significant relationship between knowledge and attitude, age, gender, and work experience (P < 0.001). There was a significant relationship between knowledge and attitude, and job groups; dental specialists had a more favorable knowledge and positive attitude than others (P < 0.001). Conclusion: We recommended developing more practical training programs in dental schools on cardiac diseases, and dental procedures requiring endocarditis prophylaxis and antibiotic diets. [ABSTRACT FROM AUTHOR]

Introduction: Dengue is a significant public health issue in the Urabá region, accounting for 37.5% of morbidity and 41.7% of mortality resulting from dengue in the department of Antioquia (Colombia) in 2018. Clinical Practice Guidelines (CPGs) are tools based on Evidence-Based Medicine, intended for medical personnel to bridge the gap between proven intervention efficacy and clinical decision-making. This study aims to identify barriers and facilitators in the implementation of CPGs for dengue patient care by healthcare officials in the municipalities of the banana axis in the Urabá region. Methodology: From a multifaceted approach to implementation research, a mixed method study that combines qualitative and quantitative approaches, was conducted during the years 2020 and 2021, using combined instruments to identify determinants (Guide Indicative Factors, Individual factors of health professionals, Patient factors, Professional interactions, Incentives and resources, Capacity for organizational change, and lastly Social, political, and legal factors) affecting adherence to the Comprehensive Clinical Care Guide for Patients with Dengue (GACIPD). Semi-structured interviews and focus groups with healthcare workers were conducted to assess determinants based on clinical experience. Questionnaires on determinants of GACIPD adherence, using an adapted version of the Chronic Disease Implementation Checklist (TICD), were also employed. Qualitative analysis of the interviews and focus groups used a concept-based coding framework. The questionnaire responses were analyzed using Likert scaling and frequency counts of determinants within and across domains. Participants included general practitioners, other health professionals, researchers, academics, and administrators. Results: There was a total of 103 participants in focus groups, 7 in semi-structured interviews, and 136 participants through questionnaires. Among the domains studied, the identification of barriers and facilitators emphasized institutional factors and individual factors. Organizational change capacity was identified as a major barrier, with only 3.6% of respondents indicating that their institution adjusted the prioritization of adequate care according to the guideline. The GACIPD domain received the highest facilitator rating, with 66.7% acceptance due to its practicality, simplicity, clarity, documentation, and ease of implementation, despite this, only 10% of professionals completely agree that their work is in accordance with the GACIPD. The determinant of patient factors was significant in the negative perception of adherence to GACIPD. Conclusions: Although barriers outweighed facilitators for GACIPD adherence, determinants for its use were generally positive, as most participants reported it as being a complete, documented, and easy-to-implement guide. The lack of knowledge of the guidelines impacting health professional's decision making was identified as a potentially modifiable barrier, and educational strategies could be implemented to overcome it. The region requires greater emphasis on the management of chronic health conditions, comorbidities, and coinfections of dengue with other endemic diseases. Author summary: Dengue is a significant public health issue in the Urabá, this region reported around 40% of morbidity and mortality for the disease in the department of Antioquia (Colombia) in 2018. Clinical Practice Guidelines are tools intended for medical personnel to bridge the gap between proven intervention efficacy and clinical decision-making. A study was conducted s to identify determinants affecting adherence to the Comprehensive Clinical Care Guide for Patients with Dengue. Focus groups, questionnaires, and interviews were used. Participants included general practitioners, other health professionals, researchers, academics, and administrators. The barrier most frequently identified by participants was organizational change capacity, however individual health professionals also identified a lack of interest in self-learning and knowledge of the guidelines. On the other hand, among facilitators, they identified the guideline's inherent characteristics. Although barriers outweighed facilitators for GACIPD adherence, determinants for its use were generally positive, as most participants reported it as being a complete, documented, and easy-to-implement guide. The lack of interest in self-learning and knowledge of the guidelines was identified as a potentially modifiable barrier and educational strategies could be implemented to overcome it. [ABSTRACT FROM AUTHOR]

Background: Breast cancer is the most common cancer in women in many countries. Breast cancer is a multifactorial disease. This study investigates the possible influencing factors and preventive measures for breast cancer. Methods: The data for this study were obtained from WHO databases. First, age standardization was performed, followed by a correlation analysis. Relationships between the mortality rates of breast cancer and the possible influencing factors were analyzed. The significant results from the correlation analysis were analyzed using a stepwise regression analysis. In order to find out whether the application of a uniform screening program can reduce breast cancer mortality, the countries were divided into groups according to the time of initiation of the screening program, and breast cancer mortality was compared. Results: The correlation analysis showed a significant relationship with breast cancer mortality for 15 of 30 potential influencing factors. A stepwise multivariate regression analysis was performed with these 15 factors, which revealed 13 relevant factors. Two factors were more relevant: the number of radiotherapy units per 100,000 inhabitants and the proportion of the population (over 50 years of age) with a social network. These were followed by the proportion of general practitioners and obstetricians, as well as healthcare expenses. Breast cancer mortality differed between the countries that introduced the screening program in the 1990s and those that did so in the 2020s. Conclusions: A country's healthcare system influences breast cancer mortality through prevention, diagnosis. and treatment. Regular screening, counseling for socially disadvantaged women, and prompt treatment are important factors. In the future, prevention measures should also aim to strengthen the social environment. The prescription of social activities should be used as preventive care. [ABSTRACT FROM AUTHOR]

Background: A longer duration of untreated psychosis (DUP) is associated with poorer treatment outcomes. Screening for psychosis spectrum disorders in the primary care setting could help support the earlier detection and treatment of individuals in need. However, the acceptability of screening for psychosis in this setting as part of routine care is currently unknown. Methods: We conducted a qualitative interview study with providers and service users who participated in an early psychosis screening program conducted in an integrated behavioral health primary care (IBH-PC) setting. Interviews were recruited from one of eight WellSpace Federally Qualified Health Center IBH-PC clinics in the Sacramento, CA area. Transcripts of the recorded interviews were analyzed using thematic analysis. Results: In total, 12 providers and eight service users participated in the interviews. Most service user and provider participants were supportive of psychosis screening in an IBH-PC setting, but not as part of the general practitioner consultation due to the brief, non-behavioral health nature of many of the appointments, and the expected low prevalence of psychosis in this population. The support of leadership, adequate training and support, staff turnover, and organizational changes were all seen to impact the successful implementation of the program. Different barriers and facilitators were considered important at each stage of the process from introducing the screening procedures to service users; to determining when, where, and how to screen; and how to effectively manage the referral and post-referral stages. Conclusions: Despite the additional challenges of screening in an IBH-PC setting relative to secondary mental health services, the process was considered acceptable and feasible to providers and service users. Services that plan to conduct psychosis screening in their clinics need to consider the challenges and their potential solutions to implementation at each stage of the screening process. [ABSTRACT FROM AUTHOR]

Background: Multiple myeloma often presents with vague and non-specific symptoms. Many patients are diagnosed in unplanned rather than elective (planned) diagnostic pathways. This study investigates the diagnosis of multiple myeloma in unplanned pathways and the association with patient characteristics, disease profile, and survival. Methods: We conducted a nationwide register-based study, including all patients diagnosed with multiple myeloma in Denmark in 2014–2018. Patients were categorised as diagnosed in an unplanned pathway if registered with an acute admission within 30 days prior to the multiple myeloma diagnosis and no other previously registered pathway to this diagnosis. Unplanned pathways were compared to all other pathways combined. Results: We included 2,213 patients diagnosed with multiple myeloma, hereof 32% diagnosed in an unplanned pathway. Comorbidity, no prior cancer diagnosis, a history of few visits to the general practitioner (GP), multiple myeloma complications at diagnosis, high-risk cytogenetics, and advanced cancer stage were associated with a higher probability of being diagnosed in an unplanned pathway. For example, 24.4% (95% confidence interval (CI): 21.8–27.0) of patients with low comorbidity (Charlson Comorbidity Index (CCI) score 0) were diagnosed in an unplanned pathway as were 50.9% (95% CI: 45.6–56.1) of patients with high comorbidity (CCI score 3+). For patients with dialysis need at the time of diagnosis the probability was 66.0% (95% CI 54.2–77.8) and 30.9% (95% CI: 28.9–32.9) for patients with no dialysis need. Patients diagnosed in an unplanned pathway had inferior survival (hazard ratio 1.44 (95% CI: 1.26–1.64)). However, this association was not seen in analyses restricted to patients surviving for more than three years. Conclusions: High comorbidity level, few usual GP visits, advanced disease status at diagnosis, and complications were associated with diagnosis in an unplanned pathway. Further, patients diagnosed in an unplanned pathway had inferior survival. Promoting earlier diagnosis and preventing unplanned pathways may help improve survival in multiple myeloma. [ABSTRACT FROM AUTHOR]

Background: The aim of this study is to explore the influence of GPs'information, motivation and behavior skills on EM prescribing behavior in urban and suburban districts. Method: A cross-sectional study was conducted from June to November 2022 cross 3 urban districts and 4 suburban districts in Beijing. The structural equation model was used to analyze the factors influencing the essential medicine prescription behavior among general practitioners in urban and suburban districts. Results: A total of 511 valid questionnaires were collected. There was a statistically significant difference in mean scores for personal motivation and behavioral skills between urban GPs and suburban GPs. For urban GPs, the path analysis revealed that the social motivation had a direct effect on the essential medicine prescribing behavior (β = 0.225, p < 0.05). In contrast, for suburban GPs, both social motivation and personal motivation had a direct effect on the essential medicine prescribing behavior, respectively (β = 0.175, p < 0.05; β = 0.193, p < 0.01). Conclusion: Social motivation of urban GPs were positively and significantly associated with essential medicine prescribing behavior. Social motivation and personal motivation of suburban GPs were positively and significantly associated with essential medicine prescribing behavior. Therefore, various corresponding policies and measures should be developed to promote the National Essential Medicines Policy in China. [ABSTRACT FROM AUTHOR]

Background: Primary care is an essential pillar of health systems. Many countries have implemented different policies to improve access to primary care. However, persistent challenges remain. This paper offers a critical analysis of the evolution of primary care coverage in Portugal, focusing on the number of patients without an assigned general practitioner (GP). Methods: We collected and analyzed publicly available data from 2009 to 2023 to decompose primary care coverage in three components: the number of patients enrolled in primary care units (demand-side effect), the number of GPs measured in full-time equivalent (supply-side effect), and the average number of patients on each GP's list (patient-to-GP ratio, capturing a productivity effect). We provide national and local level estimates for these three components. Results: Between 2009 and 2023, there was an overall decline in the number of patients enrolled in primary health care units. Concurrently, there was also a net decrease of GPs measured in full-time equivalent. Additionally, there was a progressive reduction in the average number of patients on each GP's list. The rise in the number of patients without an assigned GP is attributed not only to a reduction in the number of physicians, but also to a decrease in the patient load per doctor. Conclusions: Hiring additional GPs may not suffice to enhance coverage. Achieving higher coverage may imply revisiting patient load per doctor or considering alternative care models. Understanding the challenges related to GP coverage is critical for improving the efficiency of primary care. [ABSTRACT FROM AUTHOR]

Background: In Germany, skin cancer screening (SCS) is available free of charge every two years to all those with statutory health insurance over the age of 35. General Practitioners (GP) can carry out the screening if they have completed an 8-hour training course. GPs play a crucial role in the implementation of SCS and act as gatekeepers between initial patient contact and referral to dermatologists. Objective: To record how comprehensively GPs carry out SCS in terms of patient information and body examination, as well as to explore GPs opinions on the feasibility of SCS. Methods: A cross-sectional survey was conducted. A questionnaire was sent to GPs with permission to perform SCS in two regions of Germany (Bavaria and Saxony) between August and September 2021. Data were analyzed using descriptive analysis. Subgroup analysis was performed according to regions (federal state, location of physician´s office), professional experience (experience in years, number of monthly screenings, age) and gender. Open questions were evaluated using qualitative content analysis. Results: In the survey, 204 GPs responded. Genitalia (40.7%, 83/203), anal fold (62.3%, 127/204) and oral mucosa (66.7%, 136/204) were the least examined body regions during screening. Information on risks (false-positive findings: 18.6%, 38/203; false-negative findings: 13.2%, 27/203; overdiagnosis: 7.8%, 16/203) and benefits (48.0%, 98/202) were not always provided. GPs who performed screenings more frequently were more likely to provide information about the benefits of SCS (p<0.001; >10 vs. <5 screenings per month). Opinions were provided on uncertainties, knowledge requirements, structural and organizational requirements of SCS, SCS training and evaluation. The organization and remuneration of the SCS programme was seen as a barrier to implementation. GPs expressed uncertainties especially in unclear findings and in dermatoscopy. Conclusion: Uncertainties in the implementation of the SCS should be addressed by offering refresher courses. Good networking between GPs and dermatologists is essential to improve SCS quality. [ABSTRACT FROM AUTHOR]

Objectives: Relatives of patients who died after euthanasia or physician-assisted suicide (EAS) might need (specific) aftercare. We examined if and how physicians provide aftercare to bereaved relatives of patients who died after EAS, and which patient-, physician- and process characteristics are associated with providing aftercare. Methods: A cross-sectional questionnaire study was conducted among 127 physicians (general practitioners, clinical specialists, and elderly care physicians) in the Netherlands. Associations were examined using multivariable logistic regression analyses. Results: Most physicians had had at least one follow-up conversation with bereaved relatives (77.2%). Clinical specialists less often provided aftercare compared to GPs. Also, aftercare was more often provided when the deceased had a cohabiting partner. Topics addressed during aftercare conversations included looking back on practical aspects of the EAS trajectory, the emotional experience of relatives during the EAS trajectory and relatives' current mental wellbeing. A minority of aftercare conversations led to referral to additional care (6.3%). Conclusion: Aftercare conversations with a physician covering a wide-range of topics are likely to be valuable for all bereaved relatives, and not just for "at risk" populations typically targeted by policies and guidelines. [ABSTRACT FROM AUTHOR]

Background: In Germany, general practitioners play a pivotal role in palliative care provision. Caring for patients with palliative care needs can be a burden for general practitioners, highlighting the importance of self-care and mental health support. This study aimed to explore the role of palliative care in general practitioners' daily work, the stressors they experience, their coping mechanisms, and the potential benefits of Advance Care Planning in this context. Methods: An exploratory approach was employed, combining a short quantitative survey with qualitative interviews. The analysis was based on a structuring qualitative content analysis, following a deductive-inductive procedure and integrating the Stress-Strain Model and Lazarus' Transactional Model of Stress and Coping. We recruited eleven general practitioners to take part in the study. Results: General practitioners viewed palliative care as integral to their practice but faced challenges such as time constraints and perceived expertise gaps. Societal taboos often hindered conversations on the topic of death. Most general practitioners waited for their patients to initiate the topic. Some general practitioners viewed aspects of palliative care as potentially distressing. They used problem-focused (avoiding negative stressors, structuring their daily schedules) and emotion-focused (discussions with colleagues) coping strategies. Still, general practitioners indicated a desire for specific psychological support options. Advance Care Planning, though relatively unfamiliar, was acknowledged as valuable for end-of-life conversations. Conclusions: Palliative care can be associated with negative psychological stress for general practitioners, often coming from external factors. Despite individual coping strategies in place, it is advisable to explore concepts for professional psychological relief. Trial registration: Not registered. [ABSTRACT FROM AUTHOR]

Background: Implantable cardioverter defibrillators (ICD) prevent sudden cardiac death (SCD). Patients with end-stage renal disease (ESRD) requiring dialysis are at a very high risk of infection from cardiac implantable electronic device (CIED) implantation as well as mortality. In the present study, we compared the long-term complications and outcomes between subcutaneous ICD (S-ICD) and transvenous ICD (TV-ICD) recipients. Methods: In this retrospective analysis, we analyzed a total of 43 patients with ESRD requiring dialysis who received either a prophylactic S-ICD (26 patients) or a single right ventricular lead TV-ICD (17 patients) at seven experienced centers in Germany. Follow-up was performed bi-annually, at the end of which the data concerning comorbidities and, if applicable, reason for death were checked and confirmed with patients' general practitioner, nephrologist and cardiologist. Results: The median follow up duration was 95.6 months (range 42.8–126.3 months). Baseline characteristics were without noteworthy significant differences between groups. During follow-up (FU), there were significantly more device-associated infections (HR 8.72, 95% confidence interval (CI), 1.18 to 12.85, p < 0.05) and device-associated hospitalizations (HR 10.20, 95% CI 1.22 to 84.61, p < 0.001), as well as a higher cardiovascular mortality (HR 9.17, 95% CI 1.12 to 8.33, p < 0.05), in the TV-ICD group. The number of patients requiring hospitalization for any reason was significantly higher in the TV-ICD group (HR 2.59, 95% CI 1.12 to 6.41, p < 0.05). There was no significant difference in overall mortality (HR 1.92, 95% CI 0.96 to 6.15, p = 0.274). Conclusions: Our data suggest that, in this extended follow-up in seriously compromised renal patients on dialysis, the S-ICD patients have statistically fewer device infections and hospitalizations as well as lower cardiac mortality compared with the TV-ICD cohort. [ABSTRACT FROM AUTHOR]

Renal cell carcinoma accounts for a significant proportion of cancer diagnoses in Canadians. Over the past several years, the management of renal cell cancers has undergone rapid changes in all prognostic risk categories, resulting in improved oncologic outcomes. Novel strategies for metastatic disease make use of the synergy between checkpoints and angiogenesis inhibition. Moreover, combination checkpoint inhibition has demonstrated durable efficacy in some patients. Adjuvant immunotherapy has recently shown a survival benefit for the first time in select cases. Significant efforts are underway to explore new compounds or combinations for later-line diseases, such as inhibitors of hypoxia-inducible factors and radiolabeled biomolecules targeting tumor antigens within the neoplastic microenvironment for precise payload delivery. In this manuscript, we provide a comprehensive review of the available data addressing key therapeutic areas pertaining to systemic therapy for metastatic and localized disease, review the most relevant prognostic tools, describe local therapies and management of CNS disease, and discuss practice-changing trials currently underway. Finally, we focus on some of the practical aspects for general practitioners in oncology caring for patients with renal cell carcinoma. [ABSTRACT FROM AUTHOR]

AbstractObjectiveDesign, setting, and subjectsResults and interpretation\nKEYPOINTSTo explore the views of general practitioners and physiotherapists on the current model of care for patients with musculoskeletal disorders in Norwegian primary care, and if the English First Contact Practitioner model, where patients have access to multiple professional groups with musculoskeletal health expertise, could inform service development.We analysed interviews with five GPs and 11 physiotherapists and used Lipsky’s theories about street-level bureaucracy and Foucault’s theories of mechanisms of power and institutional structures to explore task shifting and cooperation between different professions.The empirical material reflected a multi-faceted discourse about skill-mix in primary care, where financial factors, perceptions about competence, and task preferences moderated attitudes to task shifting. Competition and cooperation coexist between the professions, and the seemingly gradual blurring between historical hegemony and new models of care creates both alliances and rivalries. Examples of deviations from the Choosing Wisely principles and evidence-based practice indicate that both general practitioners and physiotherapists balance the roles of patient advocate, gatekeeper, and homo economicus, in a context where task shifting is challenged by established practice. It appears that the management of patients with musculoskeletal disorders is fragmented and to some extent reflects a supply-driven system.The demand on primary care is placing increasing pressure on general practitioners.Multidisciplinary teamwork has potential to improve primary care, for both healthcare professionals and for patients.In this study, it appeared that both competition and cooperation exist between general practitioners and physiotherapists around the management of patients with musculoskeletal disorders in primary care.There is a case for change in service delivery for patients with musculoskeletal disorders in Norwegian primary care.The demand on primary care is placing increasing pressure on general practitioners.Multidisciplinary teamwork has potential to improve primary care, for both healthcare professionals and for patients.In this study, it appeared that both competition and cooperation exist between general practitioners and physiotherapists around the management of patients with musculoskeletal disorders in primary care.There is a case for change in service delivery for patients with musculoskeletal disorders in Norwegian primary care. [ABSTRACT FROM AUTHOR]

Primary care workplaces where occupational exposure to blood and body fluids may occur should have policies and procedures in place to manage such incidents. All healthcare workers should be immunised against hepatitis B and ideally should have documentation of their antibody response to vaccination. Knowledge of hepatitis B immune status helps streamline the response to any exposure. Most occupational exposures carry a low risk of transmission of bloodborne viruses, and management can often be undertaken in general practice. Urgent risk assessment and management is crucial. If postexposure prophylaxis for hepatitis B or HIV is required, the earlier it is given, the more likely it is to be effective. Two-drug HIV postexposure prophylaxis is now more accessible because generic formulations of the drug combination are available, and general practitioners can prescribe this on a private prescription. [ABSTRACT FROM AUTHOR]

Background ST-elevation myocardial infarction (STEMI) is a cardiac emergency that requires prompt diagnosis and treatment. We describe a challenging and complex case of managing acute STEMI in a patient with severe anaemia, deranged clotting profile, and infective prodrome. Case summary A 54-year-old Caucasian gentleman was referred by his general practitioner as an emergency after presenting with acute onset of chest pain. His electrocardiogram revealed anterior ST elevation. His past medical history includes a mechanical aortic valve, requiring anticoagulation, and a recent gastrointestinal bleed secondary to type C gastritis. His initial presentation was further complicated by severe anaemia, deranged clotting profile, and elevated infective markers. He required a prompt transfer to the catheterization laboratory to assess and stabilize the situation. We discuss the emerging challenges during treatment, particularly as the diagnosis of septic embolism from infective prosthetic valve endocarditis was unfolding, requiring urgent cardiac surgery. Discussion Acute coronary vessel closure leading to STEMI from septic embolism secondary to prosthetic aortic valve endocarditis is very rare. It is essential to consider the whole picture of the presentation for timely diagnosis and tailored treatment. [ABSTRACT FROM AUTHOR]

Introduction: Aspirin nowadays is widely used in pregnancy, but implementation among gynecologists took nearly four decades. For a complete insight in the implementation of aspirin, community midwives are to be involved. Community midwives do not have authority to prescribe aspirin and have to refer to a general practitioner or consultant obstetrician for a prescription. Methods: The study was an online, national pilot survey about the implementation of aspirin use during pregnancy among independently practicing community midwives consisting of 29 items with five categories: background, advising, prescribing, possible indications, and clinical practice. Results: Forty-seven community midwives completed the survey between April and May 2021. All respondents had experience on advising aspirin use in pregnancy. History of preterm pre-eclampsia or HELLP syndrome was identified as a risk factor for developing utero-placental complications by 97.9% of the community midwives. Moderate risk factors in women with otherwise low-risk pregnancy were identified by >75% of the participants. Practical issues in prescribing aspirin were experienced by one-third of the respondents. Suggestions were made to obtain authority for community midwives to prescribe aspirin and improve collaboration with consultant obstetricians and general practitioners. Conclusions: Community midwives seem to be adequate in identifying risk factors for developing utero-placental complications in women with otherwise low-risk pregnancy. Practical issues for prescribing aspirin occur often. Obtaining authority for community midwives to prescribe aspirin after education should be considered and consulting a consultant obstetrician should become more accessible to overcome the practical issues. Further educating community midwives and general practitioners might improve implementation rates and perinatal outcomes. [ABSTRACT FROM AUTHOR]

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This study investigated the marginal adaptation of three recently introduced bioceramic root repair materials, EdgeBioCeramic RetroFill, Endocem MTA, and One-Fil PT, using VP-SEM analysis. Extracted single-rooted lower incisors were used to simulate retrograde fillings. The results showed no statistically significant differences in the marginal gap between the materials and the dentin walls. All three materials exhibited good dimensional stability, with gap sizes comparable to previously published research on similar materials. The mean GAP was 3.91 ± 2.56 for EdgeBioCeramic RetroFill, 4.32 ± 2.69 for Endocem MTA, and 4.50 ± 2.54 for One-Fil PT. This study employed VP-SEM, a valuable tool for analyzing bioceramic materials without altering their properties. The findings suggest the possibility of daily clinical use of these bioceramics by endodontists and general practitioners that could find applications in retrograde fillings and perforation repairs. However, further in vivo studies are needed to confirm long-term stability and assess the influence of sample preparation methods. [ABSTRACT FROM AUTHOR]

Background: The purpose of this study was to evaluate the knowledge, attitude, and current practices about prevention of meningococcal disease among general practitioners (GPs) and primary care pediatricians (PCPs) in Italy. Methods: A cross-sectional survey was carried out between February 2022 and July 2023 among a random sample of GPs and PCPs in Southern Italy. The data were collected using a questionnaire accessible via an internet link with the free software Google Forms®. Results: Regarding the participants' knowledge toward meningococcal vaccinations, 84.2% of the PCPs and more than half of the GPs (55.2%) knew that the meningococcal B (MenB) vaccination is recommended for infants from the second month of life and 84.2% and 82.7% of the PCPs were aware that quadrivalent meningococcal ACWY (MenACWY) vaccine is recommended for children in the second year of life and adolescents, respectively. The GPs and PCPs considered vaccination against meningococcal disease to be very effective and safe with average values of 8.8 and 8.7, respectively, on a scale ranging from 1 to 10. Those with an older age, those who knew the medical conditions that expose patients to a higher risk of contracting meningococcal disease, and those who self-rated their knowledge on meningococcal disease as excellent/very good were more likely to consider the vaccination to be very effective and safe. Only 15.5% of the GPs and more than half of the PCPs (54.3%) administered anti-meningococcal vaccines to their patients. GPs and females were less likely to administer anti-meningococcal vaccines to their patients, whereas those who acquired information on meningococcal vaccinations by scientific journals were more likely to administer meningococcal vaccines. Conclusions: The findings of the survey highlighted the need of a greater engagement of GPs and PCPs in the immunization campaigns in order to increase meningococcal vaccination coverage. [ABSTRACT FROM AUTHOR]

Aims: Increasing numbers of patients with advanced heart failure and significant comorbidity and social barriers are considered for left ventricular assist devices (LVADs). We sought to examine health care utilization post‐LVAD implantation, including the influence of individual‐level socio‐economic position and multimorbidity. Methods and results: We conducted a Danish nationwide cohort study linking individual‐level data from clinical LVAD databases, the Scandiatransplant Database, and Danish national medical and administrative registries. Socio‐economic position included cohabitation status, educational level, and employment status. Multimorbidity was defined as two or more chronic conditions from at least two chronic disease groups. Health care utilization (hospital activity, general practice activity, and redeemed medical prescriptions) within 2 years post‐discharge after LVAD implantation was evaluated using descriptive statistics at 0.5 year intervals. We identified 119 patients discharged alive with first‐time LVAD implanted between 2006 and 2018. The median age of the patients was 56.1 years, and 88.2% were male. Patients were followed until heart transplantation, LVAD explantation, death, 31 December 2018, or for 2 years. The median follow‐up was 0.8 years. The highest median use of health care services was observed 0–0.5 years post‐LVAD discharge compared with the subsequent follow‐up intervals: 0.5–1, 1–1.5, and 1.5–2 years, respectively. The median (interquartile range) number of hospitalizations was 10 (7–14), bed days 14 (9–28), outpatient visits 8 (5–12), telephone contacts with a general practitioner 4 (2–8), and total redeemed medical prescriptions 26 (19–37) within 0–0.5 years post‐LVAD discharge compared with the median utilization within the consecutive follow‐up periods [e.g. within 0.5–1 year: hospitalizations 5 (3–8), bed days 8 (4–14), outpatient visits 5 (3–8), telephone contacts 2 (0–5), and redeemed medical prescriptions 24 (18–30)]. The median use of health care services was stable from 0.5 years onwards. The median number of hospitalizations and bed days was slightly higher in patients living alone with a low educational level or low employment status within 0–0.5 years post‐LVAD implantation. Finally, the median number of in‐hospital days and redeemed prescriptions was higher among patients with pre‐existing multimorbidity. Conclusions: Among patients who underwent LVAD implantation, health care utilization was high in the early post‐LVAD discharge phase and was influenced by socio‐economic position. Multimorbidity influenced the number of in‐hospital days and redeemed prescriptions during the 2 year follow‐up. [ABSTRACT FROM AUTHOR]

Introduction: The health system in Sudan faces several challenges, including increasing numbers of patients, shortages of health supplies, and disparities in the distribution of health services. Guidelines implementation improves patients' outcomes and ensures efficient use of the resources in such a resource limited country. The study aimed to assess the implementation of the clinical practice guidelines among family medicine doctors working in the primary health care centers in Khartoum and Gezira states to provide baseline data about the current practice in Sudan. Methods: Descriptive cross-sectional facility-based survey, conducted from April to December 2021, on 373 of the practicing family-medicine doctors. A total of 101 Primary health care centers were surveyed (77 centers in Khartoum state and 24 in Gezira state). The questionnaire was pilot tested on a small group of physicians to improve clarity and reduce response bias. Descriptive statistics were used to summarize the data and analyzed by frequency tables. Chi square and logistic regression tests were used to determine the association between categorized variables. P value < 0.05 was considered statistically significant. Results: Most of the practicing family-medicine doctors (98.4%) reported implementation of the guidelines. Moreover, (68.6%) of them received training programs which were organized and funded by the Sudan Ministry of Health. The local Sudanese guidelines were difficult to access and not regularly updated. Services unavailability and inaccessibility (87.1%), health insurance factors (83.9%), and patient factors (81.2%) were the most frequent barriers to guidelines implementation. Service cost (79.9%), lack of regular training programs (79.9%), absence of local guidelines (77.2%), lack of continuity in the comprehensive care process (63.0%), and lack of time (57.1%) were also reported as barriers to guidelines implementation. Conclusion: Guidelines implementation is limited by unavailability and inaccessibility of the health services and the health insurance limited coverage. Expansion of the health insurance coverage, organization of continuous training programs, encouragement of regular auditing and issuing regulations to ensure the use of updated guidelines, dissemination of the updated national guidelines along with establishing clinical governance in Sudan can be useful tools for policymakers in the optimum allocation of public health resources. [ABSTRACT FROM AUTHOR]

Background: Irritable bowel syndrome (IBS) is a disorder of gut-brain interaction characterized by recurrent abdominal pain related to defecation and/or associated to a change in bowel habits. According to the stool type, four different IBS subtypes can be recognized, constipation predominant (IBS-C), diarrhea predominant (IBS-D), mixed (IBS-M), and undefined (IBS-U). Patients report that their IBS symptoms are exacerbated by food. Thus, it is important to find a nutritional approach that could be effective in reducing IBS symptoms. Objective: The present work is a post hoc analysis of the previously published DOMINO trial. It aimed to evaluate the effects of a self-instructed FODMAP-lowering diet smartphone application on symptoms and psychosocial aspects in primary care IBS stratifying the results for each IBS subtypes. Design: Post hoc analysis. Methods: Two hundred twenty-two primary care IBS patients followed a FODMAP-lowering diet for 8 weeks with the support of a smartphone application. Two follow-up visits were scheduled after 16 and 24 weeks. IBS–Symptoms Severity Score (IBS-SSS), quality of life (QoL), and adherence and dietary satisfaction were evaluated. Results: After 8 weeks, IBS-SSS improved in all IBS subtypes (p < 0.0001). Physician Health Questiionnaire (PHQ-15) improved only in IBS-D (p = 0.0006), whereas QoL improved both in IBS-D (p = 0.01) and IBS-M (p = 0.005). Conclusion: This post hoc analysis showed that the app is useful in all IBS subtypes; thus, it could be used as an effective tool by both general practitioners and patients to manage symptoms in primary care. Trial registration: Ethical Commission University Hospital of Leuven reference number: S59482. Clinicaltrial.gov reference number: NCT04270487. Plain language summary: What is already known about this subject? The low FODMAP (fermentable oligo-, di-, and monosaccharides and polyols) diet has shown efficacy for controlling IBS (irritable bowel syndrome) symptoms in small controlled trials in tertiary care patients. As this approach requires several visits with an experienced dietitian, it seems less suitable for primary care. What are the new findings? The benefit of the FODMAP lowering app was already present at 4 weeks and persisted during follow-up until 24 weeks. How might it impact on clinical practice in the foreseeable future? Given its superiority to standard first-line pharmacotherapy, and its ease of use, a FODMAP lowering app has the potential to become the preferred first-line treatment for primary care IBS. [ABSTRACT FROM AUTHOR]