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Background: Opiate use disorders are a worldwide disease. In the last 30 years, opiate maintenance treatment prescription changed patients’ and also changed physicians’ practice. General practitioners (GPs) have to deal with patients on OMT who are in acute pain. Both clinically and pharmacologically, the treatment of acute pain in patients with an opiate use disorder and an OMT(opiate maintenance treatment) differs from that given to patients with other conditions. As this situation is complex, it was important to explore whether GPs recognised this problem and whether they managed it effectively.Objective: To investigate how GPs identify and manage situations of acute pain in patients with opiate use disorders and OMT. Methods: semi-structured interviews were used as a data collection technique with a purposive sample of practising GPs. Data collection continued until saturation was reached. Analysis was undertaken using a thematic analysis method. Two independent researchers, working blind and pooling data, carried out the analysis. Results: The maximal variation of the sample and saturation of data were reached with 11 GPs. The thematic analysis resulted in 4 main themes: (1) the importance and difficulties of professional links , (2) the specific clinical reasoning , (3) the importance of the doctor-patient relationship and (4) the particular characteristics of OMT patients. Conclusion: The complexity of pain and opioid dependence represents significant challenges for GPs. It is hard to achieve a balance between pain relief and opiate use disorder treatment. These questions are particularly important in general practice, where the practitioner may feel insufficiently trained, and isolated. Existing protocols do not seem to be in line with general practice. The number of patients on OMT has increased since it was first marketed; GPs will increasingly have to deal with these situations and will have to issue their own recommendations.

Multimorbidity is a concept encompassing all medical conditions of a patient. The concept links to the European definition of Family Medicine (FM). However, the definition of multimorbidity was unclear. Consequently the European General Practice Research Network (EGPRN) considered the concept as important and set up a research group to clarify it. Using a step by step method the EGPRN operated a systematic review of literature to design a comprehensive definition of Multimorbidity, a Delphi consensus to translate it in 10 European languages, a European wide qualitative survey to explore how European FPs perceived and worked with this concept and, whether they would add new themes to it, a nominal group to draw a research agenda for FM and a pilot cohort survey to test if this broad concept was reducible. The main results are: 'Multimorbidity is defined as any combination of chronic disease with at least one other disease (acute or chronic) or bio-psychosocial factor (associated or not) or somatic risk factor. Any bio-psychosocial factor, any risk factor, the social network, the burden of diseases, the health care consumption and the patient's coping strategies may function as modifiers (of the effects of multimorbidity). Multimorbidity may modify the health outcomes and lead to an increased disability or a decreased quality of life or frailty'. The use of the Wonca's core competencies of FM and the dynamics of the doctor-patient relationship looked useful for FPs in detecting and managing Multimorbidity and patient's complexity. The concept seems reducible for clinical use.

Introduction: Therapeutic alliance is a term most commonly associated with psychotherapeutic treatment, but recently its use has become increasingly significant in the other fields of medicine. An increasing amount of evidence implies that the quality of the therapeutic alliance between the doctor and patient substantially affects treatment outcomes. A European consensus chose the Working Alliance Inventory - Short Revised (WAI-SR) scale as the most efficient for European primary care. This paper presents the process of establishing the semantic and cultural equivalence of the two WAI-SR scales in Slovene. Method: As a part of a larger international project, a group of four experts translated the two WAI SR scales (physician and patient versions) from English into Slovene. Twenty-six Slovenian family medicine doctors participated in the process of obtaining semantic, idiomatic, experiential and conceptual equivalence in translation using a Delphi consensus procedure. Afterward, a cultural equivalence was made to adapt the translations within the national context. Results: Agreement on translation was achieved after two Delphi rounds. The back-translation and cultural equivalence were accomplished without major problems, with some minor additional linguistic corrections. Conclusion: A Slovene version of the WAI-SR scale was successfully adapted and is available for further scale validation and research on therapeutic alliance.

Background: Looking at what makes General Practitioners (GPs) happy in their profession, may be important in increasing the GP workforce in the future. The European General Practice Research Network (EGPRN) created a research team (eight national groups) in order to clarify the factors involved in GP job satisfaction throughout Europe. The first step of this study was a literature review to explore how the satisfaction of GPs had been studied before. The research question was "Which factors are related to GP satisfaction in Clinical Practice?" Methods: Systematic literature review according to the PRISMA statement. The databases searched were Pubmed, Embase and Cochrane. All articles were identified, screened and included by two separate research teams, according to inclusion or exclusion criteria. Then, a qualitative appraisal was undertaken. Next, a thematic analysis process was undertaken to capture any issue relevant to the research question. Results: The number of records screened was 458. One hundred four were eligible. Finally, 17 articles were included. The data revealed 13 subthemes, which were grouped into three major themes for GP satisfaction. First there were general profession-related themes, applicable to many professions. A second group of issues related specifically to a GP setting. Finally, a third group was related to professional life and personal issues. Conclusions: A number of factors leading to GP job satisfaction, exist in literature They should be used by policy makers within Europe to increase the GP workforce. The research team needs to undertake qualitative studies to confirm or enhance those results.

Background: Strategies for the involvement of primary care in the management of patients with presumed or diagnosed dementia are heterogeneous across Europe. We wanted to explore attitudes of primary care physicians (PCPs) when managing dementia: i) the most popular cognitive tests ii) who had the right to initiate or continue cholinesterase inhibitor or memantine treatment and iii) therelationship between the permissiveness of these rules/guidelines and PCP’s approach in the dementia investigations and assessment.Methods: Key informant Survey. Setting: Primary care practices across 25 European countries. Subjects: Four hundred forty-five PCPs responded to a self-administered questionnaire. Two-step cluster analysis was performed using characteristics of the informants and the responses to the survey. Main outcome measures: Two by two contingency tables with odds ratios and 95% confidence intervals were used to assess the association between categorical variables. A multinomial logistic regression model was used to assess the association of multiple variables (age class, gender and perceived prescription rules) with the PCPs’ attitude of “trying to establish a diagnosis of dementia on their own”. Results: Discrepancies between rules/guidelines and attitudes to dementia management was found in many countries. There was a strong association between the authorization to prescribe dementia drugs and pursuing dementia diagnostic work-up (odds ratio, 3.45; 95% CI 2.28- 5.23). Conclusions: Differing regulations about who does what in dementia management seemed to affect PCP’s engagement in dementia investigations and assessment. PCPs who were allowed to prescribe dementia drugs also claimed higher engagement in dementia work-up than PCPs who were not allowed to prescribe.

Using a step-by-step careful research process this thesis created a European research team to design its research protocol. The systematic review of literature showed a huge amount of different definitions (132 different definitions) and a great diversity in those definitions (with 1631 distinct single criteria). The comprehensive definition of the concept of multimorbidity issued from the systematic literature review was a relevant step.The translations of the concept were finalized for Bulgarian, Castellan, Catalan, Croatian, French, Galician, German, Greek, Italian and Polish. The qualitative studies confirmed the concept for FPs and added two modificators of Multimorbidity with the Wonca’s core competencies of FM and the doctor-patient relationship dynamics as a help to detect and manage multimorbidity.The research agenda focused future research needs on the measurement of multimorbidity and its impact on patient. It also enhanced the need for the simplification of this concept using a pragmatic approach to determine the useful variables of the concept on its outcomes and its link to complexity., En utilisant un processus de recherche minutieux étape par étape, cette thèse a créé une équipe de recherche européenne pour concevoir son protocole de recherche. L'examen systématique de la littérature a montré une énorme quantité de définitions différentes (132 définitions différentes) et une grande diversité dans ces définitions (avec 1631 critères uniques distincts). La définition globale du concept de multimorbidité découlant de la revue systématique de la littérature est une étape pertinente.Les traductions du concept ont été finalisées pour le bulgare, le castellan, le catalan, le croate, le français, le galicien, l'allemand, le grec, l'italien et le polonais. Les études qualitatives ont confirmé le concept en MG et ont ajouté deux modificateurs de la Multimorbidité aux compétences fondamentales de la Wonca et la dynamique des relations médecin-patient comme aide à la détection et à la gestion de la multimorbidité. Le programme de recherche a porté sur les besoins futurs de recherche sur la mesure de la multimorbidité et son impact sur le patient. Elle a également renforcé la nécessité de simplifier ce concept en utilisant une approche pragmatique pour déterminer les variables utiles du concept sur ses résultats et son lien avec la complexité.

INTRODUCTION: Multimorbidity is a health issue with growing importance. During the last few decades the populations of most countries in the world have been ageing rapidly. Bulgaria is affected by the issue because of the high prevalence of ageing population in the country with multiple chronic conditions. The AIM of the present study was to validate the translated definition of multimorbidity from English into the Bulgarian language. MATERIALS AND METHODS: The present study is part of an international project involving 8 national groups. We performed a forward and backward translation of the original English definition of multimorbidity using a Delphi consensus procedure. RESULTS: The physicians involved accepted the definition with a high percentage of agreement in the first round. The backward translation was accepted by the scientific committee using the Nominal group technique. DISCUSSION: Some of the GPs provided comments on the linguistic expressions which arose in order to improve understanding in Bulgarian. The remarks were not relevant to the content. The conclusion of the discussion, using a meta-ethnographic approach, was that the differences were acceptable and no further changes were required. CONCLUSIONS: A native version of the published English multimorbidity definition has been finalized. This definition is a prerequisite for better management of multimorbidity by clinicians, researchers and policy makers.

Patients coming to their family physician (FP) usually have more than one condition or problem. Multimorbidity as well as dealing with it, is challenging for FPs even as a mere concept. The World Health Organization (WHO) has simply defined multimorbidity as two or more chronic conditions existing in one patient. However, this definition seems inadequate for a holistic approach to patient care within Family Medicine. Using systematic literature review the European General Practitioners Research Network (EGPRN) developed a comprehensive definition of multimorbidity. For practical and wider use, this definition had to be translated into other languages, including Croatian. Here presented is the Croatian translation of this comprehensive definition using a Delphi consensus procedure for Forward/Backward translation. 23 expert FPs fluent in English were asked to rank the translation from 1 (absolutely disagreeable) to 9 (fully agreeable) and to explain each score under 7. It was previously defined that consensus would be reached when 70 % of the scores are above 6. Finally, a backward translation from Croatian into English was undertaken and approved by the authors of the English definition. Consensus was reached after the first Delphi round with 100% of the scores above 6; therefore the Croatian translation was immediately accepted. The authors of the English definition accepted the backward translation. A comprehensive definition of multimorbidity is now available in English and Croatian, as well as other European languages which will surely make further implications for clinicians, researchers or policy makers.

Background. Dementia was affecting 855.000 patients in France in 2007. Lanmeur's rural hospital population was representative of the French nursing home's population. The followup was assumed by local GPs, which is also usual care in France for nursing homes. The study looked at clinical and paraclinical data transmitted at the institutionalization time of patients suffering from dementia. Aim. showing that admission letters did allow establishing a diagnosis of dementia for the GPs. Method. we included all patients with dementia at the time of institutionalization between July 2000 and July 2007. We searched in the admission letters for 25 criteria extracted from the French guidelines for dementia and Alzheimer disease diagnosis (multiple cross-sectional analysis per year). Results. 293 patients were included. The median number of diagnostic criteria present in the letters of admission is 1 (first quartile: zero, third quartile: 4, and maximum: 12). Conclusions. the data in admission letters did not allow the diagnosis of dementia according to the French guidelines. We know that dementia is underchecked and undertreated in France according to the same guidelines. What consequences did this lack of basic data give on motivation for treatment and recurrent diagnosis process for GPs? This has to be evaluated.