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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.

Background: The 'GP Daffodil Standards for Advanced Serious Illness and End of Life Care' was launched by the Royal College of General Practitioners and Marie Curie in 2019 to support improvement of end-of-life care activity in primary care., Aim: To undertake and independent evaluation of the implementation of the Daffodil Standards., Method: A multi-method evaluation, informed by Normalisation Process Theory. An online survey with GPs in the UK (Phase 1) and semi-structured interviews with a sub-sample of survey responders (Phase 2) were used to map end-of-life activities and understand the use of the standards. Illustrative case studies of good practice were used to outline recommendations to improve and sustain the implementation of the standards (Phase 3). Data were analysed both quantitatively (Phase 1: descriptive statistics) and qualitatively (Phases 2 and 3: framework analysis)., Results: For the Phase 1 survey ( n = 82) and Phase 2 semi-structured interviews ( n = 8), results demonstrated the motivation to undertake end-of-life care activities and active use of the standards. GPs find it difficult to take this further because of limitations in resources and capacity. There is the indication that a misperception exists for both the purpose and role of the standards. For Phase 3, two case studies are complete, providing more in-depth practical insights into the planning, use, and implementation of the standards. All data collection stopped in December 2023., Conclusion: Final results were reported and best practice shared, along with recommendations to sustain the ongoing implementation of the Daffodil Standards., (© British Journal of General Practice 2024.)

Background: There is a rising prevalence of multimorbidity, particularly in older patients, and a need for evidence-based medicines management interventions for this population. The Supporting Prescribing in Older Adults with Multimorbidity in Irish Primary Care (SPPiRE) trial aimed to investigate the effect of a general practitioner (GP)-delivered, individualised medication review in reducing polypharmacy and potentially inappropriate prescriptions (PIPs) in community-dwelling older patients with multimorbidity in primary care., Methods and Findings: We conducted a cluster randomised controlled trial (RCT) set in 51 GP practices throughout the Republic of Ireland. A total of 404 patients, aged ≥65 years with complex multimorbidity, defined as being prescribed ≥15 regular medicines, were recruited from April 2017 and followed up until October 2020. Furthermore, 26 intervention GP practices received access to the SPPiRE website where they completed an educational module and used a template for an individualised patient medication review that identified PIP, opportunities for deprescribing, and patient priorities for care. A total of 25 control GP practices delivered usual care. An independent blinded pharmacist assessed primary outcome measures that were the number of medicines and the proportion of patients with any PIP (from a predefined list of 34 indicators based predominantly on the STOPP/START version 2 criteria). We performed an intention-to-treat analysis using multilevel modelling. Recruited participants had substantial disease and treatment burden at baseline with a mean of 17.37 (standard deviation [SD] 3.50) medicines. At 6-month follow-up, both intervention and control groups had reductions in the numbers of medicines with a small but significantly greater reduction in the intervention group (incidence rate ratio [IRR] 0.95, 95% confidence interval [CI]: 0.899 to 0.999, p = 0.045). There was no significant effect on the odds of having at least 1 PIP in the intervention versus control group (odds ratio [OR] 0.39, 95% CI: 0.140 to 1.064, p = 0.066). Adverse events recorded included mortality, emergency department (ED) presentations, and adverse drug withdrawal events (ADWEs), and there was no evidence of harm. Less than 2% of drug withdrawals in the intervention group led to a reported ADWE. Due to the inability to electronically extract data, primary outcomes were measured at just 2 time points, and this is the main limitation of this work., Conclusions: The SPPiRE intervention resulted in a small but significant reduction in the number of medicines but no evidence of a clear effect on PIP. This reduction in significant polypharmacy may have more of an impact at a population rather than individual patient level., Trial Registration: ISRCTN Registry ISRCTN12752680., Competing Interests: The authors have declared that no competing interests exist.

Objective: To assess general practitioners' (GPs') knowledge of and practice in the diagnosis and management of endometriosis following the publication of updated French national guidelines in 2017., Materials and Methods: A descriptive, anonymous, epidemiological survey of 102 GPs in the Picardie region of France., Results: Only 25% of the GPs considered that they knew enough about endometriosis for their routine clinical practice. This proportion was 58.9% amongst GPs with an university diploma in gynaecology and 31.4% amongst those participating in continuing medical education courses on gynaecology. Only 19.6% of the GPs were aware of the updated French national guidelines. With regard to five main suggestive, localizing signs of endometriosis, dyspareunia, dysmenorrhoea and infertility were mentioned as being of diagnostic value by 55.9%, 37.3% and 43.1% of the GPs, respectively; in contrast, functional urinary tract disorders and painful defecation were not mentioned very often. GPs with a qualification in gynaecology and those participating in continuing medical education in gynaecology knew more about treating endometriosis., Conclusion: In the Picardie region of France, GPs appear to be only moderately aware of how to manage endometriosis; this probably contributes to the diagnostic delay associated with this condition. GPs with a university diploma in gynaecology and those participating in continuing medical education in gynaecology appeared to have a better grasp of the subject. Continuing medical education on this topic should therefore be promoted and expanded., Competing Interests: Declaration of Competing Interest The authors state no conflicts of interest., (Copyright © 2021 Elsevier Masson SAS. All rights reserved.)

Background: Early in the COVID-19 pandemic, general practices were asked to expand triage and to reduce unnecessary face-to-face contact by prioritizing other consultation modes, e.g., online messaging, video, or telephone. The current study explores the potential barriers and facilitators general practitioners experienced to expanding triage systems and their attitudes towards triage during the COVID-19 pandemic., Method: A mixed-method study design was used in which a quantitative online survey was conducted along with qualitative interviews to gain a more nuanced appreciation for practitioners' experiences in the United Kingdom. The survey items were informed by the Theoretical Domains Framework so they would capture 14 behavioral factors that may influence whether practitioners use triage systems. Items were responded to using seven-point Likert scales. A median score was calculated for each item. The responses of participants identifying as part-owners and non-owners (i.e., "partner" vs. "non-partner" practitioners) were compared. The semi-structured interviews were conducted remotely and examined using Braun and Clark's thematic analysis., Results: The survey was completed by 204 participants (66% Female). Most participants (83%) reported triaging patients. The items with the highest median scores captured the 'Knowledge,' 'Skills,' 'Social/Professional role and identity,' and 'Beliefs about capabilities' domains. The items with the lowest median scores captured the 'Beliefs about consequences,' 'Goals,' and 'Emotions' domains. For 14 of the 17 items, partner scores were higher than non-partner scores. All the qualitative interview participants relied on a phone triage system. Six broad themes were discovered: patient accessibility, confusions around what triage is, uncertainty and risk, relationships between service providers, job satisfaction, and the potential for total digital triage. Suggestions arose to optimize triage, such as ensuring there is sufficient time to conduct triage accurately and providing practical training to use triage efficiently., Conclusions: Many general practitioners are engaging with expanded triage systems, though more support is needed to achieve total triage across practices. Non-partner practitioners likely require more support to use the triage systems that practices take up. Additionally, practical support should be made available to help all practitioners manage the new risks and uncertainties they are likely to experience during non-face-to-face consultations.

Background: Despite their adverse effects, antipsychotics are frequently prescribed to manage behavioural and psychological symptoms of dementia (BPSD). At present, we do not have a good understanding of general practitioners' (GPs) current management of BPSD., Aims: To explore the knowledge, attitudes, and opinions of GPs regarding the prescribing of psychoactive drugs in managing BPSD., Methods: This was a descriptive cross-sectional study. A questionnaire was adapted from a previous study and piloted with three GPs and was posted to a census sample of all GPs working in counties Cork and Kerry, Ireland. We collected and analysed both quantitative and qualitative data., Results: Of the 456 eligible GPs who received the questionnaire, 168 GPs returned completed questionnaires (response rate 36.8%). All respondents (100%, 168/168) believed that antipsychotics did not benefit all patients with BPSD. The majority of GPs (69%, 116/168) routinely recommended non-pharmacological interventions before medication to manage BPSD. Most GPs (60.7%, 102/168) welcomed more training and experience to improve their management of BPSD. The qualitative comments provided by GPs described a pressure to prescribe from nursing home staff. GPs highlighted that the management of BPSD is difficult in daily practice and felt that antipsychotics still have a role to play., Conclusions: This study identified several factors influencing the prescription of antipsychotics for patients with BPSD as well as the prescribing dilemmas faced by GPs in their daily practice. These findings can be used to guide future interventions aimed at reducing inappropriate prescribing in dementia care.

Objectives: The study aimed to develop a brief geriatric assessment (BGA) tool for the general practitioner to evaluate geriatric syndromes in community-dwelling older adults., Design: A cross-sectional study., Setting: 58 communities from four aging cities in Taiwan., Participants: 1,258 community-dwelling older adults aged 65 years and above., Measurements: The BGA targeted physical function impairment, cognitive impairment, and mood impairment. The cutoff values of physical function tests (handgrip strength and 6-meter walk test [6MWT]) were estimated by receiver operating characteristic analysis. Second, the diagnostic validity of the BGA was calculated in terms of sensitivity, specificity, and predictive values, which were compared to corresponding comprehensive geriatric assessment (CGA) items. Third, the associated risk factors of geriatric syndromes were selected using stepwise logistic regression. Finally, we combined items selected from literature and CGA and then proposed a practical BGA framework., Results: The proposed BGA comprised dominant handgrip strength, 6MWT, self-report personal birthday, address, and telephone number, question 'Do you have depressive mood for the past two weeks?', Rinne tuning-fork tests, Snellen scale, and body mass index. It evaluated multidimensional aspects of geriatrics syndromes including physical, cognitive, mood, and sensory impairment, sarcopenia, and nutrition status. Sensitivities in the Taiwan BGA items ranged from 48% for dominant handgrip strength to 97.6% for 6MWT corresponding to physical impairment; 58.3% for cognitive impairment corresponding to Short Portable Mental Status Questionnaire; 62.7% for mood impairment corresponding to Geriatric Depression Scale. The Taiwan BGA for the general practitioner takes less than 10 minutes and is suitable in the community setting., Conclusion: Early management of geriatric syndromes in the community is important. The current study demonstrated a practical BGA tool for the general practitioner to comprehensively assess geriatric syndromes in community-dwelling older adults., Competing Interests: All authors declare that they have no competing interests.

Aims: Creation of an algorithm that includes the most important parameters (history, clinical parameters, and anamnesis) that can be linked to heart failure, helping general practitioners in recognizing heart failure in an early stage and in a better follow-up of the patients., Methods and Results: The algorithm was created using a consensus-based Delphi panel technique with fifteen general practitioners and seven cardiologists from Belgium. The method comprises three iterations with general statements on diagnosis, referral and treatment, and follow-up. Consensus was obtained for the majority of statements related to diagnosis, referral, and follow-up, whereas a lack of consensus was seen for treatment statements. Based on the statements with good and perfect consensus, an algorithm for general practitioners was assembled, helping them in diagnoses and follow-up of heart failure patients. The diagnosis should be based on three essential pillars, i.e. medical history, anamnesis and clinical examination. In case of suspected heart failure, blood analysis, including the measurement of NT-proBNP levels, can already be performed by the general practitioner followed by referral to the cardiologist who is then responsible for proper diagnosis and initiation of treatment. Afterwards, a multidisciplinary health care process between the cardiologist and the general practitioner is crucial with an important role for the general practitioner who has a key role in the up-titration of heart failure medication, down-titration of the dose of diuretics and to assure drug compliance., Conclusions: Based on the consensus levels of statements in a Delphi panel setting, an algorithm is created to help general practitioners in the diagnosis and follow-up of heart failure patients., Competing Interests: The authors have read the journal's policy and have the following Competing Interests to declare: Dr G. Weijers, Dr A. Ciarka, Dr M. Goethals and Dr S. Droogmans received a consultancy fee from Novartis Pharma Belgium for the interpretation of the results, development of the algorithm and review of the manuscript. Michael Maris and Caroline Verhestraeten are employees of Novartis Pharma Belgium. Daphné Debleu was doing an internship during the development of this project at Novartis Pharma Belgium. There are no patents, products in development or marketed products associated with this research to declare. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

Objective: General practitioners (GPs) play a key role in the provision of general outpatient palliative care (AAPV) for the majority of patients at the end of life. The aim of this study was to evaluate the quality of End-of-Life Care (EoLC) from a GPs' perspective using the German version of the General Practice End of Life Care Index (GP-EoLC-I). Methods: Between autumn 2018 and spring 2019, all registered and eligible GPs in two counties in Lower Saxony (n=190) were asked to participate in a survey on EoLC using the German version of the self-assessment questionnaire GP-EoLC-I. The index comprises two subscales: clinical care (13 items) and practice organisation (12 items). The summated index of both subscales measures the quality of EoLC by GPs (25 items; range 14-40). The questionnaire was supplemented by questions on sociodemographic data, indicators for good palliative care (PC) and requirements to improve PC. Quantitative data were analysed by descriptive statistics and free text answers by conventional content analysis according to Hsieh and Shannon. Results: 52 GPs (females: n=16) of 34 practices (single practices: n=26) participated in the study. The mean GP-EoLC-I was 27.5 (SD 4.5). The items revealed potential for improvement: systematic identification of patients with potential PC needs, multidisciplinary case conferences to discuss PC patients, application of care protocols and symptom assessment tools, documentation of patients' wishes and beliefs as well as inclusion of family and carers. Regarding the indicators for good PC, the most relevant indicators from the GPs' perspective were collaboration and coordination, integration of relatives, advance care planning and documentation. As requirements to improve PC, GPs highlighted further training and the use of standardised tools such as instruments to support the systematic identification of PC patients. Conclusions: To our knowledge for the first time in Germany, an internationally tested self-assessment questionnaire measuring the quality of EoLC by GPs was applied. The GP-EoLC-I in this study was slightly lower than the index of GPs in the United Kingdom. Including relatives and family carers, implementing tools to support early identification of PC patients and strengthening cooperation between GPs and other stakeholders in PC may be promising approaches to improve general PC and EoLC in Germany., Competing Interests: The authors declare that they have no competing interests., (Copyright © 2020 van Baal et al.)

Background: Tinnitus is a phenomenon that affects approximately 15% of the adult population. A minority of patients will experience chronic bothersome tinnitus that has a detrimental effect on their quality of life. Management of such tinnitus is challenging for healthcare practitioners. Primary care services are the first point at which patients seek expert medical advice about their condition and General Practitioners (GPs) must be equipped with the knowledge to appropriately triage and guide patients., Aims: To date, there has been little research surrounding tinnitus management in Ireland. The aim of this study is to determine how GPs assess and manage tinnitus patients in Ireland., Methods: This is a quantitative study in the form of an online survey. The 15-item questionnaire was made available through SurveyMonkey and was distributed by email to GPs in Cork, Kerry and South Dublin., Results: The survey obtained 43 responses. Sixty-three percent of GPs do not follow any routine criteria for onward referral. Forty percent feel that tinnitus has sufficient impact on their practice to warrant further training. GPs expressed a need for clearer guidance on tinnitus management and better access to resources such as ENT (ear nose throat), MRI (magnetic resonance imaging) and audiology., Conclusions: This study demonstrates there is wide variation in how tinnitus is evaluated and managed by GPs, which represents a gap in clinical care. We recommend further research, implementation of a service model for tinnitus, national clinical guidelines, training pathways for primary care staff and establishment of regional direct-access tinnitus clinics throughout Ireland.

Background: A number of studies have previously been published on the benefits of GP appraisal. Ours is the first study that compares the views of doctors registered before and after the introduction of appraisals on various core elements of the appraisal process., Aim: This study aimed to explore potential differences, between GPs qualifying before and those after the introduction of NHS appraisals, on the utility of the appraisal process. Additionally, to discover the perceived impact of appraisals on interaction with colleagues and patients., Design and Setting: Suffolk appraisers were recruited to distribute a paper questionnaire, in two sections, for each appraisal undertaken over a 12-month period. The first part of the questionnaire related to that specific appraisal. The second part, seven questions using Likert scales and free-text comments, asked about the appraisal process in general. The feedback from the second part forms the data for this study., Results: Overall, doctors tended to agree that appraisals had a beneficial impact in the core areas investigated. However, there was a significant difference between generations: those registered before 1998 were less likely to find NHS appraisals beneficial. Both groups reported that preparation took up too much time. Opinions regarding the impact of appraisals on interaction were evenly divided amongst appraisees, with the older cohort more likely to report negatively., Conclusions: There is a generational difference amongst GP in the perceived utility of NHS appraisal. Current plans to redesign the process to make appraisals less onerous will be welcomed by both groups.

Background: The strengthening of the general practitioners' (GPs') role in palliative care (PC) has been identified as a top priority in order to improve PC in Germany. This study aims at exploring positive and negative experiences in PC in Germany from the perspectives of patients, relatives, and health care professionals in a primary care setting. Methods: Between March 2017 and August 2017, a total of 16 interviews with patients, relatives, GPs, medical assistants, and nurses were conducted. The Critical Incident Technique (CIT) was used to explore factors that influence excellent versus undesirable events in PC provision. Two researchers independently defined and counted critical incidents (CIs) from interview transcripts, performed a thematic analysis, and clustered the CIs into dimensions. Results: In summary, 16 interviews contained 280 CIs, divided into 130 positive and 150 negative CIs. The thematic analysis resulted in seven content domains, with each including positive and negative CIs, respectively: 1) way of care provision, 2) availability of care providers, structures, medication, and aids, 3) general formal conditions of care provision, 4) bureaucracy, 5) working practices in health care teams, 6) quality and outcome of care provision, and 7) communication. Conclusions: The results raise awareness for the aspects that lead to successful or undesirable PC experiences, observed from different perspectives. They open up the potential for primary PC improvement. Future research will facilitate development and implementation of more tailored interventions in order to improve generalists' PC., Competing Interests: The authors declare that they have no competing interests., (Copyright © 2020 Stiel et al.)

Background: General Practitioners (GPs) are the main providers of primary palliative care (PPC). At the same time they are the main initiators of specialised palliative homecare (SPHC). In Germany, little is known about factors which influence GPs in their involvement of SPHC. Aim of our study is to identify factors that drive GPs to give value to and involve SPHC., Methods: A cross-sectional survey was performed. In 2018, questionnaires were mailed to 6000 randomly selected GPs from eight German federal states, focusing on the extent of GPs' palliative care activities and their involvement of SPHC., Results: With a response rate of 19.4% and exclusion of GPs working in SPHC-teams, n = 1026 questionnaires were appropriate for analysis. GPs valued SPHC support as the most "important/very important" for both "technical/invasive treatment measures" (95%) and availability outside practice opening hours (92%). The most relevant factor influencing perceived SPHC-importance was GPs' self-reported extent of engagement in palliative care (β = - 0.283; CI 95% = - 0.384;-0.182), followed by the perceived quality of utilised SPHC (β = 0.119; CI 95% = 0.048;0.190), involvement in treatment of palliative patients after SPHC initiation (β = 0.088; CI 95% = 0.042;0.134), and conviction that palliative care should be a central part of GPs' work (β = - 0.062; CI 95% = - 0.116;-0.008). Perceived SPHC-importance is also associated with SPHC-referrals (β =0.138; p < 0.001). The lower the engagement of GPs in palliative care, the more they involve SPHC and vice versa., Conclusions: GPs with low reported activity in palliative care are more likely to initialise SPHC for palliative care activities they do not deliver themselves for various reasons, which might mean that the involvement of SPHC is substitutive instead of complementary to primary palliative care. This finding and its interpretation should be given more attention in the future policy framework for (specialised) palliative homecare., Trial Registration: German Clinical Trials Register DRKS00014726 , 14.05.2018.

Aim: This study explores the General Practice (GP) experience of Gestational Diabetes Mellitus (GDM). Much has been written about patient perspectives, yet little is known about the GP perspective at initial diagnosis and management. GDM is increasingly managed in the secondary and tertiary sector, the confidence of GPs and their role in ongoing care has not been examined. Given GDM's poor follow up rates, all aspects of the patient journey warrant close examination., Methods: Through purposive and snowball sampling, we conducted semi-structured interviews with GPs in Brisbane, Australia between April and October 2018. Data collection, until saturation, and analysis were concurrent, and the Leximancer analysis tool assisted with content analysis and suggestion of themes., Results: Dominant themes include uncertainty/urgency and feeling under-utilised. GPs have a pragmatic approach in the face of uncertainty, and adopt one of several strategies to meet patient needs. A key issue that may impact on long term follow up and high quality GP-patient relationships is concern about the patient being 'taken away' by the hospital. Communication with the hospital is generally perceived as poor., Conclusions: The experience of GPs in the initial diagnosis and management of GDM may assist in improving GDM follow up., Competing Interests: Disclosures We have no conflicts of interest to disclose., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Primary care physicians are uniquely placed to offer holistic, patient-centred care to patients with T2DM. While the recent FDA-mandated cardiovascular outcome trials offer a wealth of data to inform treatment discussions, they have also contributed to increasing complexity in treatment decisions, and in the guidelines that seek to assist in making these decisions. To assist physicians in avoiding treatment inertia, Primary Care Diabetes Europe has formulated a position statement that summarises our current understanding of the available T2DM treatment options in various patient populations. New data from recent outcomes trials is contextualised and summarised for the primary care physician. This consensus paper also proposes a unique and simple tool to stratify patients into 'very high' and 'high' cardiovascular risk categories and outlines treatment recommendations for patients with atherosclerotic cardiovascular disease, heart failure and chronic kidney disease. Special consideration is given to elderly/frail patients and those with obesity. A visual patient assessment tool is provided, and a comprehensive set of prescribing tips is presented for all available classes of glucose-lowering therapies. This position statement will complement the already available, often specialist-focused, T2DM treatment guidelines and provide greater direction in how the wealth of outcome trial data can be applied to everyday practice., Competing Interests: Declaration of Competing Interest XC has received consultancy and speaker fees from Abbott Laboratories, AstraZeneca, Boehringer Ingelheim, Eli Lilly, Merck Sharp & Dohme, Novartis, Novo Nordisk, Roche and Sanofi; and grant funding from AstraZeneca, Boehringer Ingelheim, Novartis and Sanofi. SS has received consultancy and speaker fees from Amgen, Boehringer Ingelheim, Napp Pharmaceuticals, Novartis and Roche; advisory board, consultancy and speaker fees from AstraZeneca, Eli Lilly, Merck Sharp & Dohme, Novo Nordisk and Sanofi; and trial grant funding from AstraZeneca, Janssen Pharmaceutica, Sanofi and Servier Laboratories. SB has received advisory board and speaker fees from AstraZeneca, Bayer, Boehringer Ingelheim, Janssen Pharmaceutica and Novo Nordisk; advisory board fees from Abbott Laboratories, Merck Sharp & Dohme, Sanofi and Xeris Pharmaceuticals; and speaker fees from Eli Lilly. SBH has received advisory board and consultancy fees from Abbott Laboratories, AstraZeneca, Boehringer Ingelheim, Eli Lilly, Janssen Pharmaceutica, Merck, Novo Nordisk and Sanofi. SJ received speaker fees from AstraZeneca, Boehringer Ingelheim, Eli Lilly, Novo Nordisk and Sanofi. MM-C has received fees from AstraZeneca, Bayer, Boehringer Ingelheim, Eli Lilly, GlaxoSmithKline, Merck Sharp & Dohme, Novartis, Novo Nordisk and Sanofi; and grant funding from AstraZeneca, Eli Lilly, GlaxoSmithKline, Merck Sharp & Dohme and Sanofi. AMJN has received speaker fees from Becton Dickinson; and advisory board feed from Sanofi. PT has received advisory board, consultancy and speaker fees from Eli Lilly; advisory board and consultancy fees from Boehringer Ingelheim and advisory board fees from Novo Nordisk. KK has received advisory board, consultancy and speaker fees from Novo Nordisk and Sanofi; consultancy and speaker fees from Berlin Chemie, Boehringer Ingelheim, Novartis, Novo Nordisk, Roche, Sanofi and Servier Laboratories; and grant funding from AstraZeneca, Boehringer Ingelheim, Eli Lilly, Merck Sharp & Dohme, Novartis, Novo Nordisk, Pfizer, Sanofi and Servier Laboratories., (Copyright © 2020. Published by Elsevier B.V.)

The early diagnosis of cutaneous melanoma provides less aggressive treatment reducing mortality. General practitioners are responsible for cancer diagnoses in the Brazilian Public Health System and therefore play a crucial role in the prevention and early detection of melanoma. To assess the melanoma knowledge of a primary healthcare physician, the general practitioner, compared to a dermatologist. General practitioners and dermatologists answered a questionnaire about melanoma and the management of suspected cases. The results of both groups were compared. The sample consisted of 80 specialists and 160 general practitioners. When asked about the "ABCDE" rule, 96.2% of the dermatologists knew about it, compared to 34.4% of the general practitioners. The percentage of dermatologists who examined the whole skin of the patient at high risk for melanoma was 90% vs. 24.5% amongst general practitioners. The most cited reasons for the absence of the examination of patients at risk for melanoma were lack of time at the consultations (17.6% specialists, 66.1% generalists) and an excessive number of patients (17.6% specialists, 61.5% generalists). General practitioner has less knowledge about melanoma compared to the dermatologists and presents deficient behaviors about patients at risk or who have suspicious lesions, indicating the need for training and continuing education.

Background: The benefits from the combination of 4 clinical information systems (CISs)-electronic health records (EHRs), health information exchange (HIE), personal health records (PHRs), and telehealth-in primary care depend on the configuration of their functional capabilities available to clinicians. However, our empirical knowledge of these configurations and their associated performance implications is very limited because they have mostly been studied in isolation., Objective: This study aims to pursue 3 objectives: (1) characterize general practitioners (GPs) by uncovering the typical profiles of combinations of 4 major CIS capabilities, (2) identify physician and practice characteristics that predict cluster membership, and (3) assess the variation in the levels of performance associated with each configuration., Methods: We used data from a survey of GPs conducted throughout the European Union (N=5793). First, 4 factors, that is, EHRs, HIE, PHRs, and Telehealth, were created. Second, a cluster analysis helps uncover clusters of GPs based on the 4 factors. Third, we compared the clusters according to five performance outcomes using an analysis of variance (ANOVA) and a Tamhane T2 post hoc test. Fourth, univariate and multivariate multinomial logistic regressions were used to identify predictors of the clusters. Finally, with a multivariate multinomial logistic regression, among the clusters, we compared performance in terms of the number of patients treated (3 levels) over the last 2 years., Results: We unveiled 3 clusters of GPs with different levels of CIS capability profiles: strong (1956/5793, 37.36%), medium (2764/5793, 47.71%), and weak (524/5793, 9.04%). The logistic regression analysis indicates that physicians (younger, female, and less experienced) and practice (solo) characteristics are significantly associated with a weak profile. The ANOVAs revealed a strong cluster associated with significantly high practice performance outcomes in terms of the quality of care, efficiency, productivity, and improvement of working processes, and two noncomprehensive medium and weak profiles associated with medium (equifinal) practice performance outcomes. The logistic regression analysis also revealed that physicians in the weak profile are associated with a decrease in the number of patients treated over the last 2 years., Conclusions: Different CIS capability profiles may lead to similar equifinal performance outcomes. This underlines the importance of looking beyond the adoption of 1 CIS capability versus a cluster of capabilities when studying CISs. GPs in the strong cluster exhibit a comprehensive CIS capability profile and outperform the other two clusters with noncomprehensive profiles, leading to significantly high performance in terms of the quality of care provided to patients, efficiency of the practice, productivity of the practice, and improvement of working processes. Our findings indicate that medical practices should develop high capabilities in all 4 CISs if they have to maximize their performance outcomes because efforts to develop high capabilities selectively may only be in vain., (©Placide Poba-Nzaou, Sylvestre Uwizeyemungu, Xuecheng Liu. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 23.07.2020.)

Objectives: While the general practitioner (GP) in the Netherlands is the first point of entry to and gatekeeper of the healthcare system, no study exists to explore the experiences of women with female genital mutilation or cutting (FGM/C) in general practice. Therefore, the aim of this study is to look into the experiences of women with FGM/C in Dutch general practice., Methods: Semistructured interviews were held with 16 women with FGM/C. Sampling was purposeful. The interview guide and thematic analysis were based on the Illness Perception Model and Kleinman's Explanatory model. Interviews were held in English or Dutch. All data were anonymized, and recordings were transcribed verbatim. Transcripts were coded and thematically analyzed., Results: The women considered FGM/C to be connected to a range of health problems, for which not all of them sought medical care. They had difficulty discussing such a sensitive topic with their GP, did not know their problems could be relieved or perceived GPs to have insufficient knowledge of FGM/C. Lack of time during consultations and overall dissatisfaction with Dutch GP care hampered trust. They strongly preferred the GP to be proactive and ask about FGM/C., Conclusion: There is room for improvement as most women would like their GP to discuss their health problems related to FGM/C. GPs should take a proactive attitude and ask about FGM/C. In addition, to develop the trusted relationship needed to discuss sensitive topics and provide culturally sensitive person-centered care, sufficient time during consultations is needed., Competing Interests: The authors have declared that no competing interests exist.

Frequent attenders (FAs) of general practitioners (GPs) often complain of nonspecific physical symptoms that are difficult to define according to typical medical syndromes criteria but could be acknowledged as atypical manifestations of mental disorders. We investigated the possible correlation between somatic symptoms and panic-agoraphobic spectrum symptoms in a sample of 75 FAs of GPs in Italy, with particular attention to the impact on functional impairment. Assessments included the Patient Health Questionnaire, Panic-Agoraphobic Spectrum-Self-Report (PAS-SR) lifetime version, Global Assessment of Functioning, and Clinical Global Impression. The PAS-SR total and domains scores were significantly higher among low-functioning FAs, especially anxious somatizations, hypochondriasis, anxious expectation, and reassurance orientation domains, suggesting this undetected symptom may determine the selective attention to the physical symptoms, illness-phobic/hypochondriac elaboration, and GP frequent attendance, often aimed at searching for reassurance, leading to severe impact on overall functioning and often inefficacious treatments.

Background: The provision of minor surgical services is an established part of the task profile of general practitioners (GPs) in many countries in Europe and elsewhere. This study aimed to collect data on the clinical process and outcomes for specified minor surgical procedures undertaken in Irish general practice by GPs experienced in minor surgery in order to document the scope and safety of minor surgery being undertaken., Methods: Over a six-month period, 24 GPs in 20 practices recorded data on a pre-determined list of procedures undertaken in adults (aged 18 and older); procedures for ingrown toenails were also recorded for those aged 12-18 years. Clinical data were rendered fully anonymous by the participating GPs, entered onto the Excel database template and returned to the project team monthly., Results: On average, each practice undertook 212 procedures in a six-month period. The four most frequent procedures include two relatively non-invasive procedures (cryosurgical ablation of skin lesions and aspiration and/or injection of joints) and two more invasive procedures (full thickness excision of skin lesion and shave, punch or incisional biopsy). Overall, 83.8% of relevant specimens were submitted for histology. Combining benign and malignant cases, there was an overall 87% clinical and histological concordance; 85% of malignancies were suspected clinically. A complication was recorded in 0.9% after 1 month., Conclusions: Irish GPs with experience in minor surgery can provide a range of surgical services in the community safely.

Background: Although primary care settings provide a large-scale and high-reach opportunity for weight management and obesity prevention, the proportion of adults in the United Kingdom (UK) who report receiving weight management advice is limited. This study examines the self-reported frequency of assessing weight and providing weight management advice by General Practitioners (GPs) and Practice Nurses (PNs) working in primary care in the UK, and differences by practitioner characteristics., Methods: Cross-sectional survey with GPs and PNs in the UK (n = 2020), conducted January-March 2017. A mock consultation exercise assessed what factors led to calculating a patient's Body Mass Index (BMI) and whether weight management advice was given after determining the patient had an obese BMI. For all patients, practitioners were asked how often they calculated BMI, how often they gave weight management advice to patients with an obese BMI, and how often they utilised different advice or referral options (each: Always/Often vs. Less often/Never). Binary logistic regressions examined whether frequency of assessing weight and providing advice was associated with practitioner characteristics., Results: In the mock consultation, physical cues (40%) were most likely to prompt calculation of BMI, and half of practitioners (56%) provided weight management advice after determining the patient had an obese BMI, with GPs less likely to do so than PNs (Odds Ratio [OR] = 0.59, 95% CI: 0.47-0.75). Half of practitioners (58%) said they calculated the BMI of all patients Always/Often, with GPs less likely to do so than PNs (OR = 0.27, 95% CI: 0.21-0.34). Three quarters (78%) said they provided weight management advice to patients with an obese BMI Always/Often, with GPs less likely to do so than PNs (OR = 0.63, 95% CI: 0.47-0.85). Weight management advice was provided more frequently than referrals, particularly suggesting increased physical activity (93%) and diet modification (89%)., Conclusions: Consistent with previous research, the findings suggest that opportunities to provide weight management advice in primary care, including to patients with an obese BMI, are potentially missed. Future research should test alternative mechanisms to increase weight assessment and advice provision, examine the effectiveness of advice frequently given, and seek solutions to reported barriers for providing weight management advice.

Background: China's standardized training for residents of General Practitioners (GPs) is aimed at providing the postgraduate training for family doctors who will serve the primary health care institutions. The aim of this paper is to investigate the standardized training situation, satisfaction with standardized training, work situation, intention, satisfaction and attitude of GPs who have finished standardized training., Methods: This study was undertaken in 6 training hospitals in Gansu province using a questionnaire with 45 questions., Results: Approximately 275 residents of GPs were enrolled. Finally, 263 residents completed the questionnaire (95.64% response rate), including 133 females (50.57%) and 130 males (49.43%) with an average age of 28 years (standard deviation, 1.93 years; range, 25-36 years). Additionally, 56.65% were single and 43.35% were married. Of all subjects, 92.40% residents had obtained certification of standardized training for residents of GPs and only 39.54% residents were satisfied with monthly income during training. There were 171 oriented rural medical graduates, of whom, only 42.69% expressed the willing to continue working in the primary health care institutions after the serve time (6 years) expired. Around 86.31% of residents of GPs who had finished standardized training got jobs with more than half serving in the primary health care institutions. For medical institutions and sanitary bureau were clear about general medicine policies, only 29.96% subjects registered as GPs. Among the residents in general practice department, 68.42% were engaged in the diagnosis and treatment of common disease and frequently-occurring diseases as well as referral of patients. The percentage of residents who were satisfied with the job and income were 30.40 and 14.98%, respectively., Conclusion: Standardized training for residents of GPs in China is gradually improving. In order to cultivate more GPs and increase their willing to serve in the primary health care institutions, it is necessary to formulate and execute better policy of GPs, publize general medicine and improve the training quality.

Background: Dementia is under-diagnosed in primary care. Timely diagnosis and care management improve outcomes for patients and caregivers. This research evaluated the effectiveness of a nationwide Continuing Medical Education (CME) program to enhance dementia-related awareness, practice, knowledge and confidence of general practitioners (GPs) in Australia., Methods: Data were collected from self-report surveys by GPs who participated in an accredited CME program face-to-face or online; program evaluations from GPs; and process evaluations from workshop facilitators. CME participants completed surveys at one or more time-points (pre-, post-program, six to 9 months follow-up) between 2015 and 2017. Paired samples t-test was used to determine difference in mean outcome scores (self-reported change in awareness, knowledge, confidence, practice) between time-points. Multivariable regression analyses were used to investigate associations between respondent characteristics and key variables. Qualitative feedback was analysed thematically., Results: Of 1352 GPs who completed a survey at one or more time-points (pre: 1303; post: 1017; follow-up: 138), mean scores increased between pre-CME and post-program for awareness (M post-pre  = 0.9, p <  0.0005), practice-related items (M post-pre  = 1.3, p <  0.0005), knowledge (M post-pre  = 2.2, p <  0.0005), confidence (M post-pre  = 2.1, p <  0.0005). Significant increases were seen in all four outcomes for GPs who completed these surveys at both pre- and follow-up time-points. Male participants and those who had practised for five or more years showed greater change in knowledge and confidence. Age, years in practice, and education delivery method significantly predicted post-program knowledge and confidence. Most respondents who completed additional program evaluations (> 90%) rated the training as relevant to their practice. These participants, and facilitators who completed process evaluations, suggested adding more content addressing patient capacity and legal issues, locality-specific specialist and support services, case studies and videos to illustrate concepts., Conclusions: The sustainability of change in key elements relating to health professionals' dementia awareness, knowledge and confidence indicated that dementia CME programs may contribute to improving capacity to provide timely dementia diagnosis and management in general practice. Low follow-up response rates warrant cautious interpretation of results. Dementia CME should be adopted in other contexts and updated as more research becomes available.

Pharmacogenomic biomarker availability of Hungarian Summaries of Product Characteristics (SmPC) was assembled and compared with the information in US Food and Drug Administration (FDA) drug labels of the same active substance (July 2019). The level of action of these biomarkers was assessed from The Pharmacogenomics Knowledgebase database. From the identified 264 FDA approved drugs with pharmacogenomic biomarkers in drug label, 195 are available in Hungary. From them, 165 drugs include pharmacogenomic data disposing 222 biomarkers. Most of them are metabolizing enzymes (46%) and pharmacological targets (41%). The most frequent therapeutic area is oncology (37%), followed by infectious diseases (12%) and psychiatry (9%) (p < 0.00001). Most common biomarkers in Hungarian SmPCs are CYP2D6, CYP2C19, estrogen and progesterone hormone receptor (ESR, PGS). Importantly, US labels present more specific pharmacogenomic subheadings, the level of action has a different prominence, and offer more applicable dose modifications than Hungarians (5% vs 3%). However, Hungarian SmPCs are at 9 oncology drugs stricter than FDA, testing is obligatory before treatment. Out of the biomarkers available in US drug labels, 62 are missing completely from Hungarian SmPCs (p < 0.00001). Most of these belong to oncology (42%) and in case of 11% of missing biomarkers testing is required before treatment. In conclusion, more factual, clear, clinically relevant pharmacogenomic information in Hungarian SmPCs would reinforce implementation of pharmacogenetics. Underpinning future perspective is to support regulatory stakeholders to enhance inclusion of pharmacogenomic biomarkers into Hungarian drug labels and consequently enhance personalized medicine in Hungary.

Background and Objectives: In Australia, the uptake of the sentinel lymph node biopsy (SLNB) appears low despite clinical practice guideline recommendations. The aim of this study was to describe the knowledge and attitudes of general practitioners (GPs) to SLNB., Method: GPs were recruited at an annual conference and a skin cancer skills workshop, and using GP professional communications. A mixed methods approach comprised a cross-sectional questionnaire and, for a subset of participants, semi-structured interviews., Results: Overall, 231 GPs completed the questionnaire, of whom 23 were interviewed. One-third (32%) described themselves as quite or very familiar with the guidelines, and two-thirds (68%) thought that SLNB had an important role in the management of patients with melanoma. Of GPs who would discuss SLNB with eligible patients, <40% correctly identified that SLNB is recommended for patients with an invasive melanoma >1 mm thick., Discussion: GPs were generally supportive of SLNB. Familiarity with the guidelines was low, particularly regarding which patients should be considered for SLNB.

Introduction: A chest radiograph is one of the first-line diagnostic tools for general practitioners (GPs) to diagnose, monitor treatment, and predict the outcomes of diseases. In district hospitals, after clinical examination, GPs refer patients for imaging in the X-ray department. Radiologists specialize in interpretation of radiographs and provide a gold standard radiologist report to help diagnose support and influence patient management. A shortage of radiologists restricts continuity in radiology services and causes a delay in diagnosis, compromising the overall quality of service to patients. GPs are mandated to perform image interpretation on all chest radiographs taken at district hospitals and they sometimes request assistance from radiographers., Aim: The aim of this study was to explore methods used by GPs to interpret chest radiographs at district hospitals in the City of Tshwane, in South Africa., Methods: A qualitative, exploratory, and descriptive case study method of inquiry, with convenience sampling was used. Under discussion, the case studies were reconstructed in terms of themes. Recurring themes in these case studies were expounded and linked within the literature., Results: Results obtained from a sample of 15 participants showed that GPs used a free global search to scan radiographs without a preconceived orderly pattern. Their only training on image interpretation occurred during undergraduate education and training., Conclusions: It was concluded that the methods used by GPs for interpretations of chest radiographs were not systematic in approach, resulting in omission in identifying abnormalities in some structures of the chest/thoracic region. The researcher recommends that all GPs need continuous in-house training to acquire the knowledge of the systematic method of evaluating chest radiographs., (Copyright © 2020. Published by Elsevier Inc.)

Background: Research indicate that when general practitioners (GPs) refer their patients for specialist care, the patient often has long distance. This study had a twofold aim: in accordance to the GP's suspicion of cancer, we investigated the association between: 1) cancer patient's travel distance to the first specialised diagnostic facility and the GP's diagnostic strategy and 2) cancer patient's travel distance to the first specialised diagnostic facility and satisfaction with the waiting time and the availability of diagnostic investigations., Method: This combined questionnaire- and registry-based study included incident cancer patients diagnosed in the last 6 months of 2016 where the GP had been involved in the diagnostic process of the patients prior to their diagnosis of cancer (n = 3455). The patient's travel distance to the first specialised diagnostic facility was calculated by ArcGIS Network Analyst. The diagnostic strategy, cancer suspicion and the GP's satisfaction with the waiting times and the available investigations were assessed from GP questionnaires., Results: When the GP did not suspect cancer or serious illness, an insignificant tendency was seen that longer travel distance to the first specialised diagnostic facility increased the likelihood of the GP using 'wait-and-see' approach and 'medical treatment' as diagnostic strategies. The GPs of patients with travel distance longer than 49 km to the first specialised diagnostic facility were more likely to report dissatisfaction with the waiting time for requested diagnostic investigations (PR: 1.98, 95% CI: 1.20-3.28)., Conclusion: A insignificant tendency to use 'wait-and-see' and 'medical treatment' were seen among GPs of patients with long travel distance to the first diagnostic facility when the GP did not suspect cancer or serious illness. Long distance was associated with higher probability of GP dissatisfaction with the waiting time for diagnostic investigations.

Increasing physicians' awareness is one of the main ways to improve early diagnosis of rare diseases. A survey among physicians of different specialties to evaluate the knowledge about primary immunodeficiencies (PID) was conducted in 2016 and in 2019 -before and after the implementation of an educational program. We compare responses from 82 doctors who participated in the 2016 survey, and 67 doctors who have taken part in the survey in 2019: pediatricians, general practitioners / family physicians and physicians of pediatric sub specialties. The percentage of correct answers to all survey questions after the implementation of the educational program has significantly increased (79.0% in 2019 versus 58.3% in 2016, P<0.0001). This increase in the percentage of correct answers was noted among the surveyed doctors of all specialties. Particular progress was found among pediatricians, who have achieved more than 80% of correct answers. In 2019 the doctors demonstrated better knowledge on the warning signs of PID and specific features of Nijmegen breakage syndrome, DiGeorge syndrome and ataxia-telangiectasia syndrome. Thus, the implementation of an educational program improved physicians' awareness of PIDs, and will contribute to early detection of PIDs and their medical care., Competing Interests: The authors have declared that no competing interests exist.

Background: General practitioners (GPs) play a significant role in dementia care. However, the knowledge and attitudes of them towards dementia care are poorly characterized. The present study aimed to investigate GPs' knowledge, attitudes and skills of dementia care in primary health settings in Beijing., Methods: A cross-sectional survey was conducted in 27 community health service centers (CHSCs) in Beijing. The GPs' knowledge, attitudes and skills were assessed utilizing the Alzheimer's Disease Knowledge Scale (ADKS), Dementia Care Attitude Scale (DCAS) and self-designed questionnaire, respectively., Results: A total of 341 participants returned the questionnaire. The overall mean score of GPs' dementia knowledge measured by the ADKS was 21.42 (SD = 2.73) out of 30 (71.4%), GPs' attitudes to dementia care was 36.25 (SD = 5.12) out of 50 (72.5%), and GPs' self-confidence on dementia care skills was 53.93 (SD = 9.57) out of 75 (71.9%). GPs' overall knowledge towards dementia care was limited and the attitudes were generally positive. They had low level recognition of their roles towards dementia care. The majority of GPs believed that dementia care was within a specialist's domain not that of general practice., Conclusion: GPs demonstrate low levels of dementia knowledge and skills, but express generally positive attitudes towards dementia in this study. It is much needed to translate detailed dementia care handbook, and adequate dementia knowledge training for GPs into practice to improve care outcomes for people with dementia in China. In addition, dementia management should be covered in the national basic package of public health services in primary care.

Introduction: Previous research has highlighted the benefits of receiving care in a postgraduate GP training practice including improved patient satisfaction, more appropriate secondary care usage, cancer diagnosis, and antibiotic prescribing. Whilst the influence of being registered in a postgraduate GP training practice on patient outcomes is modest relative to other factors such as deprivation, disease burden, demography, and ethnicity, the reasons for this benefit is not clear., Aim: This study explores how GP trainers perceive engagement with clinical education influences patient care., Methods: Socio-cultural theories were used as a framework for guiding the research. Semi-structured interviews were conducted with 11 GP educators. Interviews were recorded and transcribed verbatim. Data analysis involved thematic analysis., Results: GP educators identified four overarching themes that, for them, seemed to explain how clinical education mediates its influence on patient care. These included: influencing through (i) educational leadership; (ii) learners; (iii) the educational process; and (iv) educational standards., Discussion: Findings suggest that GP trainees have a significant effect on the learning environment, professional development of GP trainers, and patient care. The nature of the relationship between GP trainers and trainees appears far more bilateral than acknowledged in the apprenticeship model.

Introduction: Proton pump inhibitors (PPIs) are frequently prescribed by general practitioners (GPs) who consider these drugs to be safe. However, more and more adverse drug reactions (ADRs) associated with PPIs are described., Objective: To determine the level of knowledge and attitude of GPs with respect to the ADRs of PPIs in adults., Method: The GPs of the Nouvelle-Aquitaine region and the chief residents or former chief residents of the 35 French university departments of general medicine were questioned online using a list of 12 ADRs based on a semi-systematic literature review (neutropenia, thrombocytopenia, anemia, hypomagnesemia, increased liver enzymes, renal failure, pneumonitis, skin reactions, fracture, gastric polyps, microscopic colitis, Clostridium difficile colitis) and their attitude towards these ADRs., Result: Out of the 232 (7.5%) GPs who participated, 38.4% had come across PPI ADRs (mainly digestive) in the last 6 months. These ADRs had been reported to pharmacovigilance in only 2.3% of the cases. No ADR at all was known by more than 70% of the GPs. The attitude of the GPs who had identified them was, in the majority, to stop PPI treatement. No difference in knowledge was found between university supervisors and non-supervisors. Finally, 74.7% of GPs declared that they required more information on IPP ADRs and 80.4% were willing to "deprescribe" these drugs., Conclusion: Aside from digestive ADRs, GPs have a poor knowledge of IPP-related ADRs. Those who do know them have an appropriate attitude and interrupt IPP treatment. The information requested by the GPs about the risks of PPIs is pertinent, particularly in a PPI-adapted prescription procedure, which also involves knowing how to "deprescribe"., (Copyright © 2019 Société française de pharmacologie et de thérapeutique. Published by Elsevier Masson SAS. All rights reserved.)

Background and Objectives: Approximately one-fifth of the population have persistent pain of moderate-to-severe intensity, which affects patients physically, mentally, psychosocially and financially. The aim of this study was to investigate the association between self‑reported wellbeing of patients with persistent pain attending a pain clinic and perceptions of care from general practitioners (GPs) and other treating health professionals., Method: Patients with persistent pain completed a self-administered survey., Results: Overall, only 29 (35%) patients with persistent pain were satisfied with their overall wellbeing, with a positive sense of wellbeing solely predicted by a belief that their GPs are 'treating their problem sympathetically' (P = 0.001; prevalence odds ratio = 5.4; 95% confidence interval: 1.9, 14.9). Voluntarily disclosed free-form comments from patients with persistent pain also appear to indicate that GP-managed pain clinics may be able to provide a more consistent level of support and care to patients with persistent pain than other practice settings., Discussion: These findings suggest psychological support provided by GPs is an important factor for the maintenance of a positive sense of wellbeing for patients with persistent pain.

Background: eConsulta is a teleconsultation service involving general practitioners (GPs) and patients. It is part of the information system belonging to Catalonia's primary care service. It has been in operation since the end of 2015 in conjunction with face-to-face consultations with Primary Care Teams as one of the services offered in the patient's Personal Health Folder., Objective: This study aimed to assess the ability of using eConsulta to reduce the number of face-to-face visits to Primary Care Teams., Methods: Using 13 categories proposed by the researchers, 18 GPs from the Central Catalonia Health Region retrospectively classified 2268 cases managed with eConsulta and indicated whether, in their opinion, the teleconsultations reduced the number of face-to-face visits., Results: There was broad consensus among the GPs that eConsulta has the potential to resolve patient queries for every type of consultation. eConsulta avoided the need for a face-to-face visit in 87.9% of cases. In addition, the GPs reported that the ease of access increased the demand for health care support in 27.7% of cases; otherwise, the patient would not have initiated the queries. Therefore, based on the equation (88% x [1-28%]), eConsulta could replace 63%-88% of conventional appointments. The most frequent uses of the teleconsultation service were for management of test results (35.2%), medical enquiries (16.0%), and the management of repeat prescriptions (12.2%). On average, the teleconsultations consisted of a mean 1.57 messages (SD 0.54 messages); 45.9% (1040/2268) of the teleconsultations consisted of 1 message, and the majority of the remaining teleconsultations consisted of 2-5 interactions. The patient initiated 60.0% (1361/2268) of the teleconsultations., Conclusions: Based on the GPs' perceptions, eConsulta could replace 63%-88% of conventional appointments. Therefore, asynchronous teleconsultations between practitioners and patients in primary care could avoid interactions that have limited added clinical value., (©Francesc López Seguí, Josep Vidal-Alaball, Marta Sagarra Castro, Anna García-Altés, Francesc García Cuyàs. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 16.03.2020.)

Introduction: Enhancing the self-management activities of patients improves the quality of care and is an integrated element of current healthcare provision. However, self-management support (SMS) is not yet common in healthcare. The Primary Care Resources and Support for Self-Management (PCRS) is a tool for healthcare professionals to assess the quality of SMS. In this study, we assessed the validity and reliability of the Dutch version of the PCRS., Method: The validation of the PCRS was performed in Dutch healthcare centres. Correlations between the PCRS scores and the Assessment of Chronic Illness Care (ACIC) and Clinician Support for Patient Activation Measure (CS-PAM) scores were calculated to assess the convergent and discriminant validity. A confirmatory factor analysis (CFA) was performed to test the factor structure. Lastly, the internal consistency and face validity were assessed., Results: The convergent and discriminant validity were good, with respective correlations of 0.730 (p < 0.001) and 0.030 (p > 0.050) between the PCRS and the ACIC SMS subscale and the PCRS and the CS-PAM. Although 49% of the variance of the PCRS was explained by one factor, the CFA could not confirm a fit between a one-factor model and the data. The reliability was excellent (Cronbach's α = 0.921)., Conclusion: The PCRS showed good validity and excellent internal consistency. However, the evidence for its validity was inconclusive. We therefore suggest rephrasing specific items., Competing Interests: We have the following interests: This study was sponsored by Boehringer Ingelheim NL. GA and MV were on the payroll of Boehringer Ingelheim bv NL at the time of the conduct of the study. A free license for the use of the CS-PAM was provided by its developer, Insignia Health, under the condition that the data will be shared with Insignia Health. There are no patents, products in development or marketed products to declare. This does not alter our adherence to all the PLOS ONE policies on sharing data and materials.

The broadening of access to HIV pre-exposure prophylaxis (PrEP) in Australia has rekindled debates about which types of clinicians are best suited to deliver HIV prevention innovations: specialist HIV services or primary care physicians and general practitioners (GPs). We conducted 21 semi-structured qualitative interviews in 2017 with Australian HIV sector experts working across policy, advocacy, clinical service provision, research, and health promotion. These interviews took place before a national policy commitment to subsidising access to PrEP was achieved. We explored how participants conceptualised PrEP, patients and GPs at this key turning point in the history of HIV prevention. Participants expressed varied views regarding GPs' anticipated ability to successfully navigate the potential complexities associated with PrEP roll-out. While participants were supportive of greater patient access to PrEP, they expressed concerns about non-specialist GPs' cultural competence and expertise regarding sexuality and clinical practice, and the potential for patients to experience discrimination and homophobia from non-expert GPs. This study has broad implications for thinking about experts and expertise, the implementation of previously specialised medicine into mainstream settings, and the anticipated challenges of LGBTIQ+ inclusive healthcare.

Background: It was the author's (LWH) observation that pterygium was frequently misdiagnosed by general practitioners that led to this study. The aim was to identify the rate of misdiagnosis of pterygium by optometrists and general practitioners based upon assessing referral accuracy to a single ophthalmologist (LWH)., Methods: This study involved a prospective case series from 25 March 2015 to 18 December 2018 in a tertiary referral practice specialising in pterygium. The accuracy of diagnosis of pterygium, based upon the content of the clinical referral, was undertaken for optometrists and general practitioners. The benchmark for diagnostic accuracy was the diagnosis made by the author (LWH) during a consultation in person by the author (LWH) using a hand-light examination and confirmed by slitlamp examination., Results: A total of 1,511 consecutive patients were included in the study with 90/549 incorrectly diagnosed (16 per cent) by general practitioners and 14/962 (1.4 per cent) by optometrists. General practitioners were 13.28 times more likely to incorrectly diagnose a pterygium than optometrists (95% CI 7.48-23.57). Almost exclusively, the incorrect diagnosis made by general practitioners was naming a pinguecula, a pterygium. The same misdiagnosis was made by optometrists but far less frequently., Conclusion: General practitioners misdiagnosed pterygium far more often than optometrists which may reflect a reduction in training in eye health., (© 2019 Optometry Australia.)

Objective: To assess knowledge and practice regarding dog bite management among general practitioners in a suburban setting., Methods: This cross-sectional knowledge and practice study was conducted from March 2017 to October 2017 in district Malir, Karachi, and comprised general practitioners conveniently recruited from 32 randomly selected union councils of the district. The participants were interviewed with the help of a self-generated structured questionnaire. Data were analysed in SS PS 21 ., Results: Of the 92 practitioners, 67(72.8%) were males, 43(46.7%) had>10 years' experience, and 63(68.5%)were privately employed. The overall mean age of the sample was 43.77±11.5 years. Mean knowledge scores varied significantly across categories of experience only (p=0.020), withthe lessexperienced practitioners having significantly higher mean knowledge compared to the seniors., Conclusions: The experience of the general practitioners significantly affected their knowledge with recent graduates found to have higher mean k nowledge scores than older graduates.

Background: Attention Deficit Hyperactivity Disorder (ADHD) is underdiagnosed in many European countries and the process of accessing care and diagnosis is complex and variable. In many countries, general practitioners (GPs) refer on to secondary care where individuals receive an assessment and, if appropriate, a diagnosis and access to care. It is therefore essential that GPs have a clear understanding of the disorder and its care pathways. While previous studies have highlighted potential barriers in GPs' ADHD awareness, this qualitative study aims to further explore individual stakeholders' experiences., Methods: Semi-structured interviews explored the views of multiple stakeholders- GPs (n = 5), healthcare specialists (n = 5), patients (adults with ADHD n = 5) and parents (n = 5) with experience of the presentation and management of ADHD in primary care. These interviews were analysed using thematic analyses and following principles of grounded theory., Results: Stakeholders described ADHD assessment, diagnosis and treatment as an intricate process. Many factors affected this process such as complex pathways, lack of services, limited GP recognition and knowledge, and communicative difficulties between and within multiple stakeholders., Conclusion: This analysis underlines the significant impact that receiving (or not) a diagnosis can have, and further explores muddled ADHD care pathways, highlighting key issues around GP identification and the shortage of adult services. Implications for practice and future research are discussed, suggesting a strong need for more commissioned pathways and GP specific educational programs.

Objectives: To investigate the practices of healthcare professionals in relation to best practice recommendations for the multidisciplinary management of people with diabetes and periodontitis, focusing on two clinical behaviours: informing patients about the links between diabetes and periodontitis, and suggesting patients with poorly controlled diabetes go for a dental check-up., Design: Cross-sectional design utilising online questionnaires to assess self-reported performance and constructs from Social Cognitive Theory (SCT) and Normalisation Process Theory., Setting: Primary care medical practices (n=37) in North East, North Cumbria and South West of England Clinical Research Networks., Participants: 96 general practitioners (GPs), 48 nurses and 21 healthcare assistants (HCAs)., Results: Participants reported little to no informing patients about the links between diabetes and periodontitis or suggesting that they go for a dental check-up. Regarding future intent, both GPs (7.60±3.38) and nurses (7.94±3.69) scored significantly higher than HCAs (4.29±5.07) for SCT proximal goals (intention) in relation to informing patients about the links (p<0.01); and nurses (8.56±3.12) scored significantly higher than HCAs (5.14±5.04) for suggesting patients go for a dental check-up (p<0.001). All professional groups agreed on the potential value of both behaviours, and nurses scored significantly higher than GPs for legitimation (conforms to perception of job role) in relation to informing (nurses 4.16±0.71; GPs 3.77±0.76) and suggesting (nurses 4.13±0.66; GPs 3.75±0.83) (both p<0.01). The covariate background information (OR=2.81; p=0.03) was statistically significant for informing patients about the links., Conclusions: Despite evidence-informed best practice recommendations, healthcare professionals currently report low levels of informing patients with diabetes about the links between diabetes and periodontitis and suggesting patients go for a dental check-up. However, healthcare professionals, particularly nurses, value these behaviours and consider them appropriate to their role. While knowledge of the evidence is important, future guidelines should consider different strategies to enable implementation of the delivery of healthcare interventions., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY. Published by BMJ.)

Background: Cancer care involves many different healthcare providers. Delayed or inaccurate communication between specialists and general practitioners (GP) may negatively affect care., Aim: To describe the pattern and variation of communication between primary healthcare (PHC) services and hospitals and specialists in relation to the patient's cancer care., Methods: A retrospective audit of clinical records of Indigenous Australians diagnosed with cancer during 2010-2016 identified through 10 PHC services in Queensland is described. Poisson regression was used to model the dichotomous outcome availability of hospital discharge summary versus not., Results: A total of 138 patient records was audited; 115 of those patients visited the PHC service for cancer-related care after cancer diagnosis; 40.0% visited the service before a discharge summary was available, and 36.5% of the patients had no discharge summary in their medical notes. While most discharge summaries noted important information about the patient's cancer, 42.4% lacked details regarding the discharge medications regimen., Conclusions: Deficits in communication and information transfer between specialists and GP may adversely affect patient care. Indigenous Australians are a relatively disadvantaged group that experience poor health outcomes and relatively poor access to care. The low proportion of discharge summaries noting discharge medication regimen is of concern among Indigenous Australians with cancer who have high comorbidity burden and low health literacy. Our findings provide an insight into some of the factors associated with quality of cancer care, and may provide guidance for focus areas for further research and improvement efforts., (© 2019 Royal Australasian College of Physicians.)

Objective: Lengthy delays in receiving treatment have been reported for people with bulimia nervosa (BN) and binge-eating disorder (BED). This study aimed to investigate healthcare use and predictors of mental health specialist healthcare use in a community sample of individuals with diagnostic threshold symptoms of BN, BED-Broad, or another eating disorder (Other ED)., Method: In 2017, 2,977 individuals aged ≥15 years were interviewed in a general population survey. Participants were asked questions relating to sociodemographic, ED symptoms, other clinical features, and healthcare use data. Assessment of ED symptoms was based on diagnostic questions derived from the eating disorder examination., Results: Thirty-six participants with symptoms of BN, 33 participants with BED-Broad, and 369 with an Other ED were identified. Fewer people with symptoms of BN/BED-Broad (23%) or an Other ED (6%) had treatment from a mental health specialist than from a general practitioner (GP; 80%, 71.6%). Healthcare use differed significantly across type of ED only for treatment from a mental health specialist. In multivariate analyses, being asked about a person's mental health by a GP was the best explanatory variable for receiving treatment from a mental health specialist., Discussion: A large treatment gap exists in healthcare for people with EDs. Inquiry about an individual's mental health by a GP was associated with higher rates of treatment from mental health specialists. However, a similar diet/eating inquiry did not have this association. Future research should consider the use of this patient and practitioner consultation in targeting improved detection of EDs., (© 2019 Wiley Periodicals, Inc.)