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Background. Comorbidity is increasingly important in the medical literature, with ever-increasing impacts as populations age. Comorbidity has multiple and complex implications for the processes of diagnosis, treatment, prognosis, management and health care. The objective of this study is to measure casual versus causal comorbidity in primary care in three family practice populations.Methods. This is a longitudinal observational study using the Transition Project datasets. Transition Project family doctors in the Netherlands, Malta and Serbia recorded details of all patient contacts in an episode of care structure using electronic medical records and the International Classification of Primary Care, collecting data on all elements of the doctor-patient encounter, including diagnoses (1,178,178 in the Netherlands, 93,606 in Malta, 405,150 in Serbia), observing 158,370 patient years in the Netherlands, 43,577 in Malta, 72,673 in Serbia. Comorbidity was measured using the odds ratio of both conditions being incident or rest-prevalent in the same patient in one-year dataframes, as against not.Results. Comorbidity in family practice in the three population databases is expressed as odds ratios between the 41 joint most prevalent (joint top 20) episode titles in the three populations. Specific associations were explored in different age groups to observe the changes in odds ratios with increasing age as a surrogate for a temporal or biological gradient.Conclusion. After applying accepted criteria for testing the causality of associations, it is reasonable to conclude that most observed primary care comorbidity is casual. It would be incorrect to assume causal relationships between co-occurring diseases in family medicine, even if such a relationship might be plausible or consistent with current conceptualisations of the causation of disease. Most observed comorbidity in primary care is the result of increasing illness diversity.Trial registration.This study was performed on electronic patient record datasets made publicly available by the University of Amsterdam Department of General Practice, and did not involve any patient intervention.Funding. Self-funded.

Background Influenza-like illness (ILI) and Acute Respiratory Infections (ARI) are a considerable health problem in Europe. Most diagnoses are made by family physicians (FPs) and based on symptoms and clinical signs rather than on diagnostic testing. The International Classification of Primary Care (ICPC) advocates that FPs record patients’ ‘Reasons for Encounters’ (RfEs) as they are presented to them. This study analyses the association of patients’ RfEs with FPs’ diagnoses of ILI and ARI diagnoses and FPs’ management of those patients. Methods Cohort study of practice populations. Over a 4-month period during the winter season 2013–14, eight FPs recorded ILI and ARI patients’ RfEs and how they were managed. FPs recorded details of their patients using the ICPC format, collecting data in an Episode of Care (EoC) structure. Results There were 688 patients diagnosed as having ILI; between them they presented with a total of 2,153 RfEs, most commonly fever (79.7%), cough (59.7%) and pain (33.0%). The 848 patients with ARI presented with a total of 1,647 RfEs, most commonly cough (50.4%), throat symptoms (25.9%) and fever (19.9%). For patients with ILI, 37.0% of actions were related to medication for respiratory symptoms; this figure was 38.4% for patients with ARI. FPs referred six patients to specialists or hospitals (0.39% of all patients diagnosed with ILI and ARI). Conclusions In this study of patients with ILI and ARI, less than half received a prescription from their FPs, and the illnesses were mainly managed in primary care, with few patients’ needing referral. The ICPC classification allowed a standardised data collection system, providing documentary evidence of the management of those diseases.

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) the relationship 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.

The impact of physician burnout on the quality of patient care is unclear. This cross-sectional study aimed to investigate the prevalence of burnout in family physicians in Croatia and its association with physician and practice characteristics, and patient enablement as a consultation outcome measure.Hundred and twenty-five out of 350 family physicians responded to our invitation to participate in the study. They were asked to collect data from 50 consecutive consultations with their adult patients who had to provide information on patient enablement (Patient Enablement Instrument). Physicians themselves provided their demographic and professional data, including workload, job satisfaction, consultation length, and burnout [Maslach Burnout Inventory - Human Services Survey (MBI-HSS )]. MBI-HSS scores were analysed in three dimensions: emotional exhaustion (EE), depersonalisation (DP), and personal accomplishment (PA).Of the responding physicians, 42.4 % scored high for EE burnout, 16.0 % for DP, and 15.2 % for PA. Multiple regression analysis showed that low job satisfaction and more patients per day predicted high EE scores. Low job satisfaction, working more years at a current workplace, and younger age predicted high DP scores. Lack of engagement in education and academic work, shorter consultations, and working more years at current workplace predicted low PA scores, respectively (PBurnout is common among family physicians in Croatia yet burnout in our physicians was not associated with patient enablement, suggesting that it did not affect the quality of interpersonal care. Job satisfaction, participation in educational or academic activities and sufficient consultation time seem to reduce the likelihood of burnout.

This is a review of the literature on the role of symptoms in family practice, with a focus on the diagnostic approach in family medicine (FM). We found two, contrasting, approaches to reducing symptoms presented by patients in primary care, especially those which do not immediately allow the definition of a disease-label diagnosis. Years of research into ‘medically unexplained symptoms’ (MUS) has failed to support an international body of knowledge and cannot convincingly support the philosophy on which the reduction itself is based. This review supports the approach of researching reasons for encounter as they present to the family doctor, without artificial mind–body metaphors. The medical model is shown to be an incomplete reduction of FM, and the concept of MUS fails to improve this situation. A new model based on a substantial paradigm shift is needed. That model should be the biopsychosocial model, reflected in the philosophical concepts of the International Classification of Primary Care and the value of the patient’s ‘reason for encounter’. There is more to life than medicine may diagnose, and FM should strive to move closer to the lives of our patients than the medical model alone could allow., The European Union Financial Protocol 7 project ‘TRANSFoRm’ (www.transformproject.eu) (FP7 247787) supported part of the protected time of the authors in performing this study, through its partner the Mediterranean Institute of Primary Care (www.mipc.org.mt)., peer-reviewed

The recently published 'Research Agenda for General Practice/Family Medicine and Primary Health Care in Europe' summarizes the evidence relating to the core competencies and characteristics of the Wonca Europe definition of GP/FM, and highlights related needs and implications for future research and policy. The European Journal of General Practice publishes a series of articles based on this document. In a first article, background, objectives, and methodology were discussed. In three subsequent, articles the results for the six core competencies of the European Definition of GP/FM were presented. This article formulates the common aims for further research and appropriate research methodologies, based on the missing evidence and research gaps identified form the comprehensive literature review. In addition, implications of this research agenda for general practitioners/family doctors, researchers, research organizations, patients and policy makers are presented. The concept of six core competencies should be abandoned in favour of a model with four dimensions, including clinical, person related, community oriented and management aspects. Future research and policy should consider more the involvement and rights of patients; more attention should be given to how new treatments or technologies are effectively translated into routine patient care, in particular primary care. There is a need for a European ethics board. The promotion of GP/FM research demands a good infrastructure in each country, including access to literature and databases, appropriate funding and training possibilities.

The European General Practice Research Network organized an international workshop on research using electronic patient records in Bertinoro, Italy, in May 2009. The authors were keynote speakers at the workshop, tasked with summarizing the theme research presentations on each of the two days of the meeting. The conference discussed the utility of capturing data in a way that can be appropriately analysed. In this application, the use of ICPC was repeatedly mentioned. Such research requires disciplined data entry and retrieval, and many times consistency in coding is a challenge, which may be met by definitions for coded classes. Quality of data is a concern in such research, and there were suggestions to involve the patients in improving the quality of their record. Clinicians are qualified to code data into electronic patient records accurately, capturing the fine nuances of the consultation. Income incentives, such as the Quality Outcomes Framework, run the risk of data distortion to improve fi...

At the WONCA Europe conference 2009 the recently published 'Research Agenda for General Practice/Family Medicine and Primary Health Care in Europe' was presented. It is a background paper and reference manual, providing advocacy of general practice/family medicine (GP/FM) in Europe. The Research Agenda summarizes the evidence relating to the core competencies and characteristics of the WONCA Europe definition of GP/FM, and its implications for general practitioners/family doctors, researchers and policy makers. The European Journal of General Practice publishes a series of articles based on this document. In a first article, background, objectives, and methodology were discussed. In this second article, the results for the core competencies 'primary care management' and 'community orientation' are presented. Though there is a large body of research on various aspects of 'primary care management', it represents a very scattered rather than a meta view. Many studies focus on care for specific diseases, the primary/secondary care interface, or the implications of electronic patient records. Cost efficiency or process indicators of quality are current outcomes. Current literature on community orientation is mainly descriptive, and focuses on either care for specific diseases, or specific patient populations, or on the uptake of preventive services. Most papers correspond poorly to the WONCA concept. For both core competencies, there is a lack of research with a longitudinal perspective and/or relevant health or quality of life outcomes as well as research on patients' preferences and education for organizational aspects of GP/FM.

At the WONCA Europe conference 2009 the recently published ‘Research Agenda for General Practice/Family Medicine and Primary Health Care in Europe’ was presented. The Research Agenda is a background paper and reference manual for GPs/ family doctors, researchers and policy makers, providing advocacy of general practice/family medicine GP/FM in Europe. The Research Agenda summarizes the evidence relating to the core competencies and characteristics of the WONCA Europe defi nition of GP/FM, and its meaning for researchers and policy makers. Evidence gaps and research needs are pointed out to provide a basis for planning research for which there is a need and for action that may infl uence health and research policy, i.e. applying/lobbying for research funds. WONCA Europe and its associated networks and special interest groups could consider the agenda’s research priorities when planning future conferences, courses, or projects, and for funding purposes. The European Journal of General Practice will publish a series of articles based on this document. In this fi rst article, background, objectives, methodology and relevant literature are discussed. In subsequent articles, the results will be presented.

Background Analysis of encounter data relevant to the diagnostic process sourced from routine electronic medical record (EMR) databases represents a classic example of the concept of a learning healthcare system (LHS). By collecting International Classification of Primary Care (ICPC) coded EMR data as part of the Transition Project from Dutch and Maltese databases (using the EMR TransHIS), data mining algorithms can empirically quantify the relationships of all presenting reasons for encounter (RfEs) and recorded diagnostic outcomes. We have specifically looked at new episodes of care (EoC) for two urinary system infections: simple urinary tract infection (UTI, ICPC code: U71) and pyelonephritis (ICPC code: U70). Methods Participating family doctors (FDs) recorded details of all their patient contacts in an EoC structure using the ICPC, including RfEs presented by the patient, and the FDs’ diagnostic labels. The relationships between RfEs and episode titles were studied using probabilistic and data mining methods as part of the TRANSFoRm project. Results The Dutch data indicated that the presence of RfE’s “Cystitis/Urinary Tract Infection”, “Dysuria”, “Fear of UTI”, “Urinary frequency/urgency”, “Haematuria”, “Urine symptom/complaint, other” are all strong, reliable, predictors for the diagnosis “Cystitis/Urinary Tract Infection” . The Maltese data indicated that the presence of RfE’s “Dysuria”, “Urinary frequency/urgency”, “Haematuria” are all strong, reliable, predictors for the diagnosis “Cystitis/Urinary Tract Infection”. The Dutch data indicated that the presence of RfE’s “Flank/axilla symptom/complaint”, “Dysuria”, “Fever”, “Cystitis/Urinary Tract Infection”, “Abdominal pain/cramps general” are all strong, reliable, predictors for the diagnosis “Pyelonephritis” . The Maltese data set did not present any clinically and statistically significant predictors for pyelonephritis. Conclusions We describe clinically and statistically significant diagnostic associations observed between UTIs and pyelonephritis presenting as a new problem in family practice, and all associated RfEs, and demonstrate that the significant diagnostic cues obtained are consistent with the literature. We conclude that it is possible to generate clinically meaningful diagnostic evidence from electronic sources of patient data. Electronic supplementary material The online version of this article (doi:10.1186/s12875-015-0271-4) contains supplementary material, which is available to authorized users.

(2005). Using electronic medical records for research. European Journal of General Practice: Vol. 11, No. 1, pp. 2-4.

Introduction There has not yet been an audit of achievement rates of therapeutic targets for cholesterol management in the rural Italian primary care setting. The purpose of this study was to measure the percentage of patients with hypercholesterolaemia in a rural primary care setting in southern Italy, classify their risk category and measure the proportions of those patients who achieved optimal cholesterol levels according to the Adult Treatment Panel III guidelines. Methods The audit was completed using records from 1 January 2005 to 31 December 2007. An electronic search key was entered into the electronic clinical records of 10 family doctors in a rural area of southern Italy for subjects with a diagnosis of or being treated for hypercholesterolaemia. A total of 194 hypercholesterolaemic patients were randomly selected from a cohort of patients registered with these family doctors. The low density lipoprotein cholesterol (LDL-C) target level was 100 mg/dL (2.6 mmol/L) in patients with existing cardiovascular disease, 130 mg/dL (3.3 mmol/L) for patients with ≥2 risk factors, and 160 mg/dL (4.1 mmol/L) for all other patients. The results regarding the efficacy of the therapy were categorised as follows: (1) on target, LDL-C lower or equal to levels of affiliated class; (2) poor control, 1-30 mg/dL (0.03-0.78 mmol/L) above the target level of LDL-C; (3) very poor control, ≥31 mg/dL (≥0.8 mmol/L) above the LDL-C target level. Results The average age of the hypercholesterolaemic patients included in the study was 62.0 ± 9.0 years; 55% were males, 30% were smokers, 71.3% suffered from hypertension, 46.3% had diabetes, 39.9% were obese and 31.9% had a family history of coronary disease. There were 114 subjects in Class I (personal history of coronary disease, cardiovascular risk ≥ 20, diabetes mellitus) LDL-C target level. Of these patients, 24.6% were at target, 30.7% had poor control and 44.7% had very poor control. A total of 42.3% of the subjects examined with the score system adopted by the Italian Heart Project showed levels of cardiovascular risk between 5% and 19% and were not eligible for a free prescription of lipid-lowering drugs. Conclusions These data suggest that cholesterol management in this rural area is not always optimal in patients with high cardiovascular risk. Italian healthcare regulation seems to be a barrier to drug prescription and it may influence optimal LDL-C control.

Objective To document family medicine research in the 25 EGPRN member countries in 2010. Design Semi-structured survey with open-ended questions. Setting Academic family medicine in 23 European countries, Israel, and Turkey. Subjects 25 EGPRN national representatives. Main outcome measures Demographics of the general population and family medicine. Assessments, opinions, and suggestions. Results EGPRN has represented family medicine for almost half a billion people and > 300 000 general practitioners (GPs). Turkey had the largest number of family medicine departments and highest density of GPs, 2.1/1000 people, Belgium had 1.7, Austria 1.6, and France 1.5. Lowest GP density was reported from Israel 0.17, Greece 0.18, and Slovenia 0.4 GPs per 1000 people. Family medicine research networks were reported by 22 of 25 and undergraduate family medicine research education in 20 of the 25 member countries, and in 10 countries students were required to do research projects. Postgraduate family medicine research was reported by 18 of the member countries. Open-ended responses showed that EGPRN meetings promoted stimulating and interesting research questions such as comparative studies of chronic pain management, sleep disorders, elderly care, healthy lifestyle promotion, mental health, clinical competence, and appropriateness of specialist referrals. Many respondents reported a lack of interest in family medicine research related to poor incentives and low family medicine status in general and among medical students in particular. It was suggested that EGPRN exert political lobbying for family medicine research. Conclusion Since 1974, EGPRN organizes biannual conferences that unite and promote primary care practice, clinical research and academic family medicine in 25 member countries.

Background This is a study of the epidemiology of acute and chronic episodes of care (EoCs) in the Transition Project in three countries. We studied the duration of EoCs for acute and chronic health problems and the relationship of incidence to prevalence rates for these EoCs.Method The Transition Project databases collect data on all elements of the doctor–patient encounter in family medicine. Family doctors code these elements using the International Classification of Primary Care.We used the data from three practice populations to study the duration of EoCs and the ratio of incidence to prevalence for common health problems.Results We found that chronic health problems tended to have proportionately longer duration EoCs, as expected, but also a lower incidence to prevalence rate ratio than acute health problems. Thus, the incidence to prevalence index could be used to define a chronic condition as one with a low ratio, below a defined threshold.Conclusions Chronic health problems tend to have longer duration EoCs, proportionately, across populations. This result is expected, but we found important similarities and differences which make defining a problem as chronic on the basis of time rather difficult. The ratio of incidence to prevalence rates has potential to categorise health problems into acute or chronic categories, at different ratio thresholds (such as 20, 30 or 50%). It seems to perform well in this study of three family practice populations, and is proposed to the scientific community for further evaluation.

Background This is a study of the relationships between common reasons for encounter and common diagnoses (episode titles) within episodes of care in family practice populations in four countries.Method Participating family doctors recorded details of all their patient contacts in an EoC structure using the International Classification of Primary Care, including RfEs presented by the patient, and the FDs’ diagnostic labels. The relationships between RfEs and episode titles were studied using Bayesian methods.Results The RfE ‘cough’ is a strong, reliable predictor for the diagnoses ‘cough’, ‘acute bronchitis’, ‘URTI’ and ‘acute laryngitis/tracheitis’ and a less strong, but reliable predictor for ‘sinusitis’, ‘pneumonia’, ‘influenza’, ‘asthma’, ‘other viral diseases’, ‘whooping cough’, ‘chronic bronchitis’, ‘wheezing’ and ‘phlegm’. The absence of cough is a weak but reliable predictor to exclude a diagnosis of ‘cough’, ‘acute bronchitis’ and ‘tracheitis’. Its presence allows strong, reliable exclusion of the diagnoses ‘gastroenteritis’, ‘no disease’ and ‘health promotion/prevention’, and less strong exclusion of ‘adverse effects of medication’. The RfE ‘sadness’ is a strong, reliable predictor for the diagnoses ‘feeling sad/depressed’ and ‘depressive disorder’. It is a less strong, but reliable predictor of a diagnosis of ‘acute stress reaction’. The absence of sadness is a weak but reliable predictor to exclude the symptom diagnosis ‘feeling sad/depressed’. Its presence does not support the exclusion of any diagnosis.Conclusions We describe clinically and statistically significant diagnostic associations observed between the RfEs ‘cough’ and ‘sadness’, presenting as a new problem in family practice, and all the episode titles in ICPC.

The impact of physician burnout on the quality of patient care is unclear. This cross-sectional study aimed to investigate the prevalence of burnout in family physicians in Croatia and its association with physician and practice characteristics, and patient enablement as a consultation outcome measure. Hundred and twenty-five out of 350 family physicians responded to our invitation to participate in the study. They were asked to collect data from 50 consecutive consultations with their adult patients who had to provide information on patient enablement (Patient Enablement Instrument). Physicians themselves provided their demographic and professional data, including workload, job satisfaction, consultation length, and burnout [Maslach Burnout Inventory – Human Services Survey (MBI-HSS)]. MBI-HSS scores were analysed in three dimensions: emotional exhaustion (EE), depersonalisation (DP), and personal accomplishment (PA). Of the responding physicians, 42.4 % scored high for EE burnout, 16.0 % for DP, and 15.2 % for PA. Multiple regression analysis showed that low job satisfaction and more patients per day predicted high EE scores. Low job satisfaction, working more years at a current workplace, and younger age predicted high DP scores. Lack of engagement in education and academic work, shorter consultations, and working more years at current workplace predicted low PA scores, respectively (P, Povezanost sindroma izgaranja liječnika i kvalitete skrbi nije potpuno jasna. Cilj rada bio je istražiti učestalost sindroma izgaranja u liječnika obiteljske medicine (LOM) u Hrvatskoj te povezanost sindroma izgaranja i obilježja liječnika i njegove prakse te osposobljenosti bolesnika kao mjere ishoda konzultacije. Provedeno je presječno istraživanje na nacionalnom stratificiranom slučajnom uzorku od 350 LOM koji su prikupili podatke od 50 odraslih bolesnika tijekom 50 susljednih konzultacija. Za bolesnike su prikupljeni podaci o osposobljenosti bolesnika (Upitnik za procjenu osposobljenosti bolesnika, PEI), duljini konzultacije, a za liječnike podaci o demografskim i profesionalnim značajkama, opterećenju poslom, zadovoljstvu poslom, prisutnosti sindroma izgaranja na poslu (Maslach Burnout Inventory – MBI-HSS). Vrijednosti MBI-HSS analizirane su u tri dimenzije: emocionalna iscrpljenost (EI), depersonalizacija (DP) i osobno postignuće (OP). Među 125 liječnika, EI visokog stupnja zabilježena je kod 42,4 %, DP visokog stupnja kod 16,0 % te OP visokog stupnja kod 15,2 % liječnika. U regresijskoj analizi visoke vrijednosti EI su predviđali manje zadovoljstvo poslom i veći broj bolesnika dnevno. Visoke vrijednosti DP su predviđali manje zadovoljstvo poslom, više godina na sadašnjem radnom mjestu i mlađa dob. Niske vrijednosti OP su predviđale izostanak sudjelovanja u nastavnim ili akademskim aktivnostima, kraće konzultacije te više godina na sadašnjem radnom mjestu (P

On 9 September 2000, a meeting on General Practice/Family Medicine (GP/FM) in the Mediterranean was held at the 6th Mediterranean Congress in Malta. The creation of a Mediterranean GP/FM group was discussed among delegates from seven Mediterranean countries. Historical, cultural and epidemiological concepts supporting this initiative are presented. The main aims of this group and the key issues of the Malta consensus are clarified.

The Research Agenda should be used as a key reference point to which new research should relate its usefulness and added value. Primary care evolves towards more interdisciplinary care, and research should focus more on the core competency of person-centred team care. There is an urgent need to develop clear definitions and appropriate research instruments for this domain. It will be a particular challenge to study comprehensive approaches in primary-care patients with multi-morbidity. The Research Agenda and the commentaries on it show future directions for primary care research. There are challenges related to a changing society, the shared responsibility and guidance of research by professionals and citizens (patients), and the need to fully integrate research as part of primary healthcare provision. There will be a need for a prioritization of spearheads to guide primary care research for the next decade: translational research, research on equity and health differences, on chronic disease and health systems research. This can not be realized without the development and maintenance of a solid research infrastructure: easily maintained and accessed observational databases, helpful information technology, strategies and techniques for patient involvement, advanced research training possibilities, and the development and validation of appropriate research instruments and outcome measures to capture the different challenges. Worldwide, primary care not only is a priority for health care policy, but it needs to become a research priority as well.

INTRODUCTION Type 2 diabetes mellitus and hypertension are commonly associated chronic conditions which require regular structured treatment. In the UK many quality markers have been improved through an incentivisation scheme. The aim of this study was to discover if there is potential for improving the quality of care for patients with type 2 diabetes and hypertension in rural Italy, through a quality and outcome incentivisation scheme. METHODS The study was conducted in a rural practice context in Southern Italy and seven family doctors were involved. The main outcome measures were glycated haemoglobin A1c (HbA1c), LDL cholesterol, and systolic and diastolic blood pressure. The patient characteristics examined were age, sex, educational level, behaviour-related factors such as smoking and BMI, and the presence of comorbidities. RESULTS A poor level of registration was found for important variables such as HBA1c (61.4% compared with the UK Quality Indicator of 90%). An adequate level of registration and control was found only for blood pressure (95.7% and 82.1%, respectively), while an acceptable but not optimal level of control for HBA1c was also achieved (88.4% &n8804;10%). In comparison with levels in UK practices, the Italian district studied performed much less favorably, especially regarding process indicators. Intermediate outcome and treatment indicators were slightly better for blood pressure control but slightly worse for HBA1c and cholesterol control. CONCLUSION The data confirm a poor registration level for important healthcare indicators in the study area, and that optimal levels are rarely reached for many quality indicators. A quality and outcome incentivisation scheme similar to the UK Quality and Outcomes Framework may offer a tool for achieving improvements.

At the WONCA Europe conference 2009 the recently published 'Research Agenda for General Practice/Family Medicine and Primary Health Care in Europe' was presented. It is a background paper and reference manual, providing advocacy of general practice/family medicine (GP/FM) in Europe. The Research Agenda summarizes the evidence relating to the core competencies and characteristics of the WONCA Europe definition of GP/FM, and its implications for general practitioners/family doctors, researchers and policy makers. The European Journal of General Practice publishes a series of articles based on this document. In a first article, background, objectives, and methodology were discussed. In this second article, the results for the core competencies 'primary care management' and 'community orientation' are presented. Though there is a large body of research on various aspects of 'primary care management', it represents a very scattered rather than a meta view. Many studies focus on care for specific diseases, the primary/secondary care interface, or the implications of electronic patient records. Cost efficiency or process indicators of quality are current outcomes. Current literature on community orientation is mainly descriptive, and focuses on either care for specific diseases, or specific patient populations, or on the uptake of preventive services. Most papers correspond poorly to the WONCA concept. For both core competencies, there is a lack of research with a longitudinal perspective and/or relevant health or quality of life outcomes as well as research on patients' preferences and education for organizational aspects of GP/FM.

At the WONCA Europe conference 2009 the recently published 'Research Agenda for General Practice/Family Medicine and Primary Health Care in Europe' was presented. The Research Agenda is a background paper and reference manual for GPs/ family doctors, researchers and policy makers, providing advocacy of general practice/family medicine GP/FM in Europe. The Research Agenda summarizes the evidence relating to the core competencies and characteristics of the WONCA Europe definition of GP/FM, and its meaning for researchers and policy makers. Evidence gaps and research needs are pointed out to provide a basis for planning research for which there is a need and for action that may influence health and research policy, i.e. applying/lobbying for research funds. WONCA Europe and its associated networks and special interest groups could consider the agenda's research priorities when planning future conferences, courses, or projects, and for funding purposes. The European Journal of General Practice will publish a series of articles based on this document. In this first article, background, objectives, methodology and relevant literature are discussed. In subsequent articles, the results will be presented.

The recently published ‘ Research Agenda for General Practice/Family Medicine and Primary Health Care in Europe ’ summarizes the evidence relating to the core competencies and characteristics of the Wonca Europe defi nition of GP/ FM, and its implications for general practitioners/family doctors, researchers and policy makers. The European Journal of General Practice publishes a series of articles based on this document. In a fi rst article, background, objectives, and methodology were discussed. In a second article, the results for the two core competencies ‘ primary care management ’ and ‘ community orientation ’were presented. This article refl ects on the three core competencies, which deal with person related aspects of GP/FM, i.e. ‘ person centred care ’ , ‘ comprehensive approach ’and ‘ holistic approach ’ . Though there is an important body of opinion papers and (non-systematic) reviews, all person related aspects remain poorly defi ned and researched. Validated instruments to measure these competencies are lacking. Concerning patient-centredness, most research examined patient and doctor preferences and experiences. Studies on comprehensiveness mostly focus on prevention/care of specific diseases. For all domains, there has been limited research conducted on its implications or outcomes., peer-reviewed

Soler J-K, Okkes I, Wood M and Lamberts H. The coming of age of ICPC: celebrating the 21st birthday of the International Classification of Primary Care. Family Practice 2008; Pages 1‐6 of 6. The International Classification of Primary Care (ICPC) has, since its introduction in 1987, been quite successful. Now in its second revised version, it has been translated in 22 languages, accepted by the World Health Organization (WHO) as a member of the Family of International Classifications, and is being widely used both in routine daily practice and in research. In this contribution, it is explained that ICPC was designed as a theoretical classification, and that it has especially great potential when used (1) supported by the ICPC2/ICD10 Thesaurus, (2) in sufficiently large studies to allow all classes to be observed often enough to provide reliable data, and (3) in studies based on data on episodes of care, rather than encounter data only. Under these conditions, the likelihood ratios of symptoms given a diagnosis, and of co-morbidity become available, which define the clinical content of family practice.

Traditionally, medical students are trained in an algorithmic manner, to focus on excluding serious but rare diseases by conceptualizing diagnoses through a process of exclusion based on systematic and technological investigation of an extensive list of potential diagnoses applicable to the patient's presenting symptoms and signs. Students are not often exposed to common diseases, and trivialize all that which cannot be addressed within a strictly medical model. This paper reflects on the recommendations of the EURACT Educational Agenda document, and proposes a return to empiricism in basic medical training by introducing students to primary healthcare, disease, and decision-making processes early in their training. The authors recommend the teaching of communication skills within primary care doctor-patient encounters, the exploration of new ways of teaching the doctor-patient relationship, and that students and young doctors be encouraged to prioritize quality over quantity. Will this stem the current trends towards increasing workload and burnout?

In Malta, sickness certificates are needed from the first day of illness, and are issued by family doctors (FDs) either employed in the government primary healthcare system, or self-employed in private practice, or employed directly by an employer for this purpose alone. Patients visiting self-employed FDs pay directly, and are not reimbursed unless privately insured. We aimed to contribute to the discussion on the impact of sickness certification in family practice by studying the phenomenon using electronic data from an electronic patient record (EPR) used by self-employed FDs. We used this data to study the frequency of sickness certification and the relationship between the patient's reason for encounter, with or without a formal request for a certificate, and the doctor's diagnosis and certification practice.We used data collected by FDs in day-to-day private family practice using an episode-oriented EPR. The EPR database included all encounters in all episodes of care over a period of one year (1 January to 31 December 2001) documented by ten self-employed FDs, comprehensively coded with ICPC-2-E (Electronic Version of the International Classification of Primary Care, version 2).The EPR database documented care for 7497 patients (45.4% male) over one year. During 15,781 encounters, sickness certificates were issued in 11.3% of 16,319 episodes of care. 5.7% of the reasons for encounter presented by the patient in new episodes were requests for administrative procedures, and this request was made in 8.2% of all new episodes of care.The distribution of morbidity seen by the FDs appeared to be very wide, with a dominance of acute respiratory, gastrointestinal and musculoskeletal symptoms and diagnoses, and the role of sickness certification was quite important. The frequency of sick leave certification in Malta is comparable with that in other European countries, but the average duration of episodes is shorter. Just over 11% of private FD encounters involve issuing a sickness certificate. The high proportion of reasons for encounter formulated as a request for a sickness certificate suggests that the active role of FDs in this form of social security in the Maltese population has supported the local development of family practice.

Background In Malta, sickness certificates are needed from the first day of illness, and are issued by family physicians (FPs) either employed by the government primary health care system, self-employed in private practice, or employed by an employer for this purpose alone. The latter system, when applied by the employer, is compulsory. In order to contribute to the debate on the role of the FP in this context, electronic data collected by a group of company-employed FPs was used to study the phenomenon of sickness certification. This database is a complete record of the selected employees' sick leave certification during the study period. Methods Data collected by company-employed FPs from a defined population was used: all employees of selected Maltese companies served by a group of FPs. The database included episode-based data from home visits over three years (01/01/1997 – 31/12/1999), by 9 company-appointed FPs regarding 421 employees of five companies. Results 3015 episodes of sickness absenteeism, with an average duration of 2.9 days, were documented. Employees who did intensive manual work had relatively higher rates. Furthermore, a relatively higher incidence of work injury, sprains and strains, anxiety and depression and low back pain as found in manual workers, and in male workers. This trend was shown to be statistically significant. Conclusions The frequency of sick-leave certification in Malta is comparable to that in other European countries, but the average duration of certificates is much less than reported in other studies that generally did not include data on short-term illness and certification. This has important implications on future research in the field. A number of common disorders were found to be significantly more prevalent causes of sickness certification in manual workers, amongst them anxiety and depression.

In preparation for investigating burnout among general practitioners internationally, we examined the validity and reliability of an instrument called the Maslach Burnout Inventory (MBI).Twenty-four members from 16 European countries who attended the European General Practice Workshop in Gdansk, Poland (Autumn, 2001) were mailed a draft version of the MBI, and asked to administer it to a small group of family physicians.This pilot study suggests the MBI scale is reliable and valid. We believe it of use in identifying GPs at risk of, or already experiencing, burnout.

The 6th MRCG(Int) Development Days were held this year between 22 and 24 May, hosted by the Royal College of General Practitioners at Princes Gate in London. Invited participants from sister colleges and associations came from as far as Japan, India, Sri Lanka, Pakistan, Afghanistan, Oman, Brunei, the United Arab Emirates, Kuwait, Saudi Arabia, Nigeria, Kosovo, Malta, and Turkey, reflecting the wide and diverse interest in this RCGP project. The seminar was preceded by hands-on pre-conference workshops on 21 May, facilitating capacity building through test-writing exercises, with the practical outcome of producing material for the MRCGP(Int) test banks. Topics included multiple-choice question writing for applied knowledge assessment, and scenario writing and rehearsal for clinical skills assessment and OSCE. The sessions were facilitated by Dr Mei …

The aim of this study was to compare general practitioners/family doctors in different European countries to assess the psychosocial and work-related factors possibly contributing to burnout. The survey included questions on demographic-, work- and lifestyle-related job satisfaction (Yaman & Ungan, 2002a; Yayli, Yaman, & Yaman, 2003) and the Maslach Burnout Inventory (Maslach & Jackson, 1986). Surveys were conducted in 13 European countries (Yaman & Soler, 2002b) with a response rate of 33%. The 1,503 respondents (833 males, 55.4%) had an average age of 45.6 (22–74) years. 44% scored high for emotional exhaustion, 37% for depersonalization, 31% for low personal accomplishment, with 12% scoring high for all three. High burnout in one or more dimensions was best predicted by a multivariate model including income, intention to change job (yes 1.89, no 0.82), satisfaction (0.58), increasing alcohol consumption (3.93), and use of psychotropic medication (2.08). High burnout in all dimensions was best predicted by a multivariate model including working weekends (1.77), job satisfaction (0.38), increasing smoking (2.38) and psychotropic medication use (2.23). Burnout seems to be a common problem in European general practitioners and family doctors. Future research is needed to develop models to describe the phenomenon and to identify causative factors and effective intervention strategies.

ObjetivoEl objetivo de este estudio es estimar la prevalencia del síndrome de burnout entre los médicos de atención primaria españoles e identificar los factores que se relacionan con el desgaste profesional.DiseñoDescriptivo transversal. Forma parte de un estudio europeo multicéntrico sobre prevalencia de burnout en médicos de familia.EmplazamientoMédicos de familia españoles.ParticipantesFueron invitados a participar en el estudio 285 médicos de familia miembros de la Sociedad Española de Medicina de Familia y Comunitaria (semFYC). La muestra se obtuvo a partir de un muestreo aleatorio sistemático del registro de socios de la semFYC proporcional al número de asociados por cada comunidad autónoma.Mediciones principalesSe elaboró un cuestionario anónimo que fue enviado por correo a cada médico seleccionado junto con una carta de presentación del estudio y un sobre franqueado. Las mediciones fueron: - Variables demográficas del médico (edad, sexo, estado civil, número de hijos) y características relacionadas con el trabajo (ubicación del centro, años desde la licenciatura, años trabajados en atención primaria, pacientes por semana, satisfacción con el trabajo, consideración de dejar el trabajo, días de incapacidad temporal, guardias nocturnas y de fin de semana). Consumo de medicamentos psicoactivos.– El síndrome de burnout se estudió mediante el Maslach Burnout Inventory (MBI). Una vez obtenido el permiso para utilizar la escala, 2 personas bilingües realizaron una traducción/retrotraducción. El MBI mide 3 dimensiones del síndrome de desgaste profesional: cansancio emocional (CE), despersonalización (DP) y realización personal (RP). Los niveles altos de burnout son indicados por puntuaciones altas en las subescalas de CE y DP y por puntuaciones bajas en la subescala de RP.La puntuación de cada subescala se categoriza como baja, media o alta.Se estudiaron las diferencias en la distribución de las variables respecto a los resultados de la escala de burnout mediante la prueba de la χ2 en el caso de variables cualitativas y el test de la U de Mann-Whitney para las cuantitativas.ResultadosRespondieron al cuestionario 86 médicos (30,17%). De ellos, el 70,9% (n=61) era mujer; la edad media±desviación estándar de los profesionales fue de 35,39±7,47 años. El 57% (n=49) estaba casado y un 46,5% tenía hijos, 18 de ellos

Introduction Diagnostic error is a major threat to patient safety in the context of family practice. The patient safety implications are severe for both patient and clinician. Traditional approaches to diagnostic decision support have lacked broad acceptance for a number of well‐documented reasons: poor integration with electronic health records and clinician workflow, static evidence that lacks transparency and trust, and use of proprietary technical standards hindering wider interoperability. The learning health system (LHS) provides a suitable infrastructure for development of a new breed of learning decision support tools. These tools exploit the potential for appropriate use of the growing volumes of aggregated sources of electronic health records. Methods We describe the experiences of the TRANSFoRm project developing a diagnostic decision support infrastructure consistent with the wider goals of the LHS. We describe an architecture that is model driven, service oriented, constructed using open standards, and supports evidence derived from electronic sources of patient data. We describe the architecture and implementation of 2 critical aspects for a successful LHS: the model representation and translation of clinical evidence into effective practice and the generation of curated clinical evidence that can be used to populate those models, thus closing the LHS loop. Results/Conclusions Six core design requirements for implementing a diagnostic LHS are identified and successfully implemented as part of this research work. A number of significant technical and policy challenges are identified for the LHS community to consider, and these are discussed in the context of evaluating this work: medico‐legal responsibility for generated diagnostic evidence, developing trust in the LHS (particularly important from the perspective of decision support), and constraints imposed by clinical terminologies on evidence generation.