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Objectives To explore the perceptions and views of remote consultations and patient care of primary care physicians (PCPs) who work remotely regularly and have experience performing remote consultations.Design A qualitative study using thematic analysis.Setting Four online focus group interviews with 17 PCPs, working with one private health care provider, with public and private primary care patients.Subjects PCPs who had performed video or online chat consultations with primary care patients for at least 6 months.Main outcome measurements PCPs’ perceptions and views working remotely in online chat and video consultations.Results Two main themes describing how PCPs perceived remote consultations emerged: 1) remote consultations have an impact on the way physicians work, and 2) remote consultations have an impact on the service system and patients. The subthemes of the first main theme included the physicians’ new way of working, impacts on physicians’ well-being, and impacts on communication and physician competences. The subthemes for the second main theme were the importance of smoothness of services for the patients, patient suitability, and technical liabilities.Conclusion Remote consultations provide PCPs with a new way of working that could improve work-life balance. However, it is important to maintain sufficient clinical competence through versatile work. Digital consultations can make contacting healthcare smoother and easier for patients if the patient selection is performed carefully. Online chat seems suitable for singular contacts and simple issues, but remote consultations could be used to sustain continuity of care.

AbstractObjective Diagnosis of cancer is challenging in primary care due to the low incidence of cancer cases in primary care practice. A prolonged diagnostic interval may be due to doctor, patient or system factors, or may be due to the characteristics of the cancer itself. The objective of this study was to learn from Primary Care Physicians’ (PCP) experiences of incidents when they had failed to think of, or act on, a cancer diagnosis.Design A qualitative, online survey eliciting PCP narratives. Thematic analysis was used to analyse the data.Setting and subjects A primary care study, with narratives from 159 PCPs in 23 European countries.Main outcome measures PCPs’ narratives on the question ‘If you saw this patient with cancer presenting in the same way today, what would you do differently?Results The main themes identified were: thinking broadly; improvement in communication and clinical management; use of other available resources and ‘I wouldn’t do anything differently’.Conclusion (Implications) To achieve more timely cancer diagnosis, PCPs need to provide a long-term, holistic and active approach with effective communication, and to ensure shared decision-making, follow-up and continuing re-assessment of the patients’ clinical conditions.

Background Fibromyalgia is a functional syndrome. Despite recent findings, there is still considerable uncertainty about its diagnostic process.Objectives This study aimed to explore patients’ experiences with fibromyalgia during the diagnostic process in primary health care. Moreover, we tried to determine how diagnostic consultation could be improved.Methods This study is based on data from patients with fibromyalgia in a primary health care study conducted in Nokia, Finland. Patients with fibromyalgia were identified from electronic medical records. Focus-group participants with fibromyalgia diagnoses were selected using a purposive sampling method to gather a maximum variation sample. Qualitative thematic analysis was used for the coded data from four focus-group discussions in 2018. A description of the coding tree was provided and researchers organised the codes. Finally, all researchers identified themes from the data.Results The main unifying entities were the uncertainty and contradictions fibromyalgia patients faced on several occasions. Physicians sometimes offered other diagnoses – like depression – as an explanation for the symptoms, or used repetitive tests to eliminate other possible diagnoses. Furthermore, patients expressed their wishes for a holistic, empathetic, and up-to-date approach to their symptoms.Conclusion In our interviews, a good doctor-patient relationship and continuity of care were necessary, as were the physician’s attitude and knowledge of fibromyalgia. Our findings also suggest avoiding repeated or unnecessary rule-out tests and the overdiagnosis of psychiatric disorders is necessary.

Electronic health services (eHealth) have increased rapidly in the last few years. These services hold the potential to facilitate today’s challenging primary care. The aim of the study was to examine how digitalisation manifests in Finnish health centres in 2021. We aimed to find out which digital tools are used in health centres and how they are exploited. In addition, we were interested in general practitioners’ attitudes towards digitalisation in their everyday work. An online survey was distributed to general practitioners (GPs) working in primary health care centres throughout Finland, and 265 GPs replied. A health portal and various digital calculators were used daily. In remote communication with their patients, general practitioners preferred telephone calls over new tools (chat/video). Attitudes towards eHealth were positive, but digital tools were not yet commonly used. The implementation of digital solutions still needs more effort.

Abstract Objective From previous studies, it is known that the association between fibromyalgia and thyroid autoimmunity diseases exists. On the other hand, it was recently suggested that in many cases thyroid hormone treatment might be unnecessary. The aim of our study is to explore the thyroid hormone treatment among primary health care fibromyalgia patients. Our study is cross-sectional and based on fibromyalgia study from the city of Nokia Health Center. Clinical examination was performed to participants, patients filled five questionnaires and information from electronic patient records was gathered. In addition to other parameters, we studied patient’s thyroid function levels at the beginning of thyroid hormone treatment. Results From those patients participating in the study (n = 103), 34% (n = 33) had thyroid hormone treatment. From those taking thyroid hormone treatment, 48% (n = 16) had information regarding the initial TSH and T4-V levels at the beginning of the treatment. 37% (n = 6) of them had normal thyroid function. Small sample size and data gathered from single health center effects on the generalizability of our findings. However, we suggest further studies to confirm the potential association between fibromyalgia and inappropriate thyroid hormone treatment.

Abstract Background General practitioners (GPs) should regularly review patients’ medications and, if necessary, deprescribe, as inappropriate polypharmacy may harm patients’ health. However, deprescribing can be challenging for physicians. This study investigates GPs’ deprescribing decisions in 31 countries. Methods In this case vignette study, GPs were invited to participate in an online survey containing three clinical cases of oldest-old multimorbid patients with potentially inappropriate polypharmacy. Patients differed in terms of dependency in activities of daily living (ADL) and were presented with and without history of cardiovascular disease (CVD). For each case, we asked GPs if they would deprescribe in their usual practice. We calculated proportions of GPs who reported they would deprescribe and performed a multilevel logistic regression to examine the association between history of CVD and level of dependency on GPs’ deprescribing decisions. Results Of 3,175 invited GPs, 54% responded (N = 1,706). The mean age was 50 years and 60% of respondents were female. Despite differences across GP characteristics, such as age (with older GPs being more likely to take deprescribing decisions), and across countries, overall more than 80% of GPs reported they would deprescribe the dosage of at least one medication in oldest-old patients (> 80 years) with polypharmacy irrespective of history of CVD. The odds of deprescribing was higher in patients with a higher level of dependency in ADL (OR =1.5, 95%CI 1.25 to 1.80) and absence of CVD (OR =3.04, 95%CI 2.58 to 3.57). Interpretation The majority of GPs in this study were willing to deprescribe one or more medications in oldest-old multimorbid patients with polypharmacy. Willingness was higher in patients with increased dependency in ADL and lower in patients with CVD.

Abstract Background The aim of this study was to assess the validity and reliability of the Patient Enablement Instrument (PEI) in Finnish health care centre patients. A pilot study was conducted to assess the content validity of the PEI. A questionnaire study in three health care centres in Western Finland was performed in order to assess acceptability, construct validity, internal consistency, and measurement error of the instrument. A telephone interview 2 weeks after the appointment was performed to evaluate reproducibility. Results The pilot study with 17 participants indicated good content validity of the PEI. In the questionnaire study, altogether 483 with a completed PEI score were included in the analyses. Factor analysis and item-scale correlations suggested high structural validity. The internal consistency of the instrument was high (Cronbach’s α = 0.93). The PEI score diminished strongly over the two-week period. Conclusions The PEI has good content validity and acceptability, good construct validity, high internal consistency but low reproducibility. Thus, the PEI seems to be an applicable tool to measure patient enablement in Finnish primary health care.

Objective To explore dementia management from a primary care physician perspective. Design One-page seven-item multiple choice questionnaire; free text space for every item; final narrative question of a dementia case story. Inductive explorative grounded theory analysis. Derived results in cluster analyses. Appropriateness of dementia drugs assessed by tertiary care specialist. Setting Twenty-five European General Practice Research Network member countries. Subjects Four hundred and forty-five key informant primary care physician respondents of which 106 presented 155 case stories. Main outcome measures Processes and typologies of dementia management. Proportion of case stories with drug treatment and treatment according to guidelines. Results Unburdening dementia – a basic social process – explained physicians’ dementia management according to a grounded theory analysis using both qualitative and quantitative data. Unburdening starts with Recognizing the dementia burden by Burden Identification and Burden Assessment followed by Burden Relief. Drugs to relieve the dementia burden were reported for 130 of 155 patients; acetylcholinesterase inhibitors or memantine treatment in 89 of 155 patients – 60% appropriate according to guidelines and 40% outside of guidelines. More Central and Northern primary care physicians were allowed to prescribe, and more were engaged in dementia management than Eastern and Mediterranean physicians according to cluster analyses. Physicians typically identified and assessed the dementia burden and then tried to relieve it, commonly by drug prescriptions, but also by community health and home help services, mentioned in more than half of the case stories. Conclusions Primary care physician dementia management was explained by an Unburdening process with the goal to relieve the dementia burden, mainly by drugs often prescribed outside of guideline indications. Implications: Unique data about dementia management by European primary care physicians to inform appropriate stakeholders.Key points Dementia as a syndrome of cognitive and functional decline and behavioural and psychological symptoms causes a tremendous burden on patients, their families, and society. •We found that a basic social process of Unburdening dementia explained dementia management according to case stories and survey comments from primary care physicians in 25 countries. •First, Burden Recognition by Identification and Assessment and then Burden Relief – often by drugs. •Prescribing physicians repeatedly broadened guideline indications for dementia drugs. The more physicians were allowed to prescribe dementia drugs, the more they were responsible for the dementia work-up. Our study provides unique data about dementia management in European primary care for the benefit of national and international stakeholders.

Abstract Background The Patient Enablement Instrument (PEI) is an established patient-reported outcome measure (PROM) that reflects the quality of appointments with general practitioners (GPs). It is a six-item questionnaire administered to the patient immediately after a consultation. The aim of this study was to evaluate whether a single-item measure could replace the PEI when measuring patient enablement among Finnish health care centre patients. Methods Two single-item measures, Q1 and Q2, were chosen for comparison with the PEI. Firstly, a pilot study with questionnaire testing and brief interviews with the respondents were performed in order to assess the content validity of the PEI and the single-item measures. Secondly, a questionnaire study after a single appointment with a GP was carried out in three health care centres in Western Finland in order to evaluate the construct and criterion validity of the single-item measures. A telephone interview was performed 2 weeks after the appointment in order to assess the test-retest reliability of the single-item measures. The sensitivity, specificity, and both positive and negative predictive values of Q1 and Q2 were calculated with different PEI score cut-off points. Results Altogether 483 patients with a completed PEI were included in the questionnaire study analyses. Altogether 149 and 175 patients had completed Q1 and Q2, respectively, both in the questionnaire and the telephone interview. The correlations between the PEI and Q1 and Q2 were 0.48 and 0.84, respectively. Both the single-item measures had a high sensitivity and a negative predictive value in relation to patients with lower PEI scores. The reliability coefficients were 0.24 for Q1 and 0.76 for Q2. The test-retest values of Q1, Q2, and the PEI were low. Conclusions Q2 seems to be a valid and reliable measure of patient enablement. Q1 seems to be less correlated with the PEI, but it also has a high negative predictive value in relation to low enablement scores.

Abstract Objective Access to care is a multidimensional concept, considered as a structural aspect of health care quality; it reflects the functioning of a health care organization. The aim of this study was to investigate patients’ experiences of access to care and to analyse factors associated with waiting times to GP appointments at Finnish health centres. A questionnaire survey was addressed to Finnish GPs within the Quality and Costs of Primary Care in Europe study framework. Two to nine patients per GP completed the questionnaire, altogether 1196. Main outcome measures were waiting times for appointments with GPs and factors associated with waiting times. In addition, patients’ opinions of access to appointments were analysed. Results Of the 988 patients who had made their appointment in advance, 84.9% considered it easy to secure an appointment, with 51.9% obtaining an appointment within 1 week. Age and reason for contact were the most significant factors affecting the waiting time. Elderly patients tended to have longer waiting times than younger ones, even when reporting illness as their reason for contact. Thus, waiting times for appointments tend to be prolonged in particular for the elderly and there is room for improvement in the future.

Objectives: We previously found large variations in general practitioner (GP) hypertension treatment probability in oldest-old (>80 years) between countries. We wanted to explore whether differences in country-specific cardiovascular disease (CVD) burden and life expectancy could explain the differences. Design: This is a survey study using case-vignettes of oldest-old patients with different comorbidities and blood pressure levels. An ecological multilevel model analysis was performed. Setting: GP respondents from European General Practice Research Network (EGPRN) countries, Brazil and New Zeeland. Subjects: This study included 2543 GPs from 29 countries. Main outcome measures: GP treatment probability to start or not start antihypertensive treatment based on responses to case-vignettes; either low (80 years of age). • In this study including 1947 GPs from 29 countries, we found that a high country-specific cardiovascular disease (CVD) burden (i.e. myocardial infarction and/or stroke) was associated with a higher GP treatment probability in patients aged >80 years. • However, the association was modified by country-specific life expectancy at age 60. While there was a positive association for GPs in countries with a low life expectancy at age 60, there was no association in countries with a high life expectancy at age 60. • These findings help explaining some of the large variation seen in the decision as to whether or not to treat hypertension in the oldest-old.

Abstract Background In oldest-old patients (>80), few trials showed efficacy of treating hypertension and they included mostly the healthiest elderly. The resulting lack of knowledge has led to inconsistent guidelines, mainly based on systolic blood pressure (SBP), cardiovascular disease (CVD) but not on frailty despite the high prevalence in oldest-old. This may lead to variation how General Practitioners (GPs) treat hypertension. Our aim was to investigate treatment variation of GPs in oldest-olds across countries and to identify the role of frailty in that decision. Methods Using a survey, we compared treatment decisions in cases of oldest-old varying in SBP, CVD, and frailty. GPs were asked if they would start antihypertensive treatment in each case. In 2016, we invited GPs in Europe, Brazil, Israel, and New Zealand. We compared the percentage of cases that would be treated per countries. A logistic mixed-effects model was used to derive odds ratio (OR) for frailty with 95% confidence intervals (CI), adjusted for SBP, CVD, and GP characteristics (sex, location and prevalence of oldest-old per GP office, and years of experience). The mixed-effects model was used to account for the multiple assessments per GP. Results The 29 countries yielded 2543 participating GPs: 52% were female, 51% located in a city, 71% reported a high prevalence of oldest-old in their offices, 38% and had >20 years of experience. Across countries, considerable variation was found in the decision to start antihypertensive treatment in the oldest-old ranging from 34 to 88%. In 24/29 (83%) countries, frailty was associated with GPs’ decision not to start treatment even after adjustment for SBP, CVD, and GP characteristics (OR 0.53, 95%CI 0.48–0.59; ORs per country 0.11–1.78). Conclusions Across countries, we found considerable variation in starting antihypertensive medication in oldest-old. The frail oldest-old had an odds ratio of 0.53 of receiving antihypertensive treatment. Future hypertension trials should also include frail patients to acquire evidence on the efficacy of antihypertensive treatment in oldest-old patients with frailty, with the aim to get evidence-based data for clinical decision-making.

Background: Patient enablement is described as patient’s ability to understand and cope with illness after a consultation. The purpose of this study was to analyze factors associated with enablement in Finnish primary health care. An additional aim was to evaluate whether a single question could be used to measure enablement. Methods: A questionnaire survey was addressed to Finnish general practitioners (GPs) within the Quality and Costs of Primary Care in Europe (QUALICOPC) study framework. A trained fieldworker contacted nine patients for every participating GP. Two to 9 patients per GP (median 9 patients) completed the questionnaire. Patient enablement was measured by a single question based on the Patient Enablement Instrument questionnaire. Multivariate and multilevel analyses were performed to find variables that have an independent association with patient enablement. Results: A total of 1196 patients completed the QUALICOPC questionnaire. A total of 898 patients (75.1%) agreed that they felt better able to cope with their health problem or illness after an appointment with a GP, reflecting patient enablement. In the theme group analyses, 11 factors were found to have a statistically significant ( P < .05) association with enablement. In the final multivariable model, positive perceptions of doctor-patient communication and patient satisfaction were positively associated with enablement. Conclusions: The results, using a single question to measure enablement, are comparable to previous findings on factors associated with enablement. Further research is needed and these results should be regarded as preliminary.

Objective The aim of this study was to examine the feasibility of a noninvasive telemonitoring system used by heart failure patients and nurses in a pilot program of the Heart Hospital unit in Tampere, Finland. Methods This cross-sectional observational study used a mixed methods design. Quantitative data were collected with one self-generated questionnaire for patients, and qualitative data were collected with a questionnaire for patients and semi-structured focus group interviews for patients and nurses. The questionnaire was sent to 47 patients who were in the pilot program, and 29 patients (61.7%) responded. Purposefully selected 8 patients and 8 nurses attended the interviews. We used descriptive statistics to assess the quantitative data from the questionnaire and inductive thematic analysis to identify themes deriving from the focus group interviews. We categorized the themes into facilitators and barriers to telemonitoring. Results Both the quantitative and qualitative data show that the telemonitoring system is easy to use, supports self-care and self-monitoring, and increases the feeling of safety. The chat tool of the system facilitated communication. The patients and nurses considered the system reliable despite some technical problems. The focus group interviews addressed technical challenges, nurses’ increased workload, and patients’ engagement with daily follow-up as possible barriers to telemonitoring. Conclusions The noninvasive heart failure telemonitoring system used in the pilot program is feasible. We found facilitators and barriers to telemonitoring that should be considered when developing the noninvasive telemonitoring of heart failure in the future.

BackgroundThe aim of patient segmentation is to recognize patients with similar health care needs. The Finnish patient segmentation service Navigator segregates patients into 4 groups, including a self-acting group, who presumably manages their everyday life and coordinates their health care. Digital services could support their self-care. Knowledge on self-acting patients’ characteristics is lacking. ObjectiveThe study aims are to describe how Navigator assigns patients with diabetes to the 4 groups at nurses’ appointments at a health center, the self-acting patient group’s characteristics compared with other patient groups, and the concordance between the nurse’s evaluation of the patient’s group and the actual group assigned by Navigator (criterion validity). MethodsPatients with diabetes ≥18 years old visiting primary care were invited to participate in this cross-sectional study. Patients with disability preventing informed consent for participation were excluded. Nurses estimated the patients’ upcoming group results before the appointment. We describe the concordance (%) between the evaluation and actual groups. Nurses used Navigator patients with diabetes (n=304) at their annual follow-up visits. The self-acting patients’ diabetes care values (glycated hemoglobin [HbA1c], urine albumin to creatinine ratio, low-density lipoprotein cholesterol, blood pressure, BMI), chronic conditions, medication, smoking status, self-rated health, disability (World Health Organization Disability Assessment Schedule [WHODAS] 2.0), health-related quality of life (EQ-5D-5L), and well-being (Well-being Questionnaire [WBQ-12]) and the patients’ responses to Navigator’s question concerning their digital skills as outcome variables were compared with those of the other patients. We used descriptive statistics for the patients’ distribution into the 4 groups and demographic data. We used the Mann-Whitney U test with nonnormally distributed variables, independent samples t test with normally distributed variables, and Pearson chi-square tests with categorized variables to compare the groups. ResultsMost patients (259/304, 85.2%) were in the self-acting group. Hypertension, hyperlipidemia, and joint ailments were the most prevalent comorbidities among all patients. Self-acting patients had less ischemic cardiac disease (P=.001), depression or anxiety (P=.03), asthma or chronic obstructive pulmonary disease (P

BackgroundThe national Omaolo digital social welfare and health care service of Finland provides a symptom checker, Omaolo, which is a medical device (based on Duodecim Clinical Decision Support EBMEDS software) with a CE marking (risk class IIa), manufactured by the government-owned DigiFinland Oy. Users of this service can perform their triage by using the questions in the symptom checker. By completing the symptom checker, the user receives a recommendation for action and a service assessment with appropriate guidance regarding their health problems on the basis of a selected specific symptom in the symptom checker. This allows users to be provided with appropriate health care services, regardless of time and place. ObjectiveThis study describes the protocol for the mixed methods validation process of the symptom checker available in Omaolo digital services. MethodsThis is a mixed methods study using quantitative and qualitative methods, which will be part of the clinical validation process that takes place in primary health care centers in Finland. Each organization provides a space where the study and the nurse triage can be done in order to include an unscreened target population of users. The primary health care units provide walk-in model services, where no prior phone call or contact is required. For the validation of the Omaolo symptom checker, case vignettes will be incorporated to supplement the triage accuracy of rare and acute cases that cannot be tested extensively in real-life settings. Vignettes are produced from a variety of clinical sources, and they test the symptom checker in different triage levels by using 1 standardized patient case example. ResultsThis study plan underwent an ethics review by the regional permission, which was requested from each organization participating in the research, and an ethics committee statement was requested and granted from Pirkanmaa hospital district’s ethics committee, which is in accordance with the University of Tampere’s regulations. Of 964 clinical user–filled symptom checker assessments, 877 cases were fully completed with a triage result, and therefore, they met the requirements for clinical validation studies. The goal for sufficient data has been reached for most of the chief symptoms. Data collection was completed in September 2019, and the first feasibility and patient experience results were published by the end of 2020. Case vignettes have been identified and are to be completed before further testing the symptom checker. The analysis and reporting are estimated to be finalized in 2024. ConclusionsThe primary goals of this multimethod electronic symptom checker study are to assess safety and to provide crucial information regarding the accuracy and usability of the Omaolo electronic symptom checker. To our knowledge, this will be the first study to include real-life clinical cases along with case vignettes. International Registered Report Identifier (IRRID)DERR1-10.2196/41423

BackgroundIn recent decades, virtual care has emerged as a promising option to support primary care delivery. However, despite the potential, adoption rates remained low. With the outbreak of COVID-19, it has suddenly been pushed to the forefront of care delivery. As we progress into the second year of the COVID-19 pandemic, there is a need and opportunity to review the impact remote care had in primary care settings and reassess its potential future role. ObjectiveThis study aims to explore the perspectives of general practitioners (GPs) and family doctors on the (1) use of virtual care during the COVID-19 pandemic, (2) perceived impact on quality and safety of care, and (3) essential factors for high-quality and sustainable use of virtual care in the future. MethodsThis study used an online cross-sectional questionnaire completed by GPs distributed across 20 countries. The survey was hosted in Qualtrics and distributed using email, social media, and the researchers’ personal contact networks. GPs were eligible for the survey if they were working mainly in primary care during the period of the COVID-19 pandemic. Descriptive statistical analysis will be performed for quantitative variables, and relationships between the use of virtual care and perceptions on impact on quality and safety of care and participants’ characteristics may be explored. Qualitative data (free-text responses) will be analyzed using framework analysis. ResultsData collection took place from June 2020 to September 2020. As of this manuscript’s submission, a total of 1605 GP respondents participated in the questionnaire. Further data analysis is currently ongoing. ConclusionsThe study will provide a comprehensive overview of the availability of virtual care technologies, perceived impact on quality and safety of care, and essential factors for high-quality future use. In addition, a description of the underlying factors that influence this adoption and perceptions, in both individual GP and family doctor characteristics and the context in which they work, will be provided. While the COVID-19 pandemic may prove the first great stress test of the capabilities, capacity, and robustness of digital systems currently in use, remote care will likely remain an increasingly common approach in the future. There is an imperative to identify the main lessons from this unexpected transformation and use them to inform policy decisions and health service design. International Registered Report Identifier (IRRID)DERR1-10.2196/30099

Common colds are the most frequently encountered disease worldwide and the most frequent reason for self-care. According to the cross-sectional European Common Colds study (COCO), patients use as many as 12 items on average for self-care. Little is known about the influence of discomfort and knowledge on self-care for common colds.To understand the influence of patients' discomfort during a cold and their knowledge about the self-limited disease course on the use of self-care measures.This COCO analysis included 2,204 patients from 22 European primary care sites in 12 countries. Each site surveyed 120 consecutive adults with a 27-item questionnaire asking about patients' self-care, subjective discomfort during a cold (discomfort: yes/no), and knowledge about the self-limited course (yes/no). Country-specific medians of the number of self-care items served as a cut-off to define high and low self-care use. Four groups were stratified based on discomfort (yes/no) and knowledge (yes/no).Participants' mean age was 46.5 years, 61.7% were female; 36.3% lacked knowledge; 70.6% reported discomfort. The group has discomfort/no knowledge exhibited the highest mean item use (13.3), followed by has discomfort/has knowledge (11.9), no discomfort/no knowledge (11.1), and no discomfort/has knowledge (8.8). High use was associated with discomfort (OR 1.8; CI 1.5-2.2), female gender (OR 1.7; 1.4-2.0), chronic pain/arthritis (OR 1.6; 1.2-2.1), more years of education (OR 1.3; 1.1-1.6), age