Integrated Approach to Chronic Pain-The Role of Psychosocial Factors and Multidisciplinary Treatment: A Narrative Review.

BACKGROUND: Chronic non-malignant pain represents a growing global public health priority. Chronic pain is multifactorial, with numerous biological, psychological, and social factors contributing to this pain syndrome. It affects not only the patients, impairing their quality of life, but also their family and social environment. Chronic pain is a diagnosis and requires effective and sustainable treatment strategies. OBJECTIVE: Our aim was to critically review the available evidence on the importance of different approaches in treating patients with chronic non-malignant pain, emphasizing the effectiveness of integrating psychological and social factors within a multidisciplinary framework. METHODS: This was a non-systematic narrative review of the basic and recent literature analyzing approaches to the treatment of chronic non-malignant pain. The inclusion criteria for the papers were chronic non-malignant pain, treatment approach, review, and original research papers published in English in the last five years (PubMed search), and the basic literature was selected from the references of new papers according to the knowledge and experience of the authors. RESULTS: This literature review included 120 papers, of which 83 were basic, and 37 were new, published in the last 5 years (2018-2023). The results show that both the basic and newly published literature advocate for a biopsychosocial approach to treating chronic pain. CONCLUSIONS: New findings, compared to the earlier literature, indicate a new classification of chronic pain into primary and secondary. Chronic pain should be approached with a biopsychosocial model within a multidisciplinary treatment framework. This model addresses the complex interplay of biological, psychological, and social factors, offering a holistic strategy for effective pain management.

Exploring Personality Traits, Values, and Attitudes toward Professionalism: Implications for the Promotion of Mental Health and Functioning in Medical Students.

Healthcare workers face significant mental health challenges, including stress, burnout, and psychological distress, leading to high rates of mental health symptoms and even suicide attempts, as well as an increase in medication errors and unprofessional behavior. Targeted interventions are needed to address these issues. However, promoting healthier traits in medical students or refining selection could also prove beneficial, as research shows that mental health is significantly influenced by personality traits and personal values. This study examines the relationship between personality traits, values, and attitudes toward professionalism among medical students in Slovenia. A total of 996 participants were examined in three data collections from the academic years 2015-2016 to 2019-2020 using the Big Five Questionnaire, the Personal Values Scale, and the Attitude Toward Professionalism Scale. Hierarchical linear regression analysis was conducted to examine the factors associated with professionalism. The results showed that attitudes toward professionalism were stable over the years, with higher scores consistently associated with the female gender, agreeableness, and conscientiousness. Conversely, material value orientation had a negative impact on professionalism. In addition, we examine the associations between mental health and personality traits, personal values, and attitudes toward professionalism to illustrate the importance of selecting and nurturing medical students, based on traits that promote mental health and professional behavior. These findings may lead to improvements in medical education and selection processes to improve the well-being and functioning of future medical professionals.

Improving Antibiotic Use in Nursing Homes by Infection Prevention and Control and Antibiotic Stewardship (IMAGINE): Protocol for a Before-and-After Intervention and Implementation Study.

BACKGROUND: Despite the extensive use of antibiotics and the growing challenge of antimicrobial resistance, there has been a lack of substantial initiatives aimed at diminishing the prevalence of infections in nursing homes and enhancing the detection of urinary tract infections (UTIs). OBJECTIVE: This study aims to systematize and enhance efforts to prevent health care-associated infections, mainly UTIs and reduce antibiotic inappropriateness by implementing a multifaceted intervention targeting health care professionals in nursing homes. METHODS: A before-and-after intervention study carried out in a minimum of 10 nursing homes in each of the 8 European participating countries (Denmark, Greece, Hungary, Lithuania, Poland, Slovakia, Slovenia, and Spain). A team of 4 professionals consisting of nurses, doctors, health care assistants, or health care helpers are actively involved in each nursing home. Over the initial 3-month period, professionals in each nursing home are registering information on UTIs as well as infection and prevention control measures by means of the Audit Project Odense method. The audit will be repeated after implementing a multifaceted intervention. The intervention will consist of feedback and discussion of the results from the first registration, training on the implementation of infection and prevention control techniques provided by experts, appropriateness of the diagnostic approach and antibiotic prescribing for UTIs, and provision of information materials on infection control and antimicrobial stewardship targeted to staff, residents, and relatives. We will compare the pre- and postintervention audit results using chi-square test for prescription appropriateness and Student t test for implemented hygiene elements. RESULTS: A total of 109 nursing homes have participated in the pilot study and the first registration audit. The results of the first audit registration are expected to be published in autumn of 2024. The final results will be published by the end of 2025. CONCLUSIONS: This is a European Union-funded project aimed at contributing to the battle against antimicrobial resistance through improvement of the quality of management of common infections based on evidence-based interventions tailored to the nursing home setting and a diverse range of professionals. We expect the intervention to result in a significant increase in the number of hygiene activities implemented by health care providers and residents. Additionally, we anticipate a marked reduction in the number of inappropriately managed UTIs, as well as a substantial decrease in the overall incidence of infections following the intervention. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/60099.

Diagnosing probable urinary tract infections in nursing home residents without indwelling catheters: a narrative review.

BACKGROUND: Overdiagnosis of urinary tract infections (UTIs) is one of the most common reasons for the unnecessary use of antibiotics in nursing homes, increasing the risk of missing serious conditions. Various decision tools and algorithms aim to aid in UTI diagnosis and the initiation of antibiotic therapy for residents. However, due to the lack of a clear reference standard, these tools vary widely and can be complex, with some requiring urine testing. As part of the European-funded IMAGINE project, aimed at improving antibiotic use for UTIs in nursing home residents, we have reviewed the recommendations. OBJECTIVES: This review provides a comprehensive summary of the more relevant tools and algorithms aimed at identifying true UTIs among residents living in nursing homes and discusses the challenges in using these algorithms based on updated research. SOURCES: The discussion is based on a relevant medical literature search and synthesis of the findings and published tools to provide an overview of the current state of improving the diagnosis of UTIs in nursing homes. CONTENT: The following topics are covered: prevalence of asymptomatic bacteriuria, diagnostic challenges, clinical criteria, urinary testing, and algorithms to be implemented in nursing home facilities. IMPLICATIONS: Diagnosing UTIs in residents is challenging due to the high prevalence of asymptomatic bacteriuria and nonspecific urinary tract signs and symptoms among those with suspected UTIs. The fear of missing a UTI and the perceived antibiotic demands from residents and relatives might lead to overdiagnosis of this common condition. Despite their widespread use, urine dipsticks should not be recommended for geriatric patients. Patients who do not meet the minimum diagnostic criteria for UTIs should be evaluated for alternative conditions. Adherence to a simple algorithm can prevent unnecessary antibiotic courses without compromising resident safety.

Enhancing LGBT + primary healthcare in Slovenia: A national qualitative study of experiences and expectations of LGBT + people and family doctors.

BACKGROUND: Despite growing acceptance of LGBT + individuals, an underlying stigma persists even in healthcare, resulting in substandard care and worse healthcare outcomes for LGBT + individuals. OBJECTIVES: To examine and compare the experiences and expectations regarding primary healthcare among LGBT + individuals and general practitioners (GPs) in Slovenia. METHODS: We conducted an online national qualitative study using open-ended questions. To reach LGBT + population snowball method of recruitment was employed by sharing the questionnaire through LGBT + organisations, while GPs were invited by email of Association of family doctors in Slovenia. Anonymous data was collected from October to December 2021 and the questionnaires of 25 GPs and 90 LGBT + individuals of various ages, backgrounds, gender identities and sexual orientations were reviewed using thematic analysis. RESULTS: Both LGBT + participants and GPs expressed a desire for equal treatment. However, while all GPs claimed to treat all patients equally, LGBT + participants reported more varied experiences. Specific knowledge, especially on LGBT + terminology and healthcare, was perceived as lacking among GPs, leading LGBT + individuals to seek advice from specialists or community counselling. Systemic barriers, including societal stigmatisation and limited formal education on LGBT + issues, were identified, highlighting the need for designated safe spaces and improved GP training. Safety emerged as a central theme, crucial for fostering trust and disclosure between patients and healthcare providers. CONCLUSION: The study underscores the significance of a sense of safety in the patient-doctor relationship and highlights the need for improved training and attitudes to provide inclusive and affirming healthcare for LGBT + individuals.

Primary care settings must prioritise creating safe and non-judgmental environments for better LGBT + healthcare.Addressing formal GP education on LGBT + terminology, identities, and healthcare needs is crucial to provide inclusive care.Overcoming systemic barriers, such as societal prejudice and homophobia, requires creating visible safe space signals in primary care settings.

The Use of COVID-19 Mobile Apps in Connecting Patients with Primary Healthcare in 30 Countries: Eurodata Study.

BACKGROUND: The COVID-19 pandemic has necessitated changes in European healthcare systems, with a significant proportion of COVID-19 cases being managed on an outpatient basis in primary healthcare (PHC). To alleviate the burden on healthcare facilities, many European countries developed contact-tracing apps and symptom checkers to identify potential cases. As the pandemic evolved, the European Union introduced the Digital COVID-19 Certificate for travel, which relies on vaccination, recent recovery, or negative test results. However, the integration between these apps and PHC has not been thoroughly explored in Europe. OBJECTIVE: To describe if governmental COVID-19 apps allowed COVID-19 patients to connect with PHC through their apps in Europe and to examine how the Digital COVID-19 Certificate was obtained. METHODOLOGY: Design and setting: Retrospective descriptive study in PHC in 30 European countries. An ad hoc, semi-structured questionnaire was developed to collect country-specific data on primary healthcare activity during the COVID-19 pandemic and the use of information technology tools to support medical care from 15 March 2020 to 31 August 2021. Key informants belong to the WONCA Europe network (World Organization of Family Doctors). The data were collected from relevant and reliable official sources, such as governmental websites and guidelines. MAIN OUTCOME MEASURES: Patient's first contact with health system, governmental COVID-19 app (name and function), Digital COVID-19 Certification, COVID-19 app connection with PHC. RESULTS: Primary care was the first point of care for suspected COVID-19 patients in 28 countries, and 24 countries developed apps to complement classical medical care. The most frequently developed app was for tracing COVID-19 cases (24 countries), followed by the Digital COVID-19 Certificate app (17 countries). Bulgaria, Italy, Serbia, North Macedonia, and Romania had interoperability between PHC and COVID-19 apps, and Poland and Romania's apps considered social needs. CONCLUSIONS: COVID-19 apps were widely created during the first pandemic year. Contact tracing was the most frequent function found in the registered apps. Connection with PHC was scarcely developed. In future pandemics, connections between health system levels should be guaranteed to develop and implement effective strategies for managing diseases.

Exploring the accessibility of primary health care data in Europe's COVID-19 response: developing key indicators for managing future pandemics (Eurodata study).

BACKGROUND: Primary Health Care (PHC) plays a crucial role in managing the COVID-19 pandemic, with only 8% of cases requiring hospitalization. However, PHC COVID-19 data often goes unnoticed on European government dashboards and in media discussions. This project aims to examine official information on PHC patient care during the COVID-19 pandemic in Europe, with specific objectives: (1) Describe PHC's clinical pathways for acute COVID-19 cases, including long-term care facilities, (2) Describe PHC COVID-19 pandemic indicators, (3) Develop COVID-19 PHC activity indicators, (4) Explain PHC's role in vaccination strategies, and (5) Create a PHC contingency plan for future pandemics. METHODS: A mixed-method study will employ two online questionnaires to gather retrospective PHC data on COVID-19 management and PHC involvement in vaccination strategies. Validation will occur through focus group discussions with medical and public health (PH) experts. A two-wave Delphi survey will establish a European PHC indicators dashboard for future pandemics. Additionally, a coordinated health system action plan involving PHC, secondary care, and PH will be devised to address future pandemic scenarios. ANALYSIS: Quantitative data will be analysed using STATA v16.0 for descriptive and multivariate analyses. Qualitative data will be collected through peer-reviewed questionnaires and content analysis of focus group discussions. A Delphi survey and multiple focus groups will be employed to achieve consensus on PHC indicators and a common European health system response plan for future pandemics. The Eurodata research group involving researchers from 28 European countries support the development. DISCUSSION: While PHC manages most COVID-19 acute cases, data remains limited in many European countries. This study collects data from numerous countries, offering a comprehensive perspective on PHC's role during the pandemic in Europe. It pioneers the development of a PHC dashboard and health system plan for pandemics in Europe. These results may prove invaluable in future pandemics. However, data may have biases due to key informants' involvement and may not fully represent all European GP practices. PHC has a significant role in the management of the COVID-19 pandemic, as most of the cases are mild or moderate and only 8% needed hospitalization. However, PHC COVID-19 activity data is invisible on governments' daily dashboards in Europe, often overlooked in media and public debates.

Primary care indicators for disease burden, monitoring and surveillance of COVID-19 in 31 European countries: Eurodata Study.

BACKGROUND: During the COVID-19 pandemic, the majority of patients received ambulatory treatment, highlighting the importance of primary health care (PHC). However, there is limited knowledge regarding PHC workload in Europe during this period. The utilization of COVID-19 PHC indicators could facilitate the efficient monitoring and coordination of the pandemic response. The objective of this study is to describe PHC indicators for disease surveillance and monitoring of COVID-19's impact in Europe. METHODS: Descriptive, cross-sectional study employing data obtained through a semi-structured ad hoc questionnaire, which was collectively agreed upon by all participants. The study encompasses PHC settings in 31 European countries from March 2020 to August 2021. Key-informants from each country answered the questionnaire. Main outcome: the identification of any indicator used to describe PHC COVID-19 activity. RESULTS: Out of the 31 countries surveyed, data on PHC information were obtained from 14. The principal indicators were: total number of cases within PHC (Belarus, Cyprus, Italy, Romania and Spain), number of follow-up cases (Croatia, Cyprus, Finland, Spain and Turkey), GP's COVID-19 tests referrals (Poland), proportion of COVID-19 cases among respiratory illnesses consultations (Norway and France), sick leaves issued by GPs (Romania and Spain) and examination and complementary tests (Cyprus). All COVID-19 cases were attended in PHC in Belarus and Italy. CONCLUSIONS: The COVID-19 pandemic exposes a crucial deficiency in preparedness for infectious diseases in European health systems highlighting the inconsistent recording of indicators within PHC organizations. PHC standardized indicators and public data accessibility are urgently needed, conforming the foundation for an effective European-level health services response framework against future pandemics.

What would primary care practitioners do differently after a delayed cancer diagnosis? Learning lessons from their experiences.

OBJECTIVE: 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.

Diagnosing cancer in primary care is challenging due to the low incidence of cancer in practice and the multiple confounding factors that are involved in the diagnostic process.The need to think broadly, make improvements in communication and clinical management, and use other available resources were the main themes from Primary Care Physicians' (PCPs') narratives about their learning experiences from missed or late cancer diagnoses.A long-term, holistic and active approach with effective communication, follow-up and continuing re-assessment of the patients' clinical conditions was another theme for making improvements.Some PCPs, on reflection, would not have done anything differently.

Transitioning from face-to-face to distance education. Part 1: A cross-sectional study in the former Yugoslavia during COVID-19.

BACKGROUND: The countries of the former Yugoslavia have health and education systems with the same tradition but these have changed over the years. Little is known about how family medicine teaching transitioned from face-to-face to distance education during the COVID-19 pandemic. OBJECTIVES: to investigate student/teacher experience in transitioning from face-to-face to distance education. METHODS: A cross-sectional, online survey was conducted among 21 medical schools of the former Yugoslavia between December 2021 and March 2022. Under/postgraduate teachers and students who taught/studied family medicine during the academic year 2020/2021 were invited to participate. Of 31 questions for students and 35 for teachers, all but nine open questions were analysed using descriptive statistics. RESULTS: Seventeen of 21 medical schools contributed data involving 117 participants representing all countries of the former Yugoslavia. At the beginning of the pandemic, 30%, 26% and 15% of teachers, students and trainees, respectively, received formal preparation in distance education. Of these, 92% of teachers and 58% of students/trainees felt they were not adequately prepared. Synchronous teaching was the main method used, with a third using hybrid methods. All participants were least confident about online assessment. More than 75% of respondents agreed that lectures could be kept online, not patient consultations or practical skills' classes. CONCLUSION: Teachers used various old and new methods to provide learning opportunities despite COVID-19 constraints. Effective technology-based strategies are essential to ensure assessment integrity and enhance the learning environment.

Despite limited preparedness, teachers and students/trainees transitioned to distance education.Students/trainees believed synchronous delivery of lectures and small group work can be conducted online but not practical skills' classes.Online assessments and practical work with patients were considered the most challenging aspects of distance education.

Transitioning from face-to-face to distance education. Part 2: A qualitative study in the former Yugoslavia during COVID-19.

BACKGROUND: Similar to other countries, Departments of Family Medicine in the former Yugoslavia had to transition from face-to-face to distance education during COVID-19. OBJECTIVES: To elucidate obstacles and facilitators of the transition from face-to-face to distance education. METHODS: A cross-sectional, multicentre, qualitative study design was used to analyse nine open-ended questions from an online survey using inductive thematic analysis. The questionnaire was distributed to 21 medical schools, inviting them to involve at least two teachers/students/trainees. Data were collected between December 2021 and March 2022. RESULTS: In 17 medical schools, 23 students, 54 trainees and 40 teachers participated. The following themes were identified: facilitators and barriers of transition, innovations for enhancing distance education, convenience of distance education, classical teaching for better communication, the future of distance education, reaching learning outcomes and experience of online assessment. Innovations referred mainly to new online technologies for interactive education and communication. Distance education allowed for greater flexibility in scheduling and self-directed learning; however, participants felt that classical education allowed better communication and practical learning. Teachers believed knowledge-related learning outcomes could be achieved through distance education but not teaching clinical skills. Participants anticipated a future where a combination of teaching methods is used. CONCLUSION: The transition to distance education was made possible thanks to its flexible scheduling, innovative tools and possibility of self-directed learning. However, face-to-face education was considered preferable for fostering interpersonal relations and teaching clinical skills. Educators should strive to strike a balance between innovative approaches and the preservation of personal experiences.

Participants found that distance education offers many possibilities, mainly self-directed, flexible learning.Participants felt that face-to-face education remains invaluable since it facilitates communication and the development of practical skills.A balance between new technologies and personal encounters was believed to be best.

The role of primary health care in long-term care facilities during the COVID-19 pandemic in 30 European countries: a retrospective descriptive study (Eurodata study).

BACKGROUND AND AIM: Primary health care (PHC) supported long-term care facilities (LTCFs) in attending COVID-19 patients. The aim of this study is to describe the role of PHC in LTCFs in Europe during the early phase of the pandemic. METHODS: Retrospective descriptive study from 30 European countries using data from September 2020 collected with an ad hoc semi-structured questionnaire. Related variables are SARS-CoV-2 testing, contact tracing, follow-up, additional testing, and patient care. RESULTS: Twenty-six out of the 30 European countries had PHC involvement in LTCFs during the COVID-19 pandemic. PHC participated in initial medical care in 22 countries, while, in 15, PHC was responsible for SARS-CoV-2 test along with other institutions. Supervision of individuals in isolation was carried out mostly by LTCF staff, but physical examination or symptom's follow-up was performed mainly by PHC. CONCLUSION: PHC has participated in COVID-19 pandemic assistance in LTCFs in coordination with LTCF staff, public health officers, and hospitals.

Exploring why European primary care physicians sometimes do not think of, or act on, a possible cancer diagnosis. A qualitative study.

BACKGROUND: While primary care physicians (PCPs) play a key role in cancer detection, they can find cancer diagnosis challenging, and some patients have considerable delays between presentation and onward referral. AIM: To explore European PCPs' experiences and views on cases where they considered that they had been slow to think of, or act on, a possible cancer diagnosis. DESIGN & SETTING: A multicentre European qualitative study, based on an online survey with open-ended questions, asking PCPs for their narratives about cases when they had missed a diagnosis of cancer. METHOD: Using maximum variation sampling, PCPs in 23 European countries were asked to describe what happened in a case where they were slow to think of a cancer diagnosis, and for their views on why it happened. Thematic analysis was used to analyse the data. RESULTS: A total of 158 PCPs completed the questionnaire. The main themes were as follows: patients' descriptions did not suggest cancer; distracting factors reduced PCPs' cancer suspicions; patients' hesitancy delayed the diagnosis; system factors not facilitating timely diagnosis; PCPs felt that they had acted wrongly; and problems with communicating adequately. CONCLUSION: The study identified six overarching themes that need to be addressed. Doing so should reduce morbidity and mortality in the small proportion of patients who have a significant, avoidable delay in their cancer diagnosis. The 'Swiss cheese' model of accident causation showed how the themes related to each other.

Clinical pathway of COVID-19 patients in primary health care in 30 European countries: Eurodata study.

BACKGROUND: Most COVID-19 patients were treated in primary health care (PHC) in Europe. OBJECTIVES: To demonstrate the scope of PHC workflow during the COVID-19 pandemic emphasising similarities and differences of patient's clinical pathways in Europe. METHODS: Descriptive, cross-sectional study with data acquired through a semi-structured questionnaire in PHC in 30 European countries, created ad hoc and agreed upon among all researchers who participated in the study. GPs from each country answered the approved questionnaire. Main variable: PHC COVID-19 acute clinical pathway. All variables were collected from each country as of September 2020. RESULTS: COVID-19 clinics in PHC facilities were organised in 8/30. Case detection and testing were performed in PHC in 27/30 countries. RT-PCR and lateral flow tests were performed in PHC in 23/30, free of charge with a medical prescription. Contact tracing was performed mainly by public health authorities. Mandatory isolation ranged from 5 to 14 days. Sick leave certification was given exclusively by GPs in 21/30 countries. Patient hotels or other resources to isolate patients were available in 12/30. Follow-up to monitor the symptoms and/or new complementary tests was made mainly by phone call (27/30). Chest X-ray and phlebotomy were performed in PHC in 18/30 and 23/30 countries, respectively. Oxygen and low-molecular-weight heparin were available in PHC (21/30). CONCLUSION: In Europe PHC participated in many steps to diagnose, treat and monitor COVID-19 patients. Differences among countries might be addressed at European level for the management of future pandemics.

Translation of the working alliance inventory short revised into Italian using a Delphi procedure and a forward-backward translation.

Introduction: Enhancing treatment adherence, especially for chronic diseases, can be achieved through therapeutic alliance, potentially elevating the quality of care. An instrument to evaluate the therapeutic alliance could be beneficial in routine clinical settings, educational environments, and extensive research efforts at national and European levels. In this study, we translated therapist and patient versions of the Working Alliance Inventory Short Revised (WAI-SR) into Italian. Methodology: An email-based Delphi method was employed for the English-to-Italian translation, incorporating a forward-backward process. The initial translation team comprised two Italian family physicians proficient in English, a linguist, and a psychiatrist. The forward translation was then reviewed by 18 Italian family physicians through a Delphi process and was subjected to a backward translation by two Italian English teachers. A cultural correspondence was subsequently identified to adjust translations within a national and international framework. Results: All 18 experts fully engaged in the Delphi process, and consensus was achieved by the second Delphi round. A cultural check checked for discrepancies regarding linguistic consistency with other translations and found no difference. Conclusion: This Italian translation of the WAI-SR is expected to support Italian family physicians aiming to enhance their clinical practice and therapeutic outcomes. It could also be a valuable tool for Italian medical students to foster therapeutic relationships and improve their communication skills.

What factors empower general practitioners for early cancer diagnosis? A 20-country European Delphi Study.

BACKGROUND: Some symptoms are recognised as red flags for cancer, causing the General Practitioner (GP) to refer the patient for investigation without delay. However, many early symptoms of cancer are vague and unspecific, and in these cases, a delay in referral risks a diagnosis of cancer that is too late. Empowering GPs in their management of patients that may have cancer is likely to lead to more timely cancer diagnoses. AIM: To identify the factors that affect European GPs' empowerment in making an early diagnosis of cancer. METHODS: This was a Delphi study involving GPs in 20 European countries. We presented GPs with 52 statements representing factors that could empower GPs to increase the number of early cancer diagnoses. Over three Delphi rounds, we asked GPs to indicate the clinical relevance of each statement on a Likert scale.The final list of statements indicated those that were considered by consensus to be the most relevant. RESULTS: In total, 53 GPs from 20 European countries completed the Delphi process, out of the 68 GPs who completed round one. Twelve statements satisfied the pre-defined criteria for relevance. Five of the statements related to screening and four to the primary/secondary care interface. The other selected statements concerned information technology (IT) and GPs' working conditions. Statements relating to training, skills and working efficiency were not considered priority areas. CONCLUSION: GPs consider that system factors relating to screening, the primary-secondary care interface, IT and their working conditions are key to enhancing their empowerment in patients that could have cancer. These findings provide the basis for seeking actions and policies that will support GPs in their efforts to achieve timely cancer diagnosis.

Non-Medical Factors Associated with the Outcome of Treatment of Chronic Non-Malignant Pain: A Cross-Sectional Study.

BACKGROUND: Chronic pain is a global public health issue with increasing prevalence. Chronic pain causes sleep disorder, reactive anxiety, and depression, impairs the quality of life; it burdens the individual and society as a whole. The aim of this study was to examine non-medical factors related to the outcome of the treatment of chronic non-malignant pain. METHODS: A cross-sectional study with two groups of patients was conducted using a questionnaire with biological, psychological, and social characteristics of patients. Since this study was cross-sectional, it was not possible to determine whether some factors were the cause or the consequence of unsuccessful treatment outcome, which is at the same time one of the disadvantages of cross-sectional studies. RESULTS: The poor outcome of the treatment of chronic non-malignant pain in a multivariate binary logistic regression model was statistically significantly associated with the lower quality of life (OR = 0.95 (95% CI: 0.91-0.99; p = 0.009), and higher depression level OR = 1.08 (95% CI: 1.02-1.14; p = 0.009). The outcome of the treatment was not directly related to social support measured by the multivariate binary logistic regression model (OR = 1.04, 95% CI: 0.95-1.15, p = 0.395), but solitary life (without partner) was (OR = 2.16 (95% CI: 1.03-4.53; p = 0.043). CONCLUSION: The typical patient with a poor pain management outcome is retired, presents depressive behavior; their pain disturbs general activity and sleeping. Moreover, they have a physically disturbed quality of life and require self-treatment due to the inaccessibility of doctors and therapies. The principle of treatment of patients with chronic, non-malignant pain should take into account a biopsychosocial approach with individually adjusted procedures.

Primary Care System Factors and Clinical Decision-making in Patients that Could Have Lung Cancer: a Vignette Study in Five Balkan Region Countries.

INTRODUCTION: Lung cancer is the leading cause of cancer death, with wide variations in national survival rates. This study compares primary care system factors and primary care practitioners' (PCPs') clinical decision-making for a vignette of a patient that could have lung cancer in five Balkan region countries (Slovenia, Croatia, Bulgaria, Greece, Romania). METHODS: PCPs participated in an online questionnaire that asked for demographic data, practice characteristics, and information on health system factors. Participants were also asked to make clinical decisions in a vignette of a patient with possible lung cancer. RESULTS: The survey was completed by 475 PCPs. There were significant national differences in PCPs' direct access to investigations, particularly to advanced imaging. PCPs from Bulgaria, Greece, and Romania were more likely to organise relevant investigations. The highest specialist referral rates were in Bulgaria and Romania. PCPs in Bulgaria were less likely to have access to clinical guidelines, and PCPs from Slovenia and Croatia were more likely to have access to a cancer fast-track specialist appointment system. The PCPs' country had a significant effect on their likelihood of investigating or referring the patient. CONCLUSIONS: There are large differences between Balkan region countries in PCPs' levels of direct access to investigations. When faced with a vignette of a patient with the possibility of having lung cancer, their investigation and referral rates vary considerably. To reduce diagnostic delay in lung cancer, direct PCP access to advanced imaging, availability of relevant clinical guidelines, and fast-track referral systems are needed.

General practitioners' perceptions of using virtual primary care during the COVID-19 pandemic: An international cross-sectional survey study.

With the onset of COVID-19, general practitioners (GPs) and patients worldwide swiftly transitioned from face-to-face to digital remote consultations. There is a need to evaluate how this global shift has impacted patient care, healthcare providers, patient and carer experience, and health systems. We explored GPs' perspectives on the main benefits and challenges of using digital virtual care. GPs across 20 countries completed an online questionnaire between June-September 2020. GPs' perceptions of main barriers and challenges were explored using free-text questions. Thematic analysis was used to analyse the data. A total of 1,605 respondents participated in our survey. The benefits identified included reducing COVID-19 transmission risks, guaranteeing access and continuity of care, improved efficiency, faster access to care, improved convenience and communication with patients, greater work flexibility for providers, and hastening the digital transformation of primary care and accompanying legal frameworks. Main challenges included patients' preference for face-to-face consultations, digital exclusion, lack of physical examinations, clinical uncertainty, delays in diagnosis and treatment, overuse and misuse of digital virtual care, and unsuitability for certain types of consultations. Other challenges include the lack of formal guidance, higher workloads, remuneration issues, organisational culture, technical difficulties, implementation and financial issues, and regulatory weaknesses. At the frontline of care delivery, GPs can provide important insights on what worked well, why, and how during the pandemic. Lessons learned can be used to inform the adoption of improved virtual care solutions and support the long-term development of platforms that are more technologically robust and secure.

Digital maturity and its determinants in General Practice: A cross-sectional study in 20 countries.

Background: The extent to which digital technologies are employed to promote the delivery of high-quality healthcare is known as Digital Maturity. Individual and systemic digital maturity are both necessary to ensure a successful, scalable and sustainable digital transformation in healthcare. However, digital maturity in primary care has been scarcely evaluated. Objectives: This study assessed the digital maturity in General Practice (GP) globally and evaluated its association with participants' demographic characteristics, practice characteristics and features of Electronic Health Records (EHRs) use. Methods: GPs across 20 countries completed an online questionnaire between June and September 2020. Demographic data, practice characteristics, and features of EHRs use were collected. Digital maturity was evaluated through a framework based on usage, resources and abilities (divided in this study in its collective and individual components), interoperability, general evaluation methods and impact of digital technologies. Each dimension was rated as 1 or 0. The digital maturity score was calculated as the sum of the six dimensions and ranged between 0 to 6 (maximum digital maturity). Multivariable linear regression was used to model the total score, while multivariable logistic regression was used to model the probability of meeting each dimension of the score. Results: One thousand six hundred GPs (61% female, 68% Europeans) participated. GPs had a median digital maturity of 4 (P25-P75: 3-5). Positive associations with digital maturity were found with: male gender [B = 0.18 (95% CI 0.01; 0.36)], use of EHRs for longer periods [B = 0.45 (95% CI 0.35; 0.54)] and higher frequencies of access to EHRs [B = 0.33 (95% CI 0.17; 0.48)]. Practicing in a rural setting was negatively associated with digital maturity [B = -0.25 (95%CI -0.43; -0.08)]. Usage (90%) was the most acknowledged dimension while interoperability (47%) and use of best practice general evaluation methods (28%) were the least. Shorter durations of EHRs use were negatively associated with all digital maturity dimensions (aOR from 0.09 to 0.77). Conclusion: Our study demonstrated notable factors that impact digital maturity and exposed discrepancies in digital transformation across healthcare settings. It provides guidance for policymakers to develop more efficacious interventions to hasten the digital transformation of General Practice.