Family physicians' experiences when collaborating with district nurses in home care-based medical treatment. A grounded theory study.

BACKGROUND: This article concerns Swedish family physicians' (FPs) experiences collaborating with district nurses (DNs) when the DNs provide medical treatment for home care patients. The aim was to develop a model to illuminate this process from the FPs' perspective. METHODS: Semi-structured interviews were conducted with 13 FPs concerning one of their patients with home care by a DN. The interview focused on one patient's treatment and care by different care providers and the collaboration among them. Grounded theory methodology (GTM) was used in the analyses. RESULTS: It was essential for FPs to collaborate with and rely on DNs in the medical treatment of home care patients. According to the FPs, factors such as the disease, FPs' working conditions and attitude determined how much of the initiative in this treatment FPs retained or left to DNs. Depending on the circumstances, two different roles were adopted by the individual FPs: medical conductors who retain the initiative and medical consultants who leave the initiative to DNs. Factors as the disease, DNs' attitudes towards collaboration and DNs' working conditions influenced whether or not the FPs felt that grounds for relying on DNs were satisfactory. Regardless of the role of the FP, conditions for medical treatment were judged by the FPs to be good enough when the grounds for relying on the DN were satisfactory and problematic when they were not. CONCLUSIONS: In the role of conductor, the FP will identify when the grounds for relying on the DN are unsatisfactory and be able to take action, but in the role of consultant the FP will not detect this, leaving home care patients without appropriate support. Only when there are satisfactory grounds for relying on the DN, will conditions for providing home care medical treatment be good enough when the FP adopts a consultative role.

Family physicians' effort to stay in charge of the medical treatment when patients have home care by district nurses. A grounded theory study.

BACKGROUND: District nurses (DNs) provide home care for old persons with a mixture of chronic diseases, symptoms and reduced functional ability. Family physicians (FPs) have been criticised for their lack of involvement in this care. The aim of this study was to obtain increased knowledge concerning the FP's experience of providing medical treatment for patients with home care provided by DNs by developing a theoretical model that elucidates how FPs handle the problems they encounter regarding the individual patients and their conditions. METHODS: Semi-structured interviews were conducted with 13 Swedish FPs concerning one of their registered patients with home care by a DN, and the treatment of this patient. Grounded theory methodology (GTM) was used in the analyses. RESULTS: The core category was the effort to stay in charge of the medical treatment. This involved three types of problems: gaining sufficient insight, making adequate decisions, and maintaining appropriate medical treatment. For three categories of patients, the FPs had problems staying in charge. Patients with reduced functional ability had problems providing information and maintaining treatment. Patients who were "fixed in their ways" did not provide information and did not comply with recommendations, and for patients with complex conditions, making adequate decisions could be problematic. To overcome the problems, four different strategies were used: relying on information from others, supporting close observation and follow-up by others, being constantly ready to change the goal of the treatment, and relying on others to provide treatment. CONCLUSION: The patients in this study differed from most other patients seen at the healthcare centre as the consultation with the patient could not provide the usual foundation for decisions concerning medical treatment. Information from and collaboration with the DN and other home care providers was essential for the FP's effort to stay in charge of the medical treatment. The complexity of the situation made it problematic for the FP to make adequate decisions about the goal of the medical treatment. The goal of the treatment had to be constantly evaluated based on information from the DN and other care providers, and thus this information was absolutely crucial.

Screening and diagnosing depression in women visiting GPs' drop in clinic in Primary Health Care.

BACKGROUND: Only half of all depressions are diagnosed in Primary Health Care (PHC). Depression can remain undetected for a long time and entail high costs for care and low quality of life for the individuals. Drop in clinic is a common form of organizing health care; however the visits are short and focus on solving the most urgent problems. The aim of this study was to investigate the prevalence and severity of depression among women visiting the GPs' drop in clinic and to identify possible clues for depression among women. METHODS: The two-stage screening method with "high risk feedback" was used. Beck's Depression Inventory (BDI) was used to screen 155 women visiting two GPs' drop in clinic. Women who screened positive (BDI score > or =10) were invited by the GP to a repeat visit. Major depression (MDD) was diagnosed according to DSM-IV criteria and the severity was assessed with Montgomery-Asberg Depression Rating Scale (MADRS). Women with BDI score <10 constituted a control group. Demographic characteristics were obtained by questionnaire. Chart notations were examined with regard to symptoms mentioned at the index visit and were categorized as somatic or mental. RESULTS: The two-stage method worked well with a low rate of withdrawals in the second step, when the GP invited the women to a repeat visit. The prevalence of depression was 22.4% (95% CI 15.6-29.2). The severity was mild in 43%, moderate in 53% and severe in 3%. The depressed women mentioned mental symptoms significantly more often (69%) than the controls (15%) and were to a higher extent sick-listed for a longer period than 14 days. Nearly one third of the depressed women did not mention mental symptoms. The majority of the women who screened as false positive for depression had crisis reactions and needed further care from health professionals in PHC. Referrals to a psychiatrist were few and revealed often psychiatric co-morbidity. CONCLUSION: The prevalence of previously undiagnosed depression among women visiting GPs' drop in clinic was high. Clues for depression were identified in the depressed women's symptom presentation; they often mention mental symptoms when they visit the GP for somatic reasons e.g. respiratory infections. We suggest that GPs do selective screening for depression when women mention mental symptoms and offer to schedule a repeat visit for follow-up rather than just recommending that the patient return if the mental symptoms do not disappear.

Improving quality of life using compound mind-body therapies: evaluation of a course intervention with body movement and breath therapy, guided imagery, chakra experiencing and mindfulness meditation.

OBJECTIVE: Assess changes in quality of life and in sense of coherence (SOC), after an intervention involving a self-development course using mind-body medicine (MBM) activities. DESIGN: A questionnaire study using a health-related quality of life (HRQOL) instrument, the SWEDQUAL, with 13 subscales and scores ranging from 0 to 100, combined with the SOC-13 scale, healthcare utilisation, medication and sick listing data. SETTING: A training centre for MBM. Eligible course attendants (study group, SG, n = 83) assessed their HRQOL before and 6 months after a 1-week course. A control group (CG) of individuals who had previously attended the course (n = 69), matched for age, sex and length of course time to the SG, also made assessments. MAIN OUTCOME: Changes in HRQOL and SOC in SG and CG. RESULTS: Of the 13 HRQOL subscales, eight showed clinically significant improvement in the SG (>9%, p < 0.01), namely, General health perceptions (9%), Emotional well-being [negative (45%) and positive (26%)], Cognitive functioning (24%), Sleep (15%), Pain (10%), Role limitation due to emotional health (22%) and Family functioning (16%). Sexual, marital and physical function and role in the SG as well as all CG scores were similar to average population values. The assessed SOC also improved in the SG after intervention (p < 0.01), challenging previous statements of 'the stableness of SOC'. Use of psychotropic medication was slightly reduced in the younger aged SG participants after intervention. CONCLUSIONS: This group of men and women (SG), starting from a clinically significant low health assessment, had improved their HRQOL and SOC after the course intervention.

'Oral health is not my department'. Perceptions of elderly patients' oral health by general medical practitioners in primary health care centres: a qualitative interview study.

The purpose of this study was to explore general medical practitioners' (GPs) perceptions of the oral health of their elderly patients. The design was a qualitative study based on individual in-depth interviews with GPs. The criterion for inclusion in the study was that the GP was a specialist in family medicine working in a primary health care centre (PHCC:s) in the county of Stockholm. The participants took part in the study after informed consent. Eleven GPs were interviewed. The interview started with semi-structured questions about the respondents' clinical presentation of their elderly patients', e.g. medication, medical treatment and socioeconomic status. The interview concluded with questions about the respondents' experiences of and perceptions of the oral health of their patients. This process started with the first interview and proceeded with successive interviews until no new relevant information was forthcoming. The initial semi-structured part of the interview guide was analysed for content with special reference to descriptive answers. The final open questions were analysed by a method inspired by grounded theory (GT) and comprised three stages: open coding, axial coding and selective coding. In the GT influenced analysis process, three categories, health perspective, working conditions and cultural differences, each in turn containing subcategories, were identified and labelled. The most significant category, cultural differences, was identified as the core category, explaining the central meaning of the respondents' perceptions of the oral health of their elderly patients. The GPs in this study showed little or no awareness of the oral health of their elderly patients. The interviews disclosed several contributing factors. Barriers to closer integration of oral and general health in the elderly were identified. There existed a cultural gap between the disciplines of dentistry and medicine, which does not enhance and may be detrimental to the overall well-being of elderly patients.

Quality of life of participants in a mind-body-based self-development course: a descriptive study.

OBJECTIVE: A cross-sectional survey of quality of life of people attending a self-development course involving psychophysiological mind-body medicine (MBM) activities. DESIGN: A questionnaire study using a health-related quality of life (HRQoL) instrument, the SWED-QUAL, with 13 subscales scored 0-100, and questions about utilisation of alternative and standard health care, medication and sick leave. SETTING: A training centre for MBM, established 15 years ago. STUDY GROUP: One hundred and seven eligible course attendants (response rate 88%, age 20-70 years) during the year 2000 assessed their HRQoL just before entering the course. Attendance was self-initiated, without referral. The results on HRQoL were compared with those of control subjects from the general Swedish population. RESULTS: Six of the thirteen HRQoL subscales were strongly and significantly reduced (p < 0.0001) in the study group: Negative affectivity, Role limitation due to emotional health, Positive affectivity, Cognitive functioning, Family functioning and Marital functioning. Long-term sick leave (>6 months) was three times as frequent in the study group as in the general population. Use of psychotropic medication was slightly increased compared to the general population, at least among the younger male participants. The education level was high, health care utilisation was average and body functioning was good. CONCLUSIONS: This group of well-educated men and women gave their emotional health an unexpectedly low rating, on a par with that given by people with chronic diseases.

The medical care of patients with primary care home nursing is complex and influenced by non-medical factors: a comprehensive retrospective study from a suburban area in Sweden.

BACKGROUND: The reduced number of hospital beds and an ageing population have resulted in growing demands for home nursing. We know very little about the comprehensive care of these patients. The objectives were to identify the care, in addition to primary health care, of patients with primary-care home nursing to give a comprehensive view of their care and to investigate how personal, social and functional factors influence the use of specialised medical care. METHODS: One-third (158) of all patients receiving primary-care home nursing in an area were sampled, and 73 % (116) were included. Their care from October 1995 until October 1996 was investigated by sending questionnaires to district nurses and home-help providers and by collecting retrospective data from primary-care records and official statistics. We used non-parametric statistical methods, i.e. medians and minimum - maximum, chi2, and the Mann-Whitney test, since the data were not normally distributed. Conditional logistic regression was used to study whether personal, social or functional factors influenced the chance (expressed as odds ratio) that study patients had made visits to or had received inpatient care from specialised medical care during the study year. RESULTS: 56 % of the patients had been hospitalised. 73 % had made outpatient visits to specialised medical care. The care took place at 14 different hospitals, and more than 22 specialities were involved, but local care predominated. Almost all patients visited doctors, usually in both primary and specialised medical care. Patients who saw doctors in specialised care had more help from all other categories of care. Patients who received help from their families made more visits to specialised medical care and patients with severe ADL dependence made fewer visits. CONCLUSIONS: The care of patients with primary-care home nursing is complex. Apart from home nursing, all patients also made outpatient visits to doctors, usually in both primary and specialised medical care. Many different caregivers and professions were involved. Reduced functional capacity decreased and help from family members increased the chance of having received outpatient specialised medical care. This raises questions concerning the medical care for patients with both medical and functional problems.

Clinical effect of computer generated physician reminders in health screening in primary health care--a controlled clinical trial of preventive services among the elderly.

OBJECTIVES: To apply and evaluate the effects of a program for computer generated physician reminders, integrated with an electronic patient record (EPR) system, for opportunistic health screening in elderly patients. DESIGN: A pilot study designed as a 20-month clinical trial with a control group and a 20-month non-intervention follow-up using a computer reminder program that selects patients for screening in five intervention areas (diabetes, hypertension, cobalamin deficiency, hypothyroidism and anaemia). SETTING: Four primary health care (PHC) centres in suburban Stockholm. SUBJECTS: The intervention was designed for patients 70 years or older from one health care centre who visited a general practitioner (GP) during the first 20-month period. Patients from the three remaining centres served as controls. MAIN OUTCOME MEASURES: The number of patients who underwent the tests, who had pathological test results, new diagnoses and new pharmacological treatments in both patient groups. RESULTS: In total, 602 patients underwent screening and 1989 were controls. There was a statistically significant, moderate or marked increase (13-75%) in the number of patients who were tested in all five intervention areas. An increase in pathological test results (1-8%) was found in two areas: hypertension and cobalamin deficiency. There was an increase in the number of patients with the diagnosis of cobalamin deficiency during the study. At follow-up a decrease in new diagnoses for anaemia was found. CONCLUSION: The system seems to be associated with a moderate to large increase in laboratory and manual screening tests for both established and new screening areas. The effect on clinical outcomes was found mainly in a not-yet-established screening area (cobalamin deficiency), indicating that the system may be clinically useful when introducing new screening services.

Pain behaviour in young immigrants having chronic pain: an exploratory study in primary care.

Pain behaviour can hamper rehabilitation. The aim of this study was to explore the phenomenon of pain behaviour in an unselected group of immigrant patients on >6 weeks of sick leave before and after a transcultural treatment programme in primary care. Anxiety about pain and pain behaviour-i.e. > or = 1.5 points on the University of Alabama in Birmingham (UAB) scale with scores of 0-10-were noted before and after treatment. The sex-adjusted odds ratios (OR) for pain behaviour, before and after the treatment, were calculated using logistic regression with 95% confidence intervals (95% CIs). Forty-nine men and 102 women having a mean age of 38 years participated. Their mean sick leave was 46 weeks. All reported psychosocial stress, one-quarter were depressed and social functioning was generally low. The pain was mostly caused by muscular insertion lesions (entesopathies). The frequency of pain behaviour and anxiety about pain declined after treatment (from 68% to 54% and from 76% to 50% respectively). Duration of full-time sick leave and among men also decreasing social functioning were correlated with the UAB score. Those who reported persistent anxiety about pain, or men who were depressed, had higher scores. Only persons on full-time sick leave >1 year had a significant OR for pain behaviour before treatment (OR 3.23; 95% CI 1.17-8.85, adjusted for sex). After treatment, only persons reporting persistent anxiety about pain showed a significant OR for pain behaviour (OR 3.05; 95% CI 1.49-6.23, adjusted for sex). In conclusion, pain behaviour was common in this group of immigrant patients < or = 45 years of age on long-term sick leave. Anxiety about pain and full-time sick leave for more than 1 year significantly predicted pain behaviour.

Care by general practitioners and district nurses of patients receiving home nursing: a study from suburban Stockholm.

OBJECTIVES: To review the care by general practitioners (GPs), district nurses and assistant nurses of patients receiving home nursing. DESIGN: Retrospective data from questionnaires, records and official statistics. Statistical comparisons. SETTING: Primary health care from October 1995 to October 1996. SUBJECTS: One-third (158) of all patients receiving home nursing in a suburban area were sampled; 73% (116) participated. All patients of comparable age in one practice served as a control group. MAIN OUTCOME MEASURES: Number of and reasons for visits and other contacts. Nature of care. Relation between patient problems and care given. RESULTS: Most patients were seen by the nurses two to five times a month. They met their GPs less often than other patients. More measures were undertaken without direct contact between GP and patient. The most common measures concerned medication and the assessment of symptoms. Patients with cognitive problems seemed to get less active GP care. CONCLUSION: GPs played an active role in the care of patients receiving home nursing even though they seldom met them. Many patients were regularly assessed by the nurses, which might have diminished the need for doctor visits. The care of patients with cognitive problems needs further study.