Referral Pathways for Children with Atopic Diseases in Denmark.

Atopic diseases such as atopic dermatitis, food allergy, allergic rhinoconjunctivitis, and/or asthma are common. In Denmark, however, there are multiple referral pathways for these diseases in the healthcare system and they are poorly understood. To describe how children with atopic diseases navigate their way through the Danish healthcare system, a questionnaire was distributed to children aged ≤ 17 years, who were being treated for atopic diseases between August 2020 and June 2021, either by a practising specialist or a hospital department, in the Capital Region of Denmark. A total of 279 children completed the questionnaire and most were referred to a specialist or to a hospital by their general practitioner. No "common track" to hospital existed for patients with ≥ 3 atopic diseases. These patients were more often referred to a hospital compared with children with 2 atopic diseases or fewer (odds ratio [OR] 3.79; 95% CI 2.07-7.24). The primary determinants for hospital treatment were food allergy (OR 4.69; 95% CI 2.07-10.61) and asthma (OR 2.58; 95% CI 1.18-5.63). In conclusion, children with multiple atopic diseases were more likely to be referred to hospital departments than to practising specialists, mainly due to food allergies.

Clinical practice enhanced by interdisciplinary theoretical perspectives.

BACKGROUND: Experience-based knowing in general practice includes advanced interpretation of subjective, complex and particular phenomena in a social context. Enabling different metapositions for reflexivity may provide the accountability needed for such knowing to be recognized as evidence-based practice. OBJECTIVE: To demonstrate and discuss the potential of substantive theories to enhance interpretation of complex challenges in clinical knowing in general practice. METHODS: We present a fictional case to demonstrate how interdisciplinary substantive theories, with a relevant and specific match to concrete questions, can situate the clinical interaction at an accountable platform. A female patient with Parkinson's disease consults her GP complaining that the disease is restraining her life and threatening her future. The GP has some new ideas from Bandura's theory of self-efficacy and introduces the patient to strategies for further action. FINDINGS: The case presents an example of how a relevant substantive theory may offer the GP: 1) a sharper focus for achievement: recognising the issues of fear and identity in chronic, progressive illness, 2) a subsequent position for individualized understanding of adequate strategies: encouraging physical and social activity in a well-known context, and 3) an invitation to consider further possibilities: finding ways to alleviate the burden of fear and progressive decline; engaging in joyful living. IMPLICATIONS: General practice knowledge embraces a diversity of sources with different evidence power. The transparency mediated to clinical practice when supported by relevant substantive theories may contribute to recognition of experience-based knowing as evidence-based practice.

Experience-based knowing is an important capacity for interpretation of complex phenomena in general practice, but support for elaboration and analysis of such strategies is limitedInterdisciplinary substantive theories can enable reflexivity and enhance clinical practiceSubstantive theories may offer sharper focus, individualised understanding and recognition of additional possibilitiesA connection to specific theoretical ideas may augment the transparency of experience-based knowing, thus advancing attitudes for evidence-based practice.

Parents of children with atopic diseases - experiences with care and the interaction with healthcare professionals over time.

OBJECTIVE: To explore how the parents of children with atopic dermatitis and allergic diseases such as food allergy, allergic rhinoconjunctivitis, and asthma experience interactions with the Danish healthcare system over time. DESIGN AND METHODS: A qualitative design with individual in-depth interviews. The analysis was inspired by Systematic Text Condensation. SUBJECTS: Eleven parents of children with atopic dermatitis and allergic diseases who received treatment at hospitals in the Capital Region of Denmark. The families had experiences of cross-sectoral patient care. RESULTS: Despite having the same diseases, the children's care pathways were very different. Mapping demonstrated the intricacy of care pathways for this group of children. We identified three aspects that impacted interaction with healthcare: responsibility, tasks, and roles. The families experienced care when the distribution of tasks and responsibilities associated with treatment and system navigation were consistent with both their expectations and their actual experiences. At the same time, families frequently experienced limited collaboration between healthcare professionals resulting in perceived fragmented care and an extended role for parents as care coordinators. Families felt cared for when healthcare professionals knew both their biomedical and biographical circumstances, and adjusted the level of support and care in accordance with the families' particular needs, expectations, and evolving competences. CONCLUSION: We suggest that a possible pathway to improve care may be through a partnership approach as part of family-centered care, with general practitioners having a key role in helping to articulate the individual needs and expectations of each family.

A cross-sectional study of the association between family conflicts and children's health: Lolland-Falster Health Study.

BACKGROUND: Few family interaction processes are more detrimental to children's health than family conflicts. Conflictual relationships in childhood predict a host of adverse health outcomes across the life course. The current study examines associations between household conflicts and the health of children aged 6-12 years and explores to which extent this may vary by socioeconomic status (SES) and multimorbidity (MM) in the household. METHODS: Cross-sectional study using questionnaire data gathered between 2016 and 2020 as part of the Lolland-Falster Health Study (LOFUS) combined with routine register data on health care use and socio-demography from the Danish nationwide administrative databases. The study sample consisted of 1065 children 6-12 years old, who answered LOFUS4 or LOFUS11, from 777 households for which at least one adult answered LOFUS18. Main outcome was children's health complaints, defined as headache, abdominal pain, back pain, and sleep difficulties. Covariates included MM, SES, and conflicts, all three measured at household level. Multivariable logistic regression models were used. RESULTS: Conflicts were negatively associated with children's health. This was most pronounced for general conflicts in the household, with increased complaints of abdominal pain, back pain, and sleep difficulties. The associations varied when we stratified the households according to MM and SES. Significant associations were found within households without MM for abdominal pain, and within households with MM and low SES, and without MM and with high SES for sleep difficulties. While the higher level of abdominal pain for the above indicated households were found for both internal and external conflicts in the household, the higher level in sleep difficulties was mostly driven by internal conflicts. CONCLUSION: Children reporting frequent health complaints have a higher future health care use compared with children without such complaints. Our results indicate that growing up in a household with a high conflict level might be a predisposing factor.

Senses of Touch: The Absence and Presence of Touch in Health Care Encounters of Patients with Mental Illness.

Touch is a fundamental sense and the most unexplored of the five senses, despite its significance for everything we do in relation to ourselves and others. Studies have shown that touch generates trust, care and comfort and is essential for constituting the body. Based on ethnographic fieldwork, this study explores the absence and presence of touch in interactions between people with mental illness and professionals, in health care encounters with general practitioners, neurologists and physiotherapists, as well as masseurs. We found that touch and physical examination of patients with mental illness is absent in health care encounters, leaving the patients with feelings of being out of place, misunderstood, less socially approved and less worthy of trust. Drawing on Honneth and Guenther, we conclude that touch and being touched is an essential dimension of recognition-both of the patients' bodily sensations and symptoms and of them as human beings, detached from the psychiatric label-as well as contributing to the constitution of self and personhood. These findings confirm that touch works as an existential hinge that affirms a connection between the patient, the body and others and gives a sense of time, space and existence.

Episodic Relatedness in Socioeconomically Disadvantaged Families Where a Parent has Multiple Diagnoses.

There is a strong association between social relationships and health. In this article, we ask how a view of social relationships played out in time can help to nuance the role of patients' social networks in their healthcare-seeking behavior. We investigate this link by exploring the dynamics of relatedness in socioeconomically vulnerable young families with a multimorbid parent and their extended networks. Data were generated through repeated semi-structured and open-ended interviews and participant observation. The study found that, for much of their lives, participants experienced life as a series of events that happened to them and were out of their control. This way of being-in-the-world was linked to a consistent pattern of intense and then suddenly discontinued relationships. The relevance for health professionals is that there is a growing trend in healthcare systems worldwide to involve relatives and extended networks in a patient's treatment process. Our findings indicate challenges to this approach and recommend that health professionals are aware that for socioeconomically vulnerable patients with multimorbidity, important relationships can change dramatically, quickly, and repeatedly, over short periods of time.

Health Workers' Practices in Assessment and Management of Children with Respiratory Symptoms in Primary Care Facilities in Uganda: A FRESH AIR Descriptive Study.

INTRODUCTION: Globally, acute lower respiratory infections are the leading cause of mortality among children under 5 years. Following World Health Organization primary care guidelines, pneumonia is diagnosed based on cough/difficult breathing and fast breathing. We aimed to describe the practices of healthcare workers in primary care health facilities in Uganda in the management of young children with respiratory symptoms especially regarding asthma as opposed to pneumonia. METHODS: Health workers were observed during clinical consultations with children 1-59 months of age presenting with cough and/or difficult breathing at recruitment. Afterward, an exit interview with the caregiver was conducted. Health center availability of clinical guidelines, equipment and supplies for management of children with respiratory symptoms was assessed systematically. RESULTS: A total of 218 consultations with 50 health workers at six health centers were included. Median consultation time was 4 min. Health workers asked history relevant to distinguishing asthma from pneumonia in 16% of consultations. The respiratory rate was counted in 10%. Antibiotics were prescribed to 32% of all the children and to 39% of children diagnosed with pneumonia. Caregivers reported being informed of findings and possible diagnosis in 5% of cases. Medicine and equipment needed for diagnosing and treating asthma were generally unavailable. CONCLUSION: Clinical practices among Ugandan health workers in primary care are insufficient to distinguish between main causes of respiratory symptoms, especially asthma as opposed to pneumonia, in children under five. Irrational use of antibiotics is widespread. Clear communication with caregivers is lacking. This could be due to lack of relevant competencies, medicines, time and supplies. LAY SUMMARY: Globally, the most frequent cause of death for children under five is infections in the lower airways. The World Health Organization recommends that in local health clinics this is defined as cough/difficult breathing and fast breathing. This article focuses on the practices of local health workers in Uganda and how they in practice diagnose and treat children under five with these symptoms. In addition, we try to estimate how much the caregivers of the children understand from the consultation. This is done by observing the healthcare workers (HCWs) and by interviewing the caregivers. In general, we found that the consultations were too short, that too few of the health workers looked for important signs for lower airways disease such as fast breathing and that antibiotics were prescribed in too many of the consultations. Also, the length and quality of the consultations and the supplies at the local health clinics were not sufficient to diagnose and treat asthma, which can often be mistaken for an infection. We believe that it is an important problem that too few children with asthma are being diagnosed correctly and that antibiotics are being prescribed too frequently, the latter being an important cause of antibiotic resistance. Relevant action must be taken to improve this.

No time for change? Impact of contextual factors on the effect of training primary care healthcare workers in Kyrgyzstan and Vietnam on how to manage asthma in children - A FRESH AIR implementation study.

BACKGROUND: Training is a common and cost-effective way of trying to improve quality of care in low- and middle-income countries but studies of contextual factors for the successful translation of increased knowledge into clinical change are lacking, especially in primary care. The purpose of this study was to assess the impact of contextual factors on the effect of training rural healthcare workers in Kyrgyzstan and Vietnam on their knowledge and clinical performance in managing pediatric patients with respiratory symptoms. METHODS: Primary care health workers in Kyrgyzstan and Vietnam underwent a one-day training session on asthma in children under five. The effect of training was measured on knowledge and clinical performance using a validated questionnaire, and by direct clinical observations. RESULTS: Eighty-one healthcare workers participated in the training. Their knowledge increased by 1.1 Cohen's d (CI: 0.7 to 1.4) in Kyrgyzstan where baseline performance was lower and 1.5 Cohen's d (CI: 0.5 to 2.5) in Vietnam. Consultations were performed by different types of health care workers in Kyrgyzstan and there was a 79.1% (CI 73.9 to 84.3%) increase in consultations where at least one core symptom of respiratory illness was asked. Only medical doctors participated in Vietnam, where the increase was 25.0% (CI 15.1 to 34.9%). Clinical examination improved significantly after training in Kyrgyzstan. In Vietnam, the number of actions performed generally declined. The most pronounced difference in contextual factors was consultation time, which was median 15 min in Kyrgyzstan and 2 min in Vietnam. DISCUSSION AND CONCLUSION: The effects on knowledge of training primary care health workers in lower middle-income countries in diagnosis and management of asthma in children under five only translated into changes in clinical performance where consultation time allowed for changes to clinical practice, emphasizing the importance of considering contextual factors in order to succeed in behavioral change after training.

Group-based, person-centered diabetes self-management education: healthcare professionals' implementation of new approaches.

BACKGROUND: Healthcare professionals' person-centered communication skills are pivotal for delivering successful diabetes education. Many healthcare professionals favor person-centeredness as a concept, but implementation in practice remains challenging. Today, programs have often a fixed curriculum dominated by biomedical issues. Most person-centered methods are developed targeting individual consultations, although group-based programs are a widespread and efficient method of support. Person-centeredness in group-based programs requires a change in practice towards addressing biopsychosocial issues and facilitating group processes. The objective of this study was to explore how healthcare professionals implement new approaches to facilitate group-based, person-centered diabetes education targeting people with type 2 diabetes. METHODS: The study was guided by action research and divided into three studies: investigation, development, and pilot using a variety of qualitative methods. In the first study; observations across five settings were conducted. Forty-nine group participants and 13 professionals took part; the focus was to investigate approaches that supported or hindered person-centeredness in groups. Observations were supplemented by interviews (n = 12) and two focus groups (n = 16) with group participants, as well as interviews (n = 5) with professionals. In the second study; 14 professionals collaborated in two workshops to develop new approaches. In the third study, new approaches were pilot-tested using observations in three settings. Twenty-five group participants and five professionals took part. The analysis of the pilot test led to the final workshop where six professionals took part. RESULTS: Implementation was characterized by three categories. Some professionals chose not to implement the methods because they conflicted with their practice relying on the biomedical model. Other incorporated some approaches but was unable to structure the process, leaving participants uncertain about the aim. Finally, one setting succeeded with implementation, tailoring content and processes to group participants' needs. CONCLUSION: The use of action research created context-sensitive approaches and increased professionals' readiness to implement. More attention should be paid to systematic training of professionals. Training should be structured stepwise incorporating techniques directed towards existing skills including ample time to train and reiterate skills.

Diagnostic knowing in general practice: interpretative action and reflexivity.

Background: Getting the right diagnosis is supposed to provide an explanation of a patient's health problem and inform health care decisions. As a core element of clinical reasoning, diagnosis deserves systematic and transparent analysis. Conceptual tools can make doctors become aware of and explore diagnostic knowing.Methods: We demonstrate diagnostic knowing analysed as interpretative and contextualised activity. Our analysis is based on Lonergan's theory of knowing, constituting the cognitive structures as experiencing, understanding, and judging, in a general practice case.Findings: Analysis makes the complexity of diagnostic knowing in this context more transparent, in this case concluding with four diagnostic labels: a corn, constipation, headache and atrial fibrillation. We demonstrate how a medically significant diagnosis does not necessarily evolve deductively from complaints. The opening lines from the patient give ideas of where to look for possible explanations - questions for understanding - rather than diagnostic hypotheses. Such questions emerge from the GP's experiences from meeting the patient, including imaginations and interpretations. When ideas and questions regarding diagnoses have been developed, they may be judged and subjected to reflection. Questioning may also emerge as transitory concerns, not extensively ruled out. Lonergan's theory demonstrated a strong fit with these aspects of diagnostic knowing in general practice.Implications: Analysis demonstrated systematic, transparent approaches to diagnostic knowing, relevant for clinical teaching. We argue that an interpretative understanding of diagnosis can change clinical practice, complementing hypothetico-deductive strategies by recognising additional substantial diagnostic modes and giving access to scholarly reflection.Key PointsDiagnosis is a core element of clinical reasoning, deserving systematic and transparent analysis beyond hypothetico-deductive reasoning or pattern recognitionDiagnostic knowing in general practice is a special instance of all human knowing with subjectivity, interpretation and reflexivity as essential elementsLonergan's theory for knowing based on experiencing, understanding, and judging allowed us to map, decode and recognise advanced acts of clinical reasoning We share our experiences of how these concepts gave us a tool for systematic analysis of the complexities taking place in the GP's office on an ordinary day.

Initiating Change: Negotiations of Subjectivity in a Danish Activation Programme for Young Adults with Psychosocial Problems and Common Mental Disorders.

An increasing number of young adults in Denmark experience difficulties in completing their education and holding down a job. Many of these young adults have psychosocial problems and common mental disorders. To retain public income support they must attend education and work-directed activities, known as 'activation programmes'. Based on ethnographic fieldwork, this study presents an analysis of how one such programme unfolds in practice and how the participants engaged with the activities and negotiated the underlying rationales. We argue that the activities involved in the programme constitute 'biographical techniques' that entail a configuration of the participants as being responsible for their own biographies and having the capability to solve their problems themselves. The participants challenged this configuration of subjectivity by recounting complex or immediate problems that could not be solved through biographical techniques and by refusing to deal with their life stories as a way of configuring their futures. Biographical techniques limited the possibilities for grappling with the complexity of the participants' problems. We conclude that the participants are therefore subjected to biographical coercion because forms of subjectivity other than biographical subjectivity are disregarded.

Using a modified nominal group technique to develop general practice.

BACKGROUND: There are few areas of health care where sufficient research-based evidence exists and primary health care is no exception. In the absence of such evidence, the development of assisted support must be based on the opinions and experience of professionals with knowledge of the relevant field. The purpose of this research project is to explore how the nominal group technique can be used to establish consensus by analysing how it supported the development of structured, knowledge-based, electronic health records for preventive child health examinations in Danish general practice. METHODS: We convened an expert panel of five general practitioners with a special interest in the preventive child health examinations. We introduced the panel to the nominal group technique, a well-established, structured, multistep, facilitated, group meeting technique used to generate consensus. The panel used the technique to agree on the key clinical and socioeconomic themes to include in new electronic records for the seven preventive child health examinations in Denmark. The panel met three times over a four-month period between 2013 and 2014 and their meetings lasted between two-and-a-half and five hours. RESULTS: 1) The structured and stepwise process of the nominal group technique supported our expert panel's focus as well as their equal opportunities to speak. 2) The method's flexibility enabled participants to work as a group and in pairs to discuss and refine thematic classifications. 3) Serial meetings supported continual evaluation, critical reflection, and knowledge searches, enabling our panel to produce a template that could be adapted for all seven preventive child health examinations. CONCLUSION: The nominal group technique proved to be a useful method for reaching consensus by identifying key quality markers for use in daily clinical practice. Our study focused on the development of content and a layout for systematic, knowledge-based, electronic health records. We recommend the method as a suitable working tool for dealing with complex questions in general practice or similar settings, and we present and discuss modifications to the original model.

An ethnographic investigation of healthcare providers' approaches to facilitating person-centredness in group-based diabetes education.

AIM: To investigate approaches among healthcare providers (HCPs) that support or hinder person-centredness in group-based diabetes education programmes targeting persons with type 2 diabetes. METHODS: Ethnographic fieldwork in a municipal and a hospital setting in Denmark. The two programmes included 21 participants and 10 HCPs and were observed over 5 weeks. Additionally, 10 in-depth semi-structured interviews were conducted with patients (n = 7) and HCPs (n = 3). Data were analysed using systematic text condensation. RESULTS: Hindering approaches included a teacher-centred focus on delivering disease-specific information. Communication was dialog based, but HCPs primarily asked closed-ended questions with one correct answer. Additional hindering approaches included ignoring participants with suboptimal health behaviours and a tendency to moralize that resulted in feelings of guilt among participants. Supporting approaches included letting participants set the agenda using broad, open-ended questions. DISCUSSION: Healthcare providers are often socialized into a biomedical approach and trained to be experts. However, person-centredness involves redefined roles and responsibilities. Applying person-centredness in practice requires continuous training and supervision, but HCPs often have minimum support for developing person-centred communication skills. Techniques based on motivational communication, psychosocial methods and facilitating group processes are effective person-centred approaches in a group context. CONCLUSION: Teacher-centredness undermined person-centredness because HCPs primarily delivered disease-specific recommendations, leading to biomedical information overload for participants.

Qualitative methods in PhD theses from general practice in Scandinavia.

Qualitative methodology is gaining increasing attention and esteem in medical research, with general practice research taking a lead. With these methods, human and social interaction and meaning can be explored and shared by systematic interpretation of text from talk, observation or video. Qualitative studies are often included in Ph.D. theses from general practice in Scandinavia. Still, the Ph.D. programs across nations and institutions offer only limited training in qualitative methods. In this opinion article, we draw upon our observations and experiences, unpacking and reflecting upon values and challenges at stake when qualitative studies are included in Ph.D. theses. Hypotheses to explain these observations are presented, followed by suggestions for standards of evaluation and improvement of Ph.D. programs. The authors conclude that multimethod Ph.D. theses should be encouraged in general practice research, in order to offer future researchers an appropriate toolbox.

Balancing trust and power: a qualitative study of GPs perceptions and strategies for retaining patients in preventive health checks.

OBJECTIVE: Little is known about how strategies of retaining patients are acted out by general practitioners (GPs) in the clinical encounter. With this study, we apply Grimens' (2009) analytical connection between trust and power to explore how trust and power appear in preventive health checks from the GPs' perspectives, and in what way trust and power affect and/or challenge strategies towards retaining patients without formal education. DESIGN: Data in this study were obtained through semi-structured interviews with GPs participating in an intervention project, as well as observations of clinical encounters. RESULTS: From the empirical data, we identified three dimensions of respect: respect for the patient's autonomy, respect for professional authority and respect as a mutual exchange. A balance of respect influenced trust in the relationship between GP and patients and the transfer of power in the encounter. The GPs articulated that a balance was needed in preventive health checks in order to establish trust and thus retain the patient in the clinic. One way this balance of respect was carried out was with the use of humour. CONCLUSIONS: To retain patients without formal education in the clinical encounter, the GPs balanced trust and power executed through three dimensions of respect. In this study, retaining patients was equivalent to maintaining a trusting relationship. A strategic use of the three dimensions of respect was applied to balance trust and power and thus build or maintain a trusting relationship with patients. KEY POINTS Little is known about how strategies for retaining patients are acted out by GPs in preventive health checks. • Retaining patients requires a balance of trust and power, which is executed through three dimensions of respect by the GPs. • Challenges of recruiting and retaining patients in public health initiatives might be associated with the balance of respect.

The potential of a self-assessment tool to identify healthcare professionals' strengths and areas in need of professional development to aid effective facilitation of group-based, person-centered diabetes education.

BACKGROUND: Healthcare professionals' person-centered communication skills are pivotal for successful group-based diabetes education. However, healthcare professionals are often insufficiently equipped to facilitate person-centeredness and many have never received post-graduate training. Currently, assessing professionals' skills in conducting group-based, person-centered diabetes education primarily focus on experts measuring and coding skills on various scales. However, learner-centered approaches such as adequate self-reflective tools have been shown to emphasize professional autonomy and promote engagement. The aim of this study was to explore the potential of a self-assessment tool to identify healthcare professionals' strengths and areas in need of professional development to aid effective facilitation of group-based, person-centered diabetes education. METHODS: The study entails of two components: 1) Field observations of five different educational settings including 49 persons with diabetes and 13 healthcare professionals, followed by interviews with 5 healthcare professionals and 28 persons with type 2 diabetes. 2) One professional development workshop involving 14 healthcare professionals. Healthcare professionals were asked to assess their person-centered communication skills using a self-assessment tool based on challenges and skills related to four educator roles: Embracer, Facilitator, Translator, and Initiator. Data were analyzed by hermeneutic analysis. Theories derived from theoretical model 'The Health Education Juggler' and techniques from 'Motivational Interviewing in Groups' were used as a framework to analyze data. Subsequently, the analysis from the field notes and interview transcript were compared with healthcare professionals' self-assessments of strengths and areas in need to effectively facilitate group-based, person-centered diabetes education. RESULTS: Healthcare professionals self-assessed the Translator and the Embracer to be the two most skilled roles whereas the Facilitator and the Initiator were identified to be the most challenged roles. Self-assessments corresponded to observations of professional skills in educational programs and were confirmed in the interviews. CONCLUSION: Healthcare professionals self-assessed the same professional skills as observed in practice. Thus, a tool to self-assess professional skills in facilitating group-based diabetes education seems to be useful as a starting point to promote self-reflections and identification of healthcare professionals' strengths and areas of need of professional development.

The impact of gender on the long-term morbidity and mortality of patients with type 2 diabetes receiving structured personal care: a 13 year follow-up study.

AIMS/HYPOTHESIS: The aim of this study was to assess gender differences in mortality and morbidity during 13 follow-up years after 6 years of structured personal care in patients with type 2 diabetes mellitus. METHODS: In the Diabetes Care in General Practice (DCGP) multicentre, cluster-randomised, controlled trial (ClinicalTrials.gov registration no. NCT01074762), 1,381 patients newly diagnosed with type 2 diabetes were randomised to receive 6 years of either structured personal care or routine care. The intervention included regular follow-up, individualised goal setting and continuing medical education of general practitioners participating in the intervention. Patients were re-examined at the end of intervention. This observational analysis followed 970 patients for 13 years thereafter using national registries. Outcomes were all-cause mortality, incidence of diabetes-related death, any diabetes-related endpoint, myocardial infarction, stroke, peripheral vascular disease and microvascular disease. RESULTS: In women, but not men, a lower HR for structured personal care vs routine care emerged for any diabetes-related endpoint (0.65, p = 0.004, adjusted; 73.4 vs 107.7 events per 1,000 patient-years), diabetes-related death (0.70, p = 0.031; 34.6 vs 45.7), all-cause mortality (0.74, p = 0.028; 55.5 vs 68.5) and stroke (0.59, p = 0.038; 15.6 vs 28.9). This effect was different between men and women for diabetes-related death (interaction p = 0.015) and all-cause mortality (interaction p = 0.005). CONCLUSIONS/INTERPRETATION: Compared with routine care, structured personal diabetes care reduced all-cause mortality and diabetes-related death in women but not in men. This gender difference was also observed for any diabetes-related outcome and stroke but was not statistically significant after extensive multivariate adjustment. These observational results from a post hoc analysis of a randomised controlled trial cannot be explained by intermediate outcomes like HbA1c alone, but involves complex social and cultural issues of gender. There is a need to rethink treatment schemes for both men and women to gain benefit from intensified treatment efforts.

The role of diseases, risk factors and symptoms in the definition of multimorbidity - a systematic review.

UNLABELLED: Objective is to explore how multimorbidity is defined in the scientific literature, with a focus on the roles of diseases, risk factors, and symptoms in the definitions. DESIGN: Systematic review. METHODS: MEDLINE (PubMed), Embase, and The Cochrane Library were searched for relevant publications up until October 2013. One author extracted the information. Ambiguities were resolved, and consensus reached with one co-author. Outcome measures were: cut-off point for the number of conditions included in the definitions of multimorbidity; setting; data sources; number, kind, duration, and severity of diagnoses, risk factors, and symptoms. We reviewed 163 articles. In 61 articles (37%), the cut-off point for multimorbidity was two or more conditions (diseases, risk factors, or symptoms). The most frequently used setting was the general population (68 articles, 42%), and primary care (41 articles, 25%). Sources of data were primarily self-reports (56 articles, 42%). Out of the 163 articles selected, 115 had individually constructed multimorbidity definitions, and in these articles diseases occurred in all definitions, with diabetes as the most frequent. Risk factors occurred in 98 (85%) and symptoms in 71 (62%) of the definitions. The severity of conditions was used in 26 (23%) of the definitions, but in different ways. The definition of multimorbidity is heterogeneous and risk factors are more often included than symptoms. The severity of conditions is seldom included. Since the number of people living with multimorbidity is increasing there is a need to develop a concept of multimorbidity that is more useful in daily clinical work. Key points The increasing number of multimorbidity patients challenges the healthcare system. The concept of multimorbidity needs further discussion in order to be implemented in daily clinical practice. Many definitions of multimorbidity exist and most often a cut-off point of two or more is applied to a range of 4-147 different conditions. Diseases are included in all definitions of multimorbidity. Risk factors are often included in existing definitions, whereas symptoms and the severity of the conditions are less frequently included.

Understanding the body-mind in primary care.

Patients' experience of symptoms does not follow the body-mind divide that characterizes the classification of disease in the health care system. Therefore, understanding patients in their entirety rather than in parts demands a different theoretical approach. Attempts have been made to formulate such approaches but many of these, such as the biopsychosocial model, are still basically dualistic or methodologically reductionist. In primary care, patients often present with diffuse symptoms, making primary care the ideal environment for understanding patients' undifferentiated symptoms and disease patterns which could readily fit both bodily and mental categories. In this article we discuss theoretical models that have attempted to overcome this challenge: The psychosomatic approach could be called holistic in the sense of taking an anti-dualistic stance. Primary care theorists have formulated integrative views but these have not gained a foothold in primary care medicine. McWhinney introduced a new metaphor, 'the body-mind', and Rudebeck advocated cultivating 'bodily empathy'. These views have much in common with both phenomenological thinking and mentalization, a psychological concept for understanding others. In the process of understanding patients there is a need for the physician to enter an intersubjectivity that aims at understanding the patient's experiences and sensations without initially jumping to diagnostic conclusions or into a division into mental and physical phenomena. Mentalization theory could form the basis of an approach to a more comprehensive understanding of patients. The success of such an approach is, however, dependent upon structural and organizational conditions that do not counteract it.