Diagnostics and management of headache in general practice.

BACKGROUND: Headache disorders are globally prevalent and insufficient treatment contribute to low quality of life, increased disability, and socioeconomic costs. However, headache can to a large extent be treated appropriately by general practitioners. OBJECTIVE: To explore general practitioners' (GPs') management of patients with headache lasting ≥6 months. METHODS: In this retrospective descriptive cross-sectional study based on medical audit, all GPs practicing in Vejle municipality (population 116,992), Denmark, were invited to review their latest 20 patients with headache. Outcome measures were headache diagnostics, treatment, and referrals. Factors associated with referral to neurological treatment were examined by logistic regression. RESULTS: Of 26 invited practices, 19 participated reporting on 367 patients with lasting headache (71.4% women; mean-age 48.5 years). One hundred and sixty-one patients had migraine (44%; IQR: 28-60%), 140 (38%; IQR: 25-44%) had tension-type headache; 243 (66%; IQR: 50-79%) used simple analgesics, 147 (40%; IQR: 29-59%) triptans, 37 (10%; IQR: 0-14%) opioids, 93 (25%; IQR: 20-35%) were prescribed preventive medication; 176 (48%; IQR: 48-59%) were referred to neurologist, and 92 (25%; IQR: 10-37%) were referred to CT or MRI scan. Associated factors for referral were >1 headache diagnosis (aOR 1.75 [95% CI: 1.05-2.95]; P = 0.03), post-traumatic headache (aOR 2.53 [95% CI: 1.25-5.38]; P = 0.01), unspecific headache (aOR 2.04 [95% CI: 1.08-3.93]; P = 0.03), and using preventive treatment (aOR 2.75 [95% CI: 1.68-4.57]; P < 0.001). CONCLUSION: This study provides insights to how GPs manage patients with long-lasting headache. Focus should be on reducing opioids, increasing preventive treatment, and keeping more patients in primary care.

Profiles of GPs with high and low self-reported physician empathy-personal, professional, and antibiotic prescribing characteristics.

BACKGROUND: General Practitioners' (GPs) professional empathy has been hypothesized to have substantial impact on their healthcare delivery and medication prescribing patterns. This study compares profiles of personal, professional, and antibiotic prescribing characteristics of GPs with high and low empathy. METHODS: We apply an extreme group approach to a unique combined set of survey and drug register data. The survey included questions about demographic, professional, and antibiotic prescribing characteristics, as well as the Jefferson Scale of Empathy for Health Professionals (JSE-HP) to assess self-reported physician empathy. It was sent to a stratified sample of 1,196 GPs comprising 30% of the Danish GP population of whom 464 (38.8%) GPs responded. GPs in the top and bottom decile of empathy levels were identified. All intra- and inter-profile descriptive statistics and differences were bootstrapped to estimate the variability and related confidence intervals.  RESULTS: 61% of GPs in the top decile of the empathy score were female. GPs in this decile reported the following person-centered factors as more important for their job satisfaction than the bottom decile: The Patient-physician relationship, interaction with colleagues, and intellectual stimulation. High-empathy scoring GPs prescribed significantly less penicillin than the low-empathy GPs. This was true for most penicillin subcategories. There were no significant differences in age, practice setting (urban vs. rural), practice type (partnership vs. single-handed), overall job satisfaction, or GP's value of prestige and economic profit for their job satisfaction. The intra profile variation index and confidence intervals show less prescribing uncertainty among GPs with high empathy. CONCLUSIONS: This study reveals that high empathy GPs may have different personal, professional, and antibiotic prescribing characteristics than low empathy GPs and have less variable empathy levels as a group. Furthermore, person-centered high empathy GPs on average seem to prescribe less penicillins than low empathy GPs.

Prevalence and socio-economic factors affecting the use of traditional medicine among adults of Katikekile Subcounty, Moroto District, Uganda.

BACKGROUND: In Uganda generally and in rural areas in particular, use of traditional medicine is a common practice, yet there remains lack of evidence on the overall utilization of traditional medicine and there are many aspects that remain unclear. OBJECTIVE: To determine the use of traditional medicine and factors associated with this among the adults of Katikekile Subcounty in Moroto district. METHODS: A descriptive cross-sectional study using quantitative and qualitative methods. Interviews among 323 respondents, and focus group discussions were carried out among village traditional birth attendants, village health team members, and traditional health providers. RESULTS: Use of traditional medicine among the adults of Katikekile Subcounty was 68%. Usage was more prevalent among older people, and the majority of the adults used traditional medicine often as their first line-treatment for any illness. Herbs used for traditional medicines are usually locally available and free-of-charge. Long distance to health-facility based health care services, and medical fees contributed to the use of traditional medicine. CONCLUSION: Use of traditional medicine among adults of Katikekile Subcounty in Moroto in the Karamoja region in Uganda was high, and majority of the adults often used traditional medicine as first line-treatment. Both socioeconomic and health sector factors were associated with use of traditional medicine.

Cross-cultural adaptation of the medical engagement scale into Danish general practice setting.

Introduction: The need to involve doctors in healthcare leadership has long been recognized by clinical staff and policymakers. A Medical Engagement Scale has been designed in England to evaluate levels of medical engagement in leadership and management. Objective: The aim of this study was to translate and adapt the scale and to test the translated version for comprehension and suitability in Danish general practice setting. Design and method: The process involved forward translation, backward translation, and field tests. The field tests included cognitive debriefing interviews. In all 30 general practitioners and 5 non-general practitioners participated in the process of translation. After using the scale among 1652 general practitioners statistical analysis was carried out to test internal consistency. Setting: The study was carried out in general practice in Denmark. Results: Several changes made during the process in order to achieve a Danish version that is acceptable, understandable and still capable of measuring medical engagement comparable of the original English version. Analysis of scale internal consistency using Cronbach's alpha revealed acceptable reliability for all three meta-scales, which ranged from 0.69 to 0.81. The overall tool achieved a Cronbach's alpha of 0.89. Conclusion: The Danish version of the Medical Engagement Scale is a valid and reliable tool that is acceptable and relevant for general practice in Denmark. Key points This study describes the cross-cultural adaptation of the Medical Engagement Scale from a UK primary healthcare setting to a Danish primary healthcare setting. The process produced a relevant and acceptable questionnaire measuring medical engagement. Internal consistency revealed acceptable reliability The translation of the scale provides the possibility to use this scale for practical and academic purposes.

The Relationships Between Use of Quality-of-Care Feedback Reports on Chronic Diseases and Medical Engagement in General Practice.

BACKGROUND: There is a limited knowledge on how medical engagement influences quality of care provided in primary care. The extent of the use of feedback reports from a national quality-of-care database can be considered as a measure of process quality. This study explores relationships between the use of feedback reports and medical engagement among general practitioners, general practitioner demographics, clinic characteristics, and services. METHODS: A cross-sectional combined questionnaire and register study in a sample of 352 single-handed general practitioners in 2013. Logistic regression analysis was used to explore associations between the use of feedback reports for diabetes and chronic obstructive pulmonary disease and medical engagement. RESULTS: For both diabetes and chronic obstructive pulmonary disease, a higher degree of medical engagement was associated with an increased use of feedback reports. Furthermore, we identified positive associations between using feedback reports and general practitioner services (spirometry, influenza vaccinations, performing annual reviews for patients with chronic diseases) and a negative association between usage of quality-of-care feedback reports and the number of consultations per patient. CONCLUSION: Using feedback reports for chronic diseases in general practice was positively associated with medical engagement and also with the provision of services in general practice.

Empathy Variation in General Practice: A Survey among General Practitioners in Denmark.

Background: Previous studies have demonstrated that high levels of physician empathy may be correlated with improved patient health outcomes and high physician job satisfaction. Knowledge about variation in empathy and related general practitioner (GP) characteristics may allow for a more informed approach to improve empathy among GPs. Objective: Our objective is to measure and analyze variation in physician empathy and its association with GP demographic, professional, and job satisfaction characteristics. Methods: 464 Danish GPs responded to a survey containing the Danish version of the Jefferson Scale of Empathy for Health Professionals (JSE-HP) and questions related to their demographic, professional and job satisfaction characteristics. Descriptive statistics and a quantile plot of the ordered empathy scores were used to describe empathy variation. In addition, random-effect logistic regression analysis was performed to explore the association between empathy levels and the included GP characteristics. Results: Empathy scores were negatively skewed with a mean score of 117.9 and a standard deviation of 10.1 within a range from 99 (p5) to 135 (p95). GPs aged 45-54 years and GPs who are not employed outside of their practice were less likely to have high empathy scores (≥120). Neither gender, nor length of time since specialization, length of time in current practice, practice type, practice location, or job satisfaction was associated with odds of having high physician empathy. However, odds of having a high empathy score were higher for GPs who stated that the physician-patient relationship and interaction with colleagues has a high contribution to job satisfaction compared to the reference groups (low and medium contribution of these factors). This was also the trend for GPs who stated a high contribution to job satisfaction from intellectual stimulation. In contrast, high contribution of economic profit and prestige did not contribute to increased odds of having a high empathy score. Conclusions: Albeit generally high, we observed substantial variation in physician empathy levels among this population of Danish GPs. This variation is positively associated with values of interpersonal relationships and interaction with colleagues, and negatively associated with middle age (45-54 years) and lack of outside employment. There is room to increase GP physician empathy via educational and organizational interventions, and consequently, to improve healthcare quality and outcomes.

Resource allocation and the burden of co-morbidities among patients diagnosed with chronic obstructive pulmonary disease: an observational cohort study from Danish general practice.

BACKGROUND: Chronic obstructive pulmonary disease is a leading cause of mortality, and associated with increased healthcare utilization and healthcare expenditure. In several countries, morbidity-based systems have changed the way resources are allocated in general practice. In primary care, fee-for-services tariffs are often based on political negotiation rather than costing systems. The potential for comprehensive measures of patient morbidity to explain variation in negotiated expenditures for patients with chronic obstructive pulmonary disease has not previously been examined. The aim of this study is to analyze fee-for-service expenditure of patients diagnosed with chronic obstructive pulmonary disease visiting Danish general practice clinics and further to assess what proportion of fee-for-service expenditure variation was explained by patient morbidity and general practice clinic characteristics, respectively. METHODS: We used patient morbidity characteristics such as diagnostic markers and multi-morbidity adjustment based on adjusted clinical groups (ACGs) and fee-for-service expenditure for a sample of primary care patients for the year 2010. Our sample included 3,973 patients in 59 general practices. We used a multi-level approach. RESULTS: The average annual fee-for-service expenditure of caring for patients diagnosed with chronic obstructive pulmonary disease in general practice was about EUR 400 per patient. Variation in the expenditures was driven by multimorbidity characteristics up to 28% where as characteristics such as age and gender only explained 5%. Expenditures increased progressively with the degree of multimorbidity. In addition, expenditures were higher for patients who had diagnostic markers based on ICPC-2 (body systems and/or components such as infections and symptoms). Nevertheless, 9.8-15.4% of the variation in expenditure was related to the clinic in which the patient was cared for. CONCLUSION: Patient morbidity and general practice clinic characteristics are significant patient-related fee-for-service expenditure drivers in chronic obstructive pulmonary disease care.

Medical engagement and organizational characteristics in general practice.

BACKGROUND: Medical engagement is a mutual concept of the active and positive contribution of doctors to maintaining and enhancing the performance of their health care organization, which itself recognizes this commitment in supporting and encouraging high quality care. A Medical Engagement Scale (MES) was developed by Applied Research Ltd (2008) on the basis of emerging evidence that medical engagement is critical for implementing radical improvements. OBJECTIVES: To study the importance of medical engagement in general practice and to analyse patterns of association with individual and organizational characteristics. DESIGN AND SETTING: A cross-sectional study using a sampled survey questionnaire and the official register from the Danish General Practitioners' Organization comprising all registered Danish GPs. METHOD: The Danish version of the MES Questionnaire was distributed and the survey results were analysed in conjunction with the GP register data. RESULTS: Statistically adjusted analyses revealed that the GPs' medical engagement varied substantially. GPs working in collaboration with colleagues were more engaged than GPs from single-handed practices, older GPs were less engaged than younger GPs and female GPs had higher medical engagement than their male colleagues. Furthermore, GPs participating in vocational training of junior doctors were more engaged than GPs not participating in vocational training. CONCLUSION: Medical engagement in general practice varies a great deal and this is determined by a complex interaction between both individual and organizational characteristics. Working in collaboration, having staff and being engaged in vocational training of junior doctors are all associated with enhanced levels of medical engagement among GPs.

Postpartum infections: occurrence, healthcare contacts and association with breastfeeding.

OBJECTIVE: To investigate the following: (i) the occurrence of postpartum infections; (ii) the frequency of contact with either a general practitioner or a hospital due to postpartum infections; and (iii) the association of postpartum infections with continuation of breastfeeding. DESIGN: Cross-sectional study. SETTING: Department of Gynecology and Obstetrics Horsens Hospital, Horsens, Denmark. POPULATION: A total of 1871 women who gave birth at a regional hospital in Denmark over a one-year period (2007-2008). METHODS: Data were collected by a questionnaire given to the women and combined with data from general practitioner and hospital records. MAIN OUTCOME MEASURES: The distribution of different infections, as well as the overall occurrence of any infection, was evaluated according to mode of delivery and breastfeeding status (stopped/continued). RESULTS: Within four weeks after delivery, 24% of all women had experienced one or more self-reported episode of infection. Breast infections (12%) were most frequent, followed by wound (3%), airway (3%), vaginal (3%) and urinary tract infections (3%), endometritis (2%) and "other infections" (2%). Of the women with an infection, 66% (265 of 395) contacted their general practitioner, while 9% (37 of 395) had contact with a hospital. A significantly larger proportion of women with a postpartum infection stopped breastfeeding (21%) within the first four weeks after delivery compared with women without infection (12%; p < 0.001). CONCLUSIONS: Postpartum infections were common, and the occurrence is likely to be underestimated if based on hospital medical records only. Infection was associated with higher rates of discontinuation of breastfeeding.