Interventions promoting recovery from depression for patients transitioning from outpatient mental health services to primary care: A scoping review.

INTRODUCTION: Major Depressive Disorder (MDD) is one of the most prevalent mental disorders worldwide with significant personal and public health consequences. After an episode of MDD, the likelihood of relapse is high. Therefore, there is a need for interventions that prevent relapse of depression when outpatient mental health care treatment has ended. This scoping review aimed to systematically map the evidence and identify knowledge gaps in interventions that aimed to promote recovery from MDD for patients transitioning from outpatient mental health services to primary care. MATERIALS AND METHODS: We followed the guidance by Joanna Briggs Institute in tandem with the PRISMA extension for Scoping Reviews checklist. Four electronic databases were systematically searched using controlled index-or thesaurus terms and free text terms, as well as backward and forward citation tracking of included studies. The search strategy was based on the identification of any type of intervention, whether simple, multicomponent, or complex. Three authors independently screened for eligibility and extracted data. RESULTS: 18 studies were included for review. The studies had high heterogeneity in design, methods, sample size, recovery rating scales, and type of interventions. All studies used several elements in their interventions; however, the majority used cognitive behavioural therapy conducted in outpatient mental health services. No studies addressed the transitioning phase from outpatient mental health services to primary care. Most studies included patients during their outpatient mental health care treatment of MDD. CONCLUSIONS: We identified several knowledge gaps. Recovery interventions for patients with MDD transitioning from outpatient mental health services to primary care are understudied. No studies addressed interventions in this transitioning phase or the patient's experience of the transitioning process. Research is needed to bridge this gap, both regarding interventions for patients transitioning from secondary to primary care, and patients' and health care professionals' experiences of the interventions and of what promotes recovery. REGISTRATION: A protocol was prepared in advance and registered in Open Science Framework (https://osf.io/ah3sv), published in the medRxiv server (https://doi.org/10.1101/2022.10.06.22280499) and in PLOS ONE (https://doi.org/10.1371/journal.pone.0291559).

Factors affecting point-of-care ultrasound implementation in general practice: a survey in Danish primary care clinics.

OBJECTIVE: The implementation of point-of-care ultrasound (POCUS) in general practice varies, but it is unknown what determines this variation. The purpose of this study was to explore (1) the overall proportion of POCUS-users among general practitioners (GPs), (2) the current use of POCUS by GPs, (3) factors related to the implementation of POCUS in general practice and (4) GPs' concerns related to POCUS use in general practice. DESIGN: An online survey was distributed in June 2019. SETTING: General practice. PARTICIPANTS: GPs working in office-based primary care clinics in Denmark. MAIN OUTCOME MEASURES: The questionnaire was developed using mixed methods and included questions about participants' characteristics, past POCUS training and experience, capability, opportunity and motivation for using POCUS in the primary care setting. Results were summarised using descriptive statistics. Association between GPs' background characteristics and POCUS use was tested using logistics regression. RESULTS: Responses were analysed from 1216 questionnaires corresponding to 36.4% of all GPs in Denmark. The majority (72.3%) of participants had previous POCUS experience, 14.7% had access to a POCUS device and 11.5% used POCUS. Several factors motivated participants to use POCUS. However, barriers existed such as lack of remuneration and high workload. Additionally, many GPs questioned their ability to scan with sufficient diagnostic accuracy and the impact of POCUS on the consultation. Of non-users, 28.7% believed they would be using POCUS in the future. CONCLUSION: Although, the majority of GPs had past experience with POCUS and felt motivated to use it, few had implemented POCUS. Several factors influenced the GPs' capability, opportunity and motivation for using POCUS and several concerns were registered by non-users.

Interventions promoting recovery from depression for patients transitioning from outpatient mental health services to primary care: Protocol for a scoping review.

INTRODUCTION: Patients with severe Major Depressive Disorder (MDD) have an increasing risk of new psychiatric hospitalizations following each new episode of depression highlighting the recurrent nature of the disorder. Furthermore, patients are not fully recovered at the end of their treatment in outpatient mental health services, and residual symptoms of depression might explain why patients with MDD have a high risk of relapse. However, evidence of methods to promote recovery after discharge from outpatient mental health services is lacking. The proposed scoping review aims to systematically scope, map and identify the evidence and knowledge gaps on interventions that aims to promote recovery from MDD for patients transitioning from outpatient mental health services to primary care. MATERIALS AND METHODS: The proposed scoping review will follow the latest methodological guidance by the Joanna Briggs Institute (JBI) in tandem with the Preferred Reporting Items for Systematic reviews and Meta-Analysis-extension for Scoping Reviews (PRISMA-ScR) checklist. The review is ongoing. Four electronic databases (Medline via PubMed, PsycINFO, CINAHL, and Sociological Abstracts) were systematically searched from 20 January 2022 till 29 March 2022 using keywords and text words. The review team consists of three independent screeners. Two screeners have completed the initial title and abstract screening for all studies retrieved by the search strategy. Currently, we are in the full text screening phase. Reference lists of included studies will be screened, and data will be independently extracted by the review team. Results will be analyzed qualitatively and quantitatively. DISCUSSION: The chosen methodology is based on the use of publicly available information and does not require ethical approval. Results will be published in an international peer reviewed scientific journal, at national and international conferences and shared with relevant authorities. REGISTRATION: A pre-print has been registered at the medRxiv preprint server for health sciences (doi.org/10.1101/2022.10.06.22280499).

The SOFIA pilot study: assessing feasibility and fidelity of coordinated care to reduce excess mortality and increase quality of life in patients with severe mental illness in a general practice setting; a cluster-randomised pilot trial.

OBJECTIVE: To evaluate the feasibility and fidelity of implementing and assessing the SOFIA coordinated care program aimed at lowering mortality and increasing quality of life in patients with severe mental illness by improving somatic health care in general practice. DESIGN: A cluster-randomised, non-blinded controlled pilot trial. SETTING: General Practice in Denmark. INTERVENTION: The SOFIA coordinated care program comprised extended structured consultations carried out by the GP, group-based training of GPs and staff, and a handbook with information on signposting patients to relevant municipal, health, and social initiatives. PATIENTS: Persons aged 18 years or older with a diagnosis of psychotic, bipolar, or severe depressive disorder. MAIN OUTCOME MEASURES: We collected quantitative data on the delivery, recruitment and retention rates of practices and patients, and response rates of questionnaires MMQ and EQ-5D-5 L. RESULTS: From November 2020 to March 2021, nine practices were enrolled and assigned in a 2:1 ratio to the intervention group (n = 6) or control group (n = 3). Intervention group practices included 64 patients and Control practices included 23. The extended consultations were delivered with a high level of fidelity in the general practices; however, thresholds for collecting outcome measures, and recruitment of practices and patients were not reached. CONCLUSION: Our findings suggest that delivering the coordinated care program in a fully powered trial in primary care is likely feasible. However, the recruitment methodology requires improvement to ensure sufficient recruitment and minimize selective inclusion. TRIAL REGISTRATION: The date of pilot trial protocol registration was 05/11/2020, and the registration number is NCT04618250.

How is my child doing - parental understanding of their children when a parent has cancer.

To explore the difficulties parents face when understanding their children's reactions to parental cancer and parents' reactions to their children's perceived needs.Qualitative interviews with cancer patients and their partners.Eleven patients and seven partners took part. Their children were aged 1-15 years. Eight patients were mothers and cancer was diagnosed median 28 (7-104) months ago.Inductive analysis with systematic text condensation.Parents were groping in the dark when understanding their children's reactions. They observed signs of distress in their children, but often avoided communication about emotional reactions. We suggest parental difficulties in containing own and children's emotions as an important cause for this situation.Parents lacked relevant support offers for the family as a unit. Identification of children's difficulties cannot be based on parental evaluation alone. We suggest family support as part of standard care for patients with minor children.

General Practitioners' Perspectives on Appropriate Use of Ultrasonography in Primary Care in Denmark: A Multistage Mixed Methods Study.

PURPOSE: Researchers aimed to describe general practitioners' understanding of appropriate ultrasound use, to record actual scanning practices of early adopters in general practice, and to identify differences between attitudes and actual practice via a mixed methods analysis. METHODS: This study was part of a larger multistage mixed methods research framework exploring the use of ultrasound in general practice in Denmark. We used an exploratory sequential approach in the data collection with initial qualitative findings from an interview study applied to building a quantitative questionnaire utilized in a cohort study. In addition, we merged the qualitative and quantitative data using joint display analysis to compare and contrast the results from the 2 stages of the study. RESULTS: In the interviews, general practitioners described appropriate ultrasound use as point-of-care examinations with a clear purpose and limited to predefined specific conditions within delimited anatomic areas. They stated that general practitioners should receive formalized ultrasound training and be skilled in the examinations they perform. In the cohort study, general practitioners performed ultrasound examinations of anatomic areas with or without a defined clinical suspicion. Some performed ultrasound examinations for which they had no previous training or skills. CONCLUSIONS: We found a difference between the ideas about the appropriate uses for ultrasound in general practice and the actual use by early adopters in clinical practice. Our findings suggest a need for evidence-based guidelines to support general practitioners in choosing which examinations to perform and strategies for developing and maintaining scanning competency.

General practitioners' experiences in consultations with foreign language patients after the introduction of a user's fee for professional interpretation: a qualitative interview study.

BACKGROUND: In 2018, an amendment to the Danish Health Care Act was passed making it a requirement for patients not proficient in Danish to pay for interpretation services in health care settings. Thereafter there has been a drastic decline in the use of professional interpreters, especially in general practice. We aimed to investigate the experiences of general practitioners (GPs) in establishing an understanding with these patients in consultations, without the presence of a professional interpreter. METHODS: The study was qualitative, based on semi-structured interviews with nine purposively selected GPs. Analysis was by interpretative phenomenological analysis. RESULTS: The GPs said that after the amendment was passed, the patients chose to almost exclusively use family members or friends as ad hoc interpreters, or they attended consultations with no interpreter present at all. The GPs experienced that the use of family interpreters caused specific problems, due to both their relationship with the patient and their lack of professional interpretation skills. If no mediator was present the GPs perceived the establishment of understanding as extremely challenging. This was particularly the case if patients had chronic conditions, mental or psychosocial problems or if cultural barriers were present. According to the GPs, the challenges were not exclusively restricted to a lack of language translation, but could also involve intertwined cultural barriers or social problems. The impairment in mutual understanding had different consequences, and led to poorer treatment at many levels in health care. The lack of access to a professional interpreter also presented the GP with ethical and legal dilemmas. CONCLUSIONS: The GPs experienced that the changes in interpretation provision for patients in health care had led to professional interpretation being almost absent from general practice settings for patients subject to the fee. This led to several communication challenges, insufficient understanding in consultations, and poorer treatment of these, often very vulnerable, patients. The situation could, however, also involve the risk of epistemic injustice. The GPs experienced the situation as very unsatisfactory; it both comprised their ability to exercise their professionalism and their ethical obligations and restricted their legal rights.

Learning strategies of general practitioners striving to achieve point-of-care ultrasound competence: a qualitative study.

BACKGROUND: Point-of-care ultrasonography (POCUS) is increasingly used in general practice despite the lack of official educational programmes or guidelines for general practitioners (GPs). AIM: To explore how GPs have learnt to use POCUS and which barriers they have encountered in their learning process. DESIGN AND SETTING: Qualitative study conducted in office-based general practice in Denmark. METHODS: Semi-structured interviews were conducted with 13 GPs who had implemented POCUS without supporting guidelines or regulations. Analysis was carried out using systematic text condensation. The interview data for this study were collected along with data used in a previous study. RESULTS: The participating GPs described having composed their own ultrasound education following a continuous learning process. Basic POCUS competences were achieved through formalized training sessions at hospital departments or courses. The GPs further developed and expanded their scanning skills through additional courses and continuous self-study practice on patients often while consulting internet sources, textbooks or colleagues. Lack of available ultrasound courses, supervision, and clinical guidelines together with time constraints and financial aspects were mentioned as barriers to their ultrasound training. CONCLUSION: This study showed how GPs had composed their own ultrasound education individually and differently, guided by their own experiences and beliefs about good clinical practice. Formalized ultrasound training was considered a prerequisite for achieving basic ultrasound competences while continuous practice was considered paramount to develop and maintain scanning skills. There were several obstacles to overcome in the learning process including lack of supervision, guidance, and opportunity for practicing skills.Key pointsLittle is known about the educational needs of general practitioners striving to achieve ultrasound competences.General practitioners described using formalized training to achieve basic scanning competences and continuous self-study and practice to further develop their skills.Lack of time, supervision, clinical guidelines and ultrasound courses were considered barriers in the learning process together with financial aspects.

General practitioner responses to concerns in chronic care consultations for patients with a history of cancer.

We investigated general practitioners' (GPs') responses to patients' concerns in chronic care consultations. Video recordings of 14 consultations were analyzed with conversation analysis. We found two categories of responses: exiting and exploring the patient's concerns. Most GPs exited the concern by interrupting the patient, acknowledging the concern but then referring back to the progression of the consultation, or affiliating with the concern without exploring it. Only a few raised concerns were explored, and then most often the somatic rather than the emotional aspects of them. The findings point to the risk of missing patients' voiced concerns in consultations with a fixed agenda.

Improving the precision of depression diagnosis in general practice: a cluster-randomized trial.

BACKGROUND: Methods to enhance the accuracy of the depression diagnosis continues to be of relevance to clinicians. The primary aim of this study was to compare the diagnostic precision of two different diagnostic strategies using the Mini International Neuropsychiatric Interview (MINI) as a reference standard. A secondary aim was to evaluate accordance between depression severity found via MINI and mean Major Depression Inventory (MDI) sum-scores presented at referral. METHODS: This study was a two-armed, cluster-randomized superiority trial embedded in the Collabri trials investigating collaborative care in Danish general practices. GPs performing case-finding were instructed always to use MDI when suspecting depression. GPs performing usual clinical assessment were instructed to detect depression as they would normally do. According to guidelines, GPs would use MDI if they had a clinical suspicion, and patients responded positively to two or three core symptoms of depression. We compared the positive predictive value (PPV) in the two groups. RESULTS: Fifty-one GP clusters were randomized. In total, 244 participants were recruited in the case-finding group from a total of 19 GP clusters, and 256 participants were recruited in the usual clinical assessment group from a total of 19 GP clusters. The PPV of the GP diagnosis, when based on case-finding, was 0.83 (95% CI 0.78-0.88) and 0.93 (95% CI 0.89-0.96) when based on usual clinical assessment. The mean MDI sum-scores for each depression severity group indicated higher scores than suggested cut-offs. CONCLUSIONS: In this trial, systematic use of MDI on clinical suspicion of depression did not improve the diagnostic precision compared with the usual clinical assessment of depression. TRIAL REGISTRATION: The trial was retrospectively registered on 07/02/2016 at ClinicalTrials.gov. No. NCT02678845 .

"My private theory is that it's all in the head": Understandings of chronic widespread pain among social workers from municipality job centers in Denmark.

People with chronic widespread pain (CWP) are often unfit for work, and consequently they are dependent on the municipality job center to receive social support and sickness benefits. The job center's case management is based on a social worker's assessment of the citizen's health condition. This qualitative study investigates social workers' understandings of CWP. Interviews were carried out with 12 social workers. The results showed that the participants predominantly experienced the citizens' illnesses as psychosocially mediated-referring to trauma, or a lack of meaning in the citizens' lives. Only a few participants mentioned possibilities for somatic explanations of CWP.

Life goes on Patient perspectives on having a cancer diagnosis and other comorbid diseases: A qualitative study.

OBJECTIVES: Due to a growing population with both cancer and chronic diseases, we explored patients' experiences of living with a cancer diagnosis and comorbidities, the possible effects on everyday living and management of comorbidities. METHODS: Semi-structured interviews were conducted during 2016 with 15 patients in Denmark, with finished cancer treatment and preexisting comorbidities. Analysis was performed by Systematic Text Condensation. RESULTS: Symptoms which disrupted everyday function were given attention, regardless of the disease from which the symptoms originated. The awareness of cancer and comorbidities constituted an inverse process over time. Most patients perceived cancer as being transient, whereas experiences of comorbidities varied from ignorance to worry. Most patients reported maintaining their chronic illness consultations with their general practitioner as before cancer. CONCLUSION: Patients prioritized an everyday life with normal chores highly in contrast to paying attention to diseases. Disruptive symptoms, rather than specific diseases, took up patients' attention. Cancer did not change the patients' attendance at chronic care consultations. General practitioners should focus on maintaining the patient's functional level in everyday life. Further, they should continue to prioritize the chronic care management, as this might increase the patients' own view of the importance of self-management.

Challenging care work: General practitioners' perspectives on caring for young adults with complex psychosocial problems.

The international literature shows that primary care is well placed to address mental health problems in young people, but that primary care professionals experience a range of challenges in this regard. In Denmark, young adults who have complex psychosocial problems, and who are not in education or work, cause political and academic concern. They are also in regular contact with their general practitioners, the Danish municipalities and psychiatric services. However, little is known about general practitioners' perspectives on caring for this vulnerable group of patients. In this article, we investigate how general practitioners' care work is shaped by the bureaucratic management of care in a complex infrastructure network comprising the general practitioners, psychiatry, the municipalities and the young adults. The analysis is based on interviews and focus groups with general practitioners, psychiatric nurses and social workers. We employ Tronto's concept of care and the concept of boundary work as a theoretical framework. We argue that general practitioners strive to provide care, but they are challenged by the following: contested diagnostic interpretations and the bureaucratic significance of diagnoses for the provision of care from psychiatry and the municipalities, systemic issues with handling intertwined social and mental health problems, and the young adults' difficulties with accessing and receiving available care.

"We have two different agendas": the views of general practitioners, social workers and hospital staff on interprofessional coordination for patients with chronic widespread pain.

Patients with chronic widespread pain (CWP) are often unfit for work and go through lengthy treatment. In Denmark, this includes contacts with the job center in their municipality, their general practitioner (GP) and one or more hospital units. Little is known about how coordination around patients with CWP functions and is perceived by professionals. Therefore, our aim is to explore how GPs, social workers from municipality job centers and hospital staff experience interprofessional coordination for patients with CWP. Interviews with 7 GPs, 12 social workers, and 10 hospital staff were analyzed using interpretative phenomenological analysis. The participants experienced challenges with coordination, primarily in the relations between social workers and GPs. There was an over-reliance on written communication in situations where the actors had divergent agendas, opposing professional roles and conflicting approaches to time. GPs tended to lengthen the time spans for treating patients, while social workers tried to shorten them so that patients could get back to work. Applying the theory of relational coordination (RC), the findings correspond to a low level of RC, indicating a need for shared accountability, and strengthened interpersonal communication between professionals.Abbreviations: CWP: Chronic widespread pain; GPs: General practitioners; RC: Relational coordination; IPA: Interpretative phenomenological analysis.

Experiences of barriers to trans-sectoral treatment of patients with severe mental illness. A qualitative study.

BACKGROUND: Patients with severe mental illness (SMI) have shorter life expectancy than people without SMI, mainly due to overmortality from physical diseases. They are treated by professionals in three different health and social care sectors with sparse collaboration between them, hampering coherent treatment. Previous studies have shown difficulties involved in establishing such collaboration. As the preparatory phase of an intervention to improve physical health of people with SMI and increase collaboration across sector borders, we explored different actors' experiences of barriers for collaboration. METHOD: We collected qualitative data from patients, professionals in general practice, psychiatry and social psychiatry involved in the treatment of these patients. Data consisted of notes from meetings and observations, interviews, focus groups and workshops. Analysis was by Interpretative Phenomenological Analysis. RESULTS: The study revealed many obstacles to collaboration and coherent treatment, including the consultation structures in general practice, sectors being subject to different legislation, and incompatible IT systems. Professionals in general practice and social psychiatry felt that they were left with the responsibility for actions taken by hospital psychiatry without opportunity to discuss their concerns with psychiatrists. There were also cultural differences between health care and social psychiatry, expressed in ideology and language. Social psychiatry had an existential approach to recovery, whereas the views of health professionals were linked to symptom control and based on outcomes. Meanwhile, patients were left in limbo between these separate ideologies with no leadership in place to promote dialogue and integrate treatments between the sectors. CONCLUSION: Many obstacles to integrated trans-sectoral treatment of patients with SMI seem related to a lack of an overriding leadership and organizational support to establish collaboration and remove barriers related to legislation and IT. However, professional and ideological barriers also contribute. Psychiatry does not consider general practice to be part of the treatment team although general practitioners are left with responsibility for decisions taken in psychiatry; and different ideologies and treatment principles in psychiatry and municipal social psychiatry hamper the dialogue between them. There is a need to rethink the organization to avoid that the three sectors live autonomous lives with different cultures and lack of collaboration.

Collaborative care for depression and anxiety disorders: results and lessons learned from the Danish cluster-randomized Collabri trials.

BACKGROUND: Meta-analyses suggest that collaborative care (CC) improves symptoms of depression and anxiety. In CC, a care manager collaborates with a general practitioner (GP) to provide evidence-based care. Most CC research is from the US, focusing on depression. As research results may not transfer to other settings, we developed and tested a Danish CC-model (the Collabri-model) for depression, panic disorder, generalized anxiety disorder, and social anxiety disorder in general practice. METHODS: Four cluster-randomized superiority trials evaluated the effects of CC. The overall aim was to explore if CC significantly improved depression and anxiety symptoms compared to treatment-as-usual at 6-months' follow-up. The Collabri-model was founded on a multi-professional collaboration between a team of mental-health specialists (psychiatrists and care managers) and GPs. In collaboration with GPs, care managers provided treatment according to a structured plan, including regular reassessments and follow-up. Treatment modalities (cognitive behavioral therapy, psychoeducation, and medication) were offered based on stepped care algorithms. Face-to-face meetings between GPs and care managers took place regularly, and a psychiatrist provided supervision. The control group received treatment-as-usual. Primary outcomes were symptoms of depression (BDI-II) and anxiety (BAI) at 6-months' follow-up. The incremental cost-effectiveness ratio (ICER) was estimated based on 6-months' follow-up. RESULTS: Despite various attempts to improve inclusion rates, the necessary number of participants was not recruited. Seven hundred thirty-one participants were included: 325 in the depression trial and 406 in the anxiety trials. The Collabri-model was implemented, demonstrating good fidelity to core model elements. In favor of CC, we found a statistically significant difference between depression scores at 6-months' follow-up in the depression trial. The difference was not significant at 15-months' follow-up. The anxiety trials were pooled for data analysis due to inadequate sample sizes. At 6- and 15-months' follow-up, there was a difference in anxiety symptoms favoring CC. These differences were not statistically significant. The ICER was 58,280 Euro per QALY. CONCLUSIONS: At 6 months, a significant difference between groups was found in the depression trial, but not in the pooled anxiety trial. However, these results should be cautiously interpreted as there is a risk of selection bias and lacking statistical power. TRIAL REGISTRATION: ClinicalTrials.gov, ID: NCT02678624 and NCT02678845 . Retrospectively registered on 7 February 2016.

Use and impact of point-of-care ultrasonography in general practice: a prospective observational study.

OBJECTIVES: To describe how general practitioners (GPs) use point-of-care ultrasonography (POCUS) and how it influences the diagnostic process and treatment of patients. DESIGN: Prospective observational study using an online questionnaire before and after POCUS. SETTING: Office-based general practice. PARTICIPANTS: Twenty GPs consecutively recruited all patients examined with POCUS in 1 month. PRIMARY AND SECONDARY OUTCOME MEASURES: We estimated the use of POCUS through the indication for use, the frequency of use, the time consumption, the extent of modification of the examination and the findings.The influence on the diagnostic process was estimated through change in the tentative diagnoses, change in confidence, the ability to produce ultrasound images and the relationship between confidence and organs scanned or tentative diagnoses.The influence of POCUS on patient treatment was estimated through change in plan for the patient, change in patient's treatment and the relationship between such changes and certain findings. RESULTS: The GPs included 574 patients in the study. POCUS was used in patient consultations with a median frequency of 8.6% (IQR: 4.9-12.6). Many different organs were scanned covering more than 100 different tentative diagnoses. The median time taken to perform POCUS was 5 min (IQR: 3-8). Across applications and GPs, POCUS entailed a change in diagnoses in 49.4% of patients; increased confidence in a diagnosis in 89.2% of patients; a change in the management plan for 50.9% of patients including an absolute reduction in intended referrals to secondary care from 49.2% to 25.6%; and a change in treatment for 26.5% of patients. CONCLUSIONS: The clinical utilisation of POCUS was highly variable among the GPs included in this study in terms of the indication for performing POCUS, examined scanning modalities and frequency of use. Overall, using POCUS altered the GPs' diagnostic process and clinical decision-making in nearly three out of four consultations. TRIAL REGISTRATION NUMBER: NCT03375333.

General practitioners' perspectives on chronic care consultations for patients with a history of cancer: a qualitative interview study.

BACKGROUND: General practitioners (GPs) are responsible for managing chronic care in the growing population of patients with comorbid chronic conditions and cancer. Studies have shown, however, that cancer patients are less likely to receive appropriate chronic care compared to patients without cancer. Patients say that how GPs engage in the care of comorbidities influences their own priority of these conditions. No studies have explored GPs' attitudes to and prioritization of chronic care in patients who have completed primary cancer treatment. This study aims to explore GPs' experiences, prioritization of, and perspectives on treatment and follow-up of patients with cancer and comorbidity. METHODS: Semi-structured interviews were conducted during 2016 with 13 GPs in Region Zealand in Denmark. We used Systematic Text Condensation in the analysis. RESULTS: All participating GPs said that chronic care in patients with a history of cancer was a high priority, and due to a clear structure in their practice, they experienced that few patients were lost to follow-up. Two different approaches to chronic care consultations were identified: one group of GPs described them as imitating outpatient clinics, where the GP sets the agenda and focuses on the chronic condition. The other group described an approach that was more attuned to the patient's agenda, which could mean that chronic care consultations served as an "alibi" for the patients to disclose other matters of concern. Both groups of GPs said that chronic care consultations for these patients supported normalcy, but in different ways. Some GPs said that offering future appointments in the chronic care process gave patients hope and a sense of normalcy. Other GPs strove for normalcy by focusing exclusively on the chronic condition and dealing with cancer as cured. CONCLUSIONS: The participating GPs gave a high priority to chronic care in patients with a history of cancer. Some GPs, however, followed a rigorous agenda. GPs should be aware that a very focused and biomedical approach to chronic care might increase fragmentation of care and collide with a holistic and patient-centered approach. It could also affect GPs' self-perception of their role and the core values of general practice.

Between three chairs: Experiences of being a patient with chronic widespread pain in an intersectoral setting in Denmark.

This study explores how patients with chronic widespread pain experience their contacts with health and social services in Denmark, including general practice, hospitals, and municipality job centers. We analyzed interviews with 10 patients using interpretative phenomenological analysis and found the following four superordinate themes: meeting different attitudes, fragmentation of treatment, the importance of time, and feeling trapped. Findings show that when patients do not feel understood by professionals, they can resort to withdrawal strategies. On an organizational level, patients said that they needed sufficient time in meetings and better coordination of interventions in and between the health and social care sectors.

Danish general practitioners have found their own way of using point-of-care ultrasonography in primary care: a qualitative study.

BACKGROUND: General practitioners increasingly use point-of-care ultrasonography despite a lack of evidence-based guidelines for their appropriate use in primary care. Little is known about the integration of ultrasonography in general practice consultations and the impact of its use on patient care. The purpose of this study was to explore general practitioners' experiences of using ultrasonography in the primary care setting. METHODS: Adopting an explorative phenomenological approach, we performed semi-structured interviews with general practitioners who used ultrasonography in their daily work. Thirteen general practitioners were recruited stepwise, aiming for maximum variation in background characteristics. Interviews were conducted at the general practitioner's own clinic. Transcription and systematic text condensation analysis began immediately after conducting each interview. RESULTS: The general practitioners described using ultrasonography for both selected focused examinations and for explorative examinations. The two types of examinations were described differently for each of the following emerging themes: motivation for using ultrasonography, ultrasonography as part of the consultation, selection of an ultrasound catalogue, and consequences of the general practitioner's ultrasound examination. The general practitioners had chosen and integrated their own individual ultrasound catalogue of focused examinations as a natural part of their consultations. The focused examinations were used to answer simple clinical questions and they had a significant impact on the patients' diagnoses, clinical pathways and treatments. The general practitioners considered their own catalogue of focused examinations as their comfort zone. However, they also performed explorative ultrasound examinations outside their catalogue. These scans were performed to train, gain or maintain ultrasound competences or as explorative examinations driven by curiosity. The explorative ultrasound examinations rarely had an impact on patient care. CONCLUSIONS: This study describes how general practitioners found their own way of using ultrasonography in general practice and selected a personal catalogue of ultrasound examinations that was applicable, relevant and meaningful for their daily clinical routines. This study may serve to inform implementation strategies in general practice by offering insights into central aspects that drive general practitioners' behaviours.