Time is money: general practitioners' reflections on the fee-for-service system.

BACKGROUND: Fee-for-service is a common payment model for remunerating general practitioners (GPs) in OECD countries. In Norway, GPs earn two-thirds of their income through fee-for-service, which is determined by the number of consultations and procedures they register as fees. In general, fee-for-service incentivises many and short consultations and is associated with high service provision. GPs act as gatekeepers for various treatments and interventions, such as addictive drugs, antibiotics, referrals, and sickness certification. This study aims to explore GPs' reflections on and perceptions of the fee-for-service system, with a specific focus on its potential impact on gatekeeping decisions. METHODS: We conducted six focus group interviews with 33 GPs in 2022 in Norway. We analysed the data using thematic analysis. RESULTS: We identified three main themes related to GPs' reflections and perceptions of the fee-for-service system. First, the participants were aware of the profitability of different fees and described potential strategies to increase their income, such as having shorter consultations or performing routine procedures on all patients. Second, the participants acknowledged that the fees might influence GP behaviour. Two perspectives on the fees were present in the discussions: fees as incentives and fees as compensation. The participants reported that financial incentives were not directly decisive in gatekeeping decisions, but that rejecting requests required substantially more time compared to granting them. Consequently, time constraints may contribute to GPs' decisions to grant patient requests even when the requests are deemed unreasonable. Last, the participants reported challenges with remembering and interpreting fees, especially complex fees. CONCLUSIONS: GPs are aware of the profitability within the fee-for-service system, believe that fee-for-service may influence their decision-making, and face challenges with remembering and interpreting certain fees. Furthermore, the fee-for-service system can potentially affect GPs' gatekeeping decisions by incentivising shorter consultations, which may result in increased consultations with inadequate time to reject unnecessary treatments.

The cost of saying no: general practitioners' gatekeeping role in sickness absence certification.

BACKGROUND: General practitioners (GPs) have an important gatekeeping role in the Norwegian sickness insurance system. This role includes limiting access to paid sick leave when this is not justified according to sick leave criteria. 85% of GPs in Norway operate within a fee-for-service system that incentivises short consultations and high service provision. In this qualitative study, we explore how GPs practise the gatekeeping role in sickness absence certification. METHODS: Qualitative data was collected through six focus group interviews with 33 GPs, working in practices with a minimum of four practising GPs, in different geographical regions across Norway, including both urban and rural areas. Data was analysed using Braune and Clarke's thematic analysis approach. RESULTS: Our results indicate that GPs' sick-listing decisions are largely driven by patient demand and preferences for sick leave. GPs reported that they rarely overrule patient requests for sickness absence, including in cases where such requests conflict with the GPs' opinion of whether sick leave is justified or benefits the patient. The degree of effort made to limit unjustified or non-beneficial sick leave seems to depend on the GPs' available time and perceived risk of conflict with the patient. GPs generally expressed dissatisfaction with their role as certifiers of sickness absence. CONCLUSION: Our study suggests that GPs' decisions about sickness certification is largely driven by patient preferences. The GPs' gatekeeping function is limited to negotiations about grade and duration of absence spells.

"Balancing within a closed family system": a grounded theory study of how family life is affected by having a family member with an eating disorder.

BACKGROUND: This qualitative study explores how having an adult daughter or sister with anorexia nervosa or bulimia nervosa affects the family's daily life. Previous research has focused on the family's role in the development of an eating disorder, while more recently the focus has been on the illness's impact on the family. Caring for an individual with an eating disorder can involve distress, guilt, extra burdens, and unmet needs. By interviewing the family members of adults with eating disorders this study aims to gain insights into how the family members experience the impact of the eating disorder over time. METHODS: A constructivist grounded theory approach was comprised to gather and analyse data to develop a theory on how families experience life with an adult daughter or sister with an eating disorder. Semi-structured individual interviews were conducted with 21 parents and siblings from across Norway. RESULTS: The participants reported a lack of professional help and the families had to handle the challenges related to the illness themselves, hence being left to themselves as a family was identified as the participants' main concern. To manage this concern the families had to balance a pattern of care within the closed family system, and this comprises the core category of the study. Families balanced a pattern of care by shifting roles, adapting meal routines, and maintaining openness within the family. CONCLUSIONS: The findings implicate that families need clarification of roles and responsibilities in relation to the health services in caring for the individual with an eating disorder. More research on taking a family perspective concerning adults with eating disorders is needed.

This study explores how having an adult daughter or sister with an eating disorder affects the family's daily life. Previous research shows that having a family member with an eating disorder can have a great impact on the family life by causing distress, guilt, extra burdens, and unmet needs for the family members. In this study, we interviewed 21 parents and siblings from across Norway. Our study aimed to explore how the family members experienced the impact of the eating disorder over time, we, therefore, wanted to interview families of adults with eating disorders. The participants reported a lack of professional help and they were left to themselves as families having to handle the challenges related to the illness. The families established a system for taking care of the family member with the eating disorder. Both the parents and the siblings assumed the role of caregiver, the whole family adapted their meal routines and the families managed to keep an openness within the family. These findings show that families need clarification of roles and responsibilities in relation to the health services in caring for a family member with an eating disorder.

"Putting your own oxygen mask on first": a qualitative study of siblings of adults with anorexia or bulimia.

BACKGROUND: In families where one of the siblings has an eating disorder (ED), research indicates that the siblings without eating disorders (EDs) experience insufficient care and negative changes in family life. The illness then takes up a great deal of space within the family. Support from the siblings without EDs is considered to be important for the recovery of the sibling with ED. A key issue is how to involve siblings without EDs in treatment and establish what kind of support they themselves need. A majority of the research on EDs and family has focused on children and adolescents with EDs. The aim of this study is to expand knowledge about the experiences and coping strategies of sisters and brothers of adult women with anorexia nervosa or bulimia nervosa. METHODS: This qualitative study used a constructivist grounded theory approach. Individual semi-structured interviews were conducted with 10 sisters and brothers (aged 20-31 years). They were recruited from eating disorders and general psychiatrics units and from user organisations for patients with eating disorders within Norway. An iterative process of data collection, coding and analysis was employed in order to generate a theory about these participants' experiences and strategies. RESULTS: The core category is "put your own oxygen mask on first". It indicates that the siblings realize that they need to take care of themselves first, in order to be able to stay involved with their sister with the ED. The three subcategories; "taking a new role", "distancing" and "adapted care" describe how the siblings handle their situation as the relatives of adult sisters with an ED. The siblings without ED became more responsible and independent and assumed a caregiving role. They downplayed their own needs to reduce their parents' burden. This new role became difficult to fulfil and the siblings experienced that over time they needed more distance. Eventually, they developed a more manageable way of caring for their sister. CONCLUSIONS: The findings suggest that the ED challenged the boundaries within the family. The siblings without ED assumed a caregiver role, gradually leading to exhaustion and the need to distance from the sister with the ED, to take care of themselves.

Siblings in families where one sibling has an eating disorder have reported experiencing a lack of care and negative changes in family life. They felt that the illness took up a great deal of space. This qualitative study explores the experiences of siblings of adult women with anorexia or bulimia. Ten individual interviews with brothers and sisters were conducted. The participants were recruited from eating-disorder and general psychiatrics units and from user organisations for eating disorders within Norway. The age range was 20­31 years. Findings from this study suggest that the character of the illness challenged the whole family. Participants reported that they became more responsible and independent. Some became caregivers for their ill sister and downplayed their own needs to reduce their parents' burden. A majority of the siblings said that they experienced exhaustion after taking care of their sibling for a while and needed distance from their ill sister to take care of themselves. Eventually, they developed their own manageable ways of caring for their sister with the illness.

Integration of physical activity in reablement for community-dwelling older adults: a scoping review protocol.

OBJECTIVE: The objectives of this scoping review are to map existing evidence of how physical activity strategies are integrated and explored in studies of reablement for community-dwelling older adults and to identify knowledge gaps. INTRODUCTION: Reablement is a home-based interdisciplinary practice that aims to improve function and independence among persons receiving home care services. There is insufficient knowledge of what constitutes reablement and how it affects older adults' function and independence. Physical activity is known to influence older adults' function, but it is unclear how physical activity is integrated into reablement interventions. INCLUSION CRITERIA: This review will consider studies that investigate or explore multidisciplinary and time-limited (less than six months) reablement for community-dwelling older adults. There will be no restrictions regarding study design. Studies focusing on professionals working with reablement and carers of reablement participants will also be included. Studies focusing on persons who need end-of-life care or on reablement provided in long-term care facilities or housing arrangements with 24-hour care will be excluded. METHODS: PubMed, Cochrane Central Register of Controlled Trials, Embase, PsycINFO, AMED, PEDro, CINAHL, ProQuest Dissertations and Theses, and Google Scholar will be searched for studies published from 1996. Studies published in English, Norwegian, Danish, Swedish and German will be considered for inclusion. Study selection will be performed independently by two reviewers, and data will be extracted by two reviewers using predefined data charting forms. Data will be presented in a narrative summary.