Designing a tool ensuring older patients the right medication at the right time after discharge from hospital- the first step in a participatory design process.

BACKGROUND: On average, older patients use five or more medications daily, increasing the risk of adverse drug reactions, interactions, or medication errors. Healthcare sector transitions increase the risk of information loss, misunderstandings, unclear treatment responsibilities, and medication errors. Therefore, it is crucial to identify possible solutions to decrease these risks. Patients, relatives, and healthcare professionals were asked to design the solution they need. METHODS: We conducted a participatory design approach to collect information from patients, relatives, and healthcare professionals. The informants were asked to design their take on a tool ensuring that patients received the correct medication after discharge from the hospital. We included two patients using five or more medications daily, one relative, three general practitioners, four nurses from different healthcare sectors, two hospital physicians, and three pharmacists. RESULTS: The patients' solution was a physical location providing a medication overview, including side effects and interactions. Healthcare professionals suggested different solutions, including targeted and timely information that provided an overview of the patient's diagnoses, treatment and medication. The common themes identified across all sub-groups were: (1) Overview of medications, side effects, and diagnoses, (2) Sharing knowledge among healthcare professionals, (3) Timely discharge letters, (4) Does the shared medication record and existing communication platforms provide relevant information to the patient or healthcare professional? CONCLUSION: All study participants describe the need for a more concise, relevant overview of information. This study describes elements for further elaboration in future participatory design processes aimed at creating a tool to ensure older patients receive the correct medication at the correct time.

Sensory impairments and depressive symptoms in Europe: a cross-national cohort study.

OBJECTIVES: To investigate the associations between sensory impairments and the development of depressive symptoms across sex, age, and European regions, and to examine the mediating role of cognitive function, activities of daily living (ADL), and physical activity. METHOD: A cohort study including 56,847 Europeans aged 50+ participating in at least two waves of the Survey of Health, Ageing and Retirement in Europe (SHARE). Associations were analyzed using mixed effects logistic regression models considering several confounders. RESULTS: Overall, 17.8% developed depressive symptoms. Compared to participants with good vision and hearing, those with vision impairment (VI) (odds ratio (OR) = 1.35, 95% confidence interval (CI) 1.27-1.44), hearing impairment (HI) OR = 1.32, 95% CI 1.21-1.43, and dual sensory impairment (DSI, i.e. VI and HI) (OR = 1.93, 95% CI 1.75-2.13) had increased odds of depressive symptoms. The associations were consistent across sex and European regions but became stronger with advancing age among men. Dose-response relationships were found for all associations. Mediation analyses revealed that preventing cognitive decline, ADL limitations, and physical inactivity would eliminate 15.0%, 11.5%, and 21.4% of the total effect for VI, HI, and DSI, respectively. CONCLUSION: Our findings emphasize the importance of preventing sensory impairments to avoid depressive symptoms.

Handling polypharmacy -a qualitative study using focus group interviews with older patients, their relatives, and healthcare professionals.

BACKGROUND: On average, older patients use five or more medications daily. A consequence is an increased risk of adverse drug reactions, interactions, or medication errors. Therefore, it is important to understand the challenges experienced by the patients, relatives, and healthcare professionals pertinent to the concomitant use of many drugs. METHODS: We conducted a qualitative study using focus group interviews to collect information from patients, relatives, and healthcare professionals regarding older patients' management of prescribed medicine. We interviewed seven patients using five or more medications daily, three relatives, three general practitioners, nine nurses from different healthcare sectors, one home care assistant, two hospital physicians, and four pharmacists. RESULTS: The following themes were identified: (1) Unintentional non-adherence, (2) Intentional non-adherence, (3) Generic substitution, (4) Medication lists, (5) Timing and medication schedule, (6) Medication reviews and (7) Dose dispensing/pill organizers. CONCLUSION: Medication is the subject of concern among patients and relatives. They become confused and insecure about information from different actors and the package leaflets. Therefore, patients often request a thorough medication review to provide an overview, knowledge of possible side effects and interactions, and a clarification of the medication's timing. In addition, patients, relatives and nurses all request an indication of when medicine should be taken, including allowable deviations from this timing. Therefore, prescribing physicians should prioritize communicating information regarding these matters when prescribing.

Development over time in point-of-care test use in Danish daytime and out-of-hours general practice: a register-based study.

OBJECTIVE: To describe the development over time of the use of C-reactive protein (CRP) and rapid streptococcal detection test (RADT) point-of-care tests (POCT) in Danish general practice and to explore associations between patient characteristics and POCT use (i.e. CRP and RADT). DESIGN AND SETTINGS: A register-based study including all general practice clinic consultations in daytime and out-of-hours (OOH) settings in Denmark between 2003 and 2018. SUBJECTS: All citizens who had at least one clinic consultation in daytime or OOH general practice within the study period. MAIN OUTCOME MEASURES: We estimated the total and relative use of CRP and RADT POCTs and described the development over time. Crude and adjusted proportion ratios (PRs) were calculated to explore associations between patient characteristics and POCT use. RESULTS: Overall, the relative use of CRP POCTs increased. At OOH, a steep increase was noticed around 2012. The relative use of RADT decreased. Patient age 40-59 years and existing comorbidity were significantly associated with a higher use of CRP testing in both settings. A significantly lower use of CRP testing was found for patients with higher educational level. We found a significantly higher use of RADT testing for patients aged 0-19 years and with higher household educational level, whereas comorbidity was associated with a lower use of RADT testing. CONCLUSION: The use of CRP POCT increased over time, whereas the use of RADT POCT decreased. Perhaps the success of implementing CRP as a tool for reducing antibiotic use has reached it limit. Future studies should focus on how and when POCT are used most optimal.Key pointsCRP POC tests and RADT POCTs are frequently used diagnostic tools in general practice, both in daytime and in the out-of-hours setting.There was an increased use of CRP POCTs, particularly in out-of-hours general practice, whereas the use of RADT POCTs declined between 2003 and 2018.CRP POCTs were associated with age of 40-59 years and co-morbidity, while the use of RADT was mostly associated with younger age.

"We don't need no education" - a qualitative study of barriers to continuous medical education among Danish general practitioners.

BACKGROUND: Continuous medical education is essential for the individual patient care, the society, and the wellbeing of the general practitioner. There has been research into the reasons for participation in continuous medical education, but little is known about the barriers to participation. To tailor continuous medical education targeting general practitioners who are currently deselecting education, systematic knowledge of the barriers is needed. Continuous medical education can in addition to professional growth stimulate job satisfaction, diminish burnout, and reinforce feelings of competence. Continuous medical education may have positive implications for patients and for healthcare expenditures. Despite renumeration and a comprehensive continuous education model some Danish general practitioners do not participate in continuous medical education. METHODS: From a total of 3440 Danish general practitioners 243 did not apply for reimbursement for accredited continuous medical education in a two-year period. Ten general practitioners were selected for an interview regarding maximum variation in practice form, number of listed patients, seniority as a general practitioner, geography, gender, and age. All ten selected general practitioners accepted to be interviewed. The interviews were analysed using Systematic Text Condensation. RESULTS: Each of the ten interviewed general practitioners mentioned several barriers for participating in continuous education. The barriers fell into three main categories: barriers related to the individual general practitioner barriers related to the clinic barriers related to the accredited continuous medical education offered CONCLUSIONS: Approximately 7% of the Danish general practitioners did not participate in accredited remunerated continuous medical education. A knowledge of the barriers for participating in accredited continuous medical education can be used to better target continuous medical education to the general practitioners.

How to enhance and assess reflection in specialist training: a mixed method validation study of a new tool for global assessment of reflection ability.

BACKGROUND: In Danish GP training we had the ambition to enhance and assess global reflection ability, but since we found no appropriate validated method in the literature, we decided to develop a new assessment tool. This tool is based on individual trainee developed mind maps and structured trainer-trainee discussions related to specific complex competencies. We named the tool Global Assessment of Reflection ability (GAR) and conducted a mixed method validation study. Our goal was to investigate whether it is possible to enhance and assess reflection ability using the tool. METHODS: In order to investigate acceptability, feasibility, face validity, and construct validity of the tool we conducted a mixed method validation study that combined 1) qualitative data obtained from 750 GP trainers participating in train-the-trainer courses, 2) a questionnaire survey sent to 349 GP trainers and 214 GP trainees and 3) a thorough analysis of eight trainer-trainee discussions. RESULTS: Our study showed an immediate high acceptance of the GAR tool. Both trainers and trainees found the tool feasible, useful, and relevant with acceptable face validity. Rating of eight audio recordings showed that the tool can demonstrate reflection during assessment of complex competencies. CONCLUSIONS: We have developed an assessment tool (GAR) to enhance and assess reflection. GAR was found to be acceptable, feasible, relevant and with good face- and construct validity. GAR seems to be able to enhance the trainees' ability to reflect and provide a good basis for assessment in relation to complex competencies.

Study protocol of the X:IT II - a school-based smoking preventive intervention.

BACKGROUND: The X:IT intervention, conducted in 2010 to 2013, showed overall smoking preventive effect. However, parts of the intervention appeared less appealing to children from families with lower socioeconomic backgrounds. Therefore, the intervention components were modified and an evaluation of the amended intervention X:IT II is needed to show the effect of this revised intervention and whether children from different social backgrounds benefits equally from the current intervention. METHODS: Main intervention components are smoke free schools, a curricular component, and parental involvement (smoke free agreements and talks about tobacco). Components have been revised from the first version; 1) previously, schools should be smoke free on the school ground and were encouraged to hide smoking so that it wasn't visible to pupils from the school ground. Now they are encouraged to tighten the rules so that no pupils or teachers smoke during the school day, no matter where they are; 2) the specifically developed educational material (Up in Smoke) has been revised so that all materials are online and all texts has a ARI; 3) the parental involvement is now targeted multiple groups of parents, e.g. parents that are smokers, and parents of children that smoke. Language used is simpler and the website for parents presents very specific examples. X:IT is implemented in 46 Danish public schools from fall 2017 until summer 2020. Data is collected through electronic questionnaires to students and coordinators four times (fall 2017, spring/summer 2018, 2019 and 2020). Further, qualitative interviews and observations are conducted. DISCUSSION: Prevalence of smoking among Danish adolescents is high compared to other Nordic countries and there is social inequality in smoking, leaving individuals from the lowest social backgrounds at higher risk. Although there has been an overall decline in smoking among Danish adolescents over the last decades, a recent levelling of this development indicates an urgent need for smoking prevention in Denmark. The X:IT intervention has the potential to prevent uptake of smoking among adolescents. However, there is a particular need for evaluating the effectiveness of the revised X:IT intervention, X:IT II, with focus on the effect across socioeconomic groups of adolescents. TRIAL REGISTRATION: Current Controlled Trials ISRCTN31292019 , date of registration 24/10/2017. Retrospectively registered.

Patients' views on usefulness and effects of a risk communication tool for cardiovascular disease: a qualitative analysis.

BACKGROUND: Failing to comprehend risk communication might contribute to poor treatment adherence. Using hypertension as a case, we investigated how a risk communication tool for patients with an elevated risk of cardiovascular disease was perceived. METHODS: As part of a large project featuring a randomised controlled trial in a general practice setting in the Region of Southern Denmark, we conducted a semi-structured individual interview study. The study included patients with hypertension who had used an intervention comprising a visual and dynamic cardiovascular risk communication tool, along with receiving recurring emails providing advice on a healthy lifestyle. The analyses were based on Malterud's Systematic Text Condensation. RESULTS: This article focuses solely on the results of the interview study, which comprised a total of 9 conducted and analysed interviews. The IT setup had a major impact on adherence to the intervention. A positive impact was found when the IT setup was perceived as easy to use and accessible, while a negative impact was noted when it malfunctioned. The intervention increased patients' self-reported insight into risk of cardiovascular disease. Patients reported the intervention and their risk of cardiovascular disease to become less important to them when they had more severe comorbidities. The involved health professional was very important for treatment adherence when communicating risk visually. Patients expressed trust in their general practitioners, and the general practitioners' attitudes toward the intervention affected patients' perceptions of its usefulness. While the informants reported an increased awareness of their risk of cardiovascular disease, none of them felt more concerned. CONCLUSIONS: Patients reported an increase in their perceived insight into the risk of cardiovascular disease but not an increased concern. Our findings align with previous studies emphasizing the importance of patients' motivation as well as risk perception for adherence. General practitioners have an important role when implementing new tools for patients.

Sensory impairments and the risk of cognitive decline and dementia across sex, age, and regions: Longitudinal insights from Europe.

BACKGROUND: In aging populations, understanding predictors of cognitive decline is essential. We aimed to investigate the risk of cognitive decline and dementia by sensory impairments across sex, age, and European regions, and examined the mediating role of activities of daily living (ADL), physical activity, and depressive symptoms. METHODS: A cohort study of 72,287 Europeans aged 50+ participating in at least two waves of the Survey of Health, Ageing and Retirement in Europe. We employed mixed-effects and time-to-event models, incorporating sex interactions, and adjusting for socio-demographic factors and medical history. RESULTS: Compared to individuals with good vision and hearing, lower cognitive function was found for people with vision impairment (VI) (males: coef. -0.70, 95 % CI -0.95; -0.46; females: coef. -1.12, 95 % CI -1.33; -0.92), hearing impairment (HI) (males: coef. -0.64, 95 % CI -0.93; -0.35; females: coef. -0.96, 95 % CI -1.27; -0.65) and dual sensory impairment (DSI, i.e. VI and HI) (males: coef. -1.81, 95 % CI -2.16; -1.46; females: coef. -2.71, 95 % CI -3.05; -2.38), particularly among females. Moreover, higher dementia risk was observed among participants with VI (hazard ratio (HR) 1.29, 95 % CI 1.17; 1.43), HI (HR 1.18, 95 % CI 1.05; 1.34), and DSI (HR 1.62, 95 % CI 1.45; 1.81) with no sex-interactions. Findings were overall consistent across age and European regions. CONCLUSION: The results suggest the necessity of preventing sensory impairments to maintain good cognitive function. Mitigating depressive symptoms, ADL limitations, and physical inactivity could potentially reduce a significant portion of the total effect of sensory impairments on cognitive decline.

Barriers for continuous medical education: a cross-sectional questionnaire study among Danish GPs.

BACKGROUND: GPs' participation in continuous medical education (CME) is essential for patient care, GPs' wellbeing, and healthcare expenditure. However, one-quarter of Danish GPs did not use their reimbursement for CME in 2022. Knowledge of barriers for participating in CME is limited. AIM: To analyse the barriers GPs face to participation in CME, and patterns in perceived barriers. DESIGN & SETTING: A cross-sectional questionnaire study design was used. The study population comprised all 3257 GPs in Denmark who, in May 2023, were registered as entitled to reimbursement for CME. METHOD: The response rate was n = 1303/3257 (40%). Based on a question about use of CME, the responders were divided into 'frequent', 'partial', and 'seldom' users. Partial and seldom users answered questions about barriers related to CME (n = 726). The presence of barriers was quantified, and a latent class analysis (LCA) was used to stratify GPs according to their barrier patterns. RESULTS: The most frequent barriers were as follows: too busy (67%); fully booked courses (45%); and no substitute or locum doctor (39%). Based on the LCA, we found three distinctive patterns, clustering around the following: GPs from clinics with no tradition for CME (class 1, 17%); GPs who used time on professional work outside clinic (teaching, organisational work) (class 2, 43%); and GPs who were personally or professionally affected (class 3, 40%). Singled-handed and male GPs were slightly overrepresented among seldom users. CONCLUSION: We have identified barriers for CME. We found three different profiles of GPs who perceived different patterns of barriers. Identified patterns in barriers should be considered in future CME initiatives.

Reflection in the training of general practitioners in clinical practice settings: a scoping review protocol.

OBJECTIVE: The objective of this scoping review is to explore formalized methods of reflection that are used in clinical settings in general practice when training medical students, postgraduate trainees, general practitioners, and family physicians. INTRODUCTION: Medical professionals are increasingly required to demonstrate competency in their ability to reflect on clinical practice. To accommodate this, the teaching of reflection is common in medical programs; however, there is a lack of clarity in the literature on how reflection is taught. INCLUSION CRITERIA: This review will seek evidence describing the tools and approaches to reflection used by medical students, postgraduate trainees, and other registered medical professionals in general practice. The review will also include any evidence from those who teach reflection in a general practice setting. Evidence regarding reflection in training programs for other medical specialties will not be considered for inclusion. METHODS: This review will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR), and the JBI methodology for scoping reviews. Databases to be searched will include MEDLINE (Ovid), Emcare (Ovid), Embase (Ovid), Web of Science, Scopus, and the Cochrane Database of Systematic Reviews. Extracted evidence will be presented using figurative, tabular, and accompanying narrative synthesis, in line with the review questions. REVIEW REGISTRATION NUMBER: Open Science Framework https://osf.io/uxw7d.

An evaluation of the 18- and 12-month basic postgraduate training programmes in Denmark.

INTRODUCTION: It was decided that the Danish 18-month internship training should be replaced by a 12-month postgraduate training period including six months of employment at a hospital ward and six months at a general practice/hospital ward. This study examines how the physicians from the old and new programmes evaluate their training, and it explores their attitudes towards the new postgraduate training programme. MATERIAL AND METHODS: We developed a questionnaire by which quantitative and qualitative data were collected. The questionnaire was sent to all physicians following basic postgraduate training in 2009. A total of 1,034 doctors were invited to answer the questionnaire. One quarter of these followed the 12-month programme and three quarters followed the 18-month programme. The response rate was 66%. RESULTS: Doctors following the new 12-month programme felt less professionally equipped and less ready for continued specialisation than doctors of the 18-month programme and they requested a downward adjustment of the learning objectives associated with the educational positions which follow their basic training. Physicians do not expect the increased focus on learning and supervision to compensate for the six-month reduction of the training period. Internal medicine should be included in the basic postgraduate training of all physicians. Training in secondary as well as primary health care was requested. CONCLUSION: The young physicians were reluctant towards the new basic postgraduate training programme.

The role of general practice in postgraduate basic training.

BACKGROUND: In recent years, there has been growing interest in the role of primary care in postgraduate training. Relatively little has been published about benefits of early and sustained postgraduate basic training in general practice, especially for doctors with other ambitions than family medicine. AIM: To explore young Danish doctors' views on basic medical training including views on the participation of general practice. METHODS: We conducted a cross-sectional survey of all Danish doctors, who took part in the postgraduate basic training programmes in 2009. The survey consisted of rating scale and qualitative questions. We used a phenomenological approach. RESULTS: Almost all of the young Danish doctors responding felt that training in general practice is a necessary part of a postgraduate basic training programme. Early training in primary care not only gives doctors a broad understanding of the health care system but also strengthens the ability to collaborate with general practitioners upon entering another specialty. It also develops important medical and communicative competences. The training in general practice is considered beneficial for the development of professional identity. The educational environment in general practice is rated highly. CONCLUSION: The inclusion of family medicine in postgraduate basic training should be considered for all doctors.

Danish Evaluation of Your Heart Forecast (DANY): study protocol for a cluster randomised controlled trial on an interactive risk-communication tool aimed at improving adherence of patients with high blood pressure.

BACKGROUND: To improve communication of risk messages, they must be communicated in a way that is understandable and relevant to the patient. Communicating risk of cardiovascular disease is a complex and individualised task, since the risk itself is a combination of multiple personal risk factors. Raised blood pressure is but one of these risk factors. In Denmark, only one-third of hypertensive patients are adequately treated, with regards to national clinical guidelines. One reason for this problem is low treatment adherence; tools with documented effects for increasing adherence of patients are limited. Our objective is to evaluate the effect of a personalised, interactive and dynamic risk-assessment and risk-communication tool: 'Your Heart Forecast' (YHF) on blood pressure control, primary non-compliance, health literacy and patient empowerment. METHODS: Cluster-randomised controlled trial in general practice. Effect measures are adherence, blood pressure, lipid levels and empowerment at inclusion and after 6 and 12 months. To identify other benefits or possible adverse effects of the intervention, qualitative interviews will be conducted with a subgroup of patients. DISCUSSION: The investigators will explore effects of Your Heart Forecast on patients' health literacy, adherence, empowerment and blood pressure control. The DANish evaluation of Your heart forecast (DANY) project will be the first to rigorously evaluate effects of YHF in Denmark and to link adherence of hypertensive patients exposed to YHF with the national databases of prescriptions and health services provided. TRIAL REGISTRATION: Clinicaltrials.gov, NCT04058847. Registered on 16 August 2019.

Incidence of rheumatoid arthritis from 1995 to 2001: impact of ascertainment from multiple sources.

The aim of this study was to describe the mean incidence rate of rheumatoid arthritis over a 7-year period from 1995 to 2001 in a population in the southern part of Denmark, using the data from several sources. Cases fulfilling the 1987 American College of Rheumatology criteria for rheumatoid arthritis were identified at hospitals and private practising rheumatologists (referral centres), and in general practice. The observed incidence was 32/100,000 person-years (95% confidence interval 29-35). Using the ratio between the number of cases known only from general practice and the number known from general practice and referral centres, the estimated incidence was 35/100,000 person-years (95% confidence interval 32-38). We suggest that the estimated rate should be viewed as a plausible upper limit for the incidence of rheumatoid arthritis in the southern part of Denmark.

Why do Danish junior doctors choose general practice as their future specialty? Results of a mixed-methods survey.

Background: A well-staffed and an efficient primary healthcare sector is beneficial for a healthcare system but some countries experience problems in recruitment to general practice. Objectives: This study explored factors influencing Danish junior doctors' choice of general practice as their specialty. Methods: This study is based on an online questionnaire collecting quantitative and qualitative data. Two focus-group interviews were conducted to inform the construction of the questionnaire to ensure high content validity. All Danish junior doctors participating in general practice specialist training in 2015 were invited to participate in the survey, from which both qualitative and quantitative data were collected. The data was analysed using systematic text condensation and descriptive statistics. Results: Of 1099 invited, 670 (61%) junior doctors completed the questionnaire. Qualitative data: junior doctors found educational environments and a feasible work-life balance were important. They valued patient-centred healthcare, doctor-patient relationships based on continuity, and the possibility of organizing their work in smaller, manageable units. Quantitative data: 90.8% stated that the set-up of Danish specialist-training programme positively influenced their choice of general practice as their specialty. Junior doctors (80.4%) found that their university curriculum had too little emphasis on general practice, 64.5% agreed that early basic postgraduate training in general practice had a high impact on their choice of general practice as their specialty. Conclusion: Several factors that might positively affect the choice of general practice were identified. These factors may hold the potential to guide recruitment strategies for general practice.

A new comprehensive model for Continuous Professional Development.

BACKGROUND: It is generally agreed that continuing professional development (CPD) for GPs is important for quality of care. Internationally, however, different approaches to identify the learning objectives and the CPD content have been chosen. OBJECTIVES: To improve GPs' CPD in Denmark we explore how general practitioners' (GPs) self-experienced learning needs can be combined with learning needs experienced from a societal perspective and still make sense for GPs. METHODS: We performed a multi-dimensional learning needs analysis with a modified Delphi method in a participatory action research set-up. Twenty practice-based small learning groups and a group appointed by the Danish public health service were asked to identify learning needs with the Danish family medicine curriculum as reference. Then we asked a group of GP researchers and hospital consultants, a group of GPs with interests in narrative, person-centred medicine and a group of GP educators, and administrative staff, to triangulate the initial findings. RESULTS: We identified educational themes through a defined collaborative consensus oriented process. Examples of themes are the diagnostic challenge, care for patients with multi-morbidity, elderly patients and children. Due to variation in requested learning objectives, the identified themes do not cover all relevant areas for CPD training. The identified themes will only make sense if seen as supplementary to other CPD activities based on GPs individual needs analyses. CONCLUSION: It is possible to identify prioritized educational themes for GPs through a process involving the majority of stakeholders. Nevertheless, CPD should also include activities based on individual needs analysis. [Box: see text].

Using an online portfolio in postgraduate training.

This study describes the introduction of an online portfolio in postgraduate medical training in Family Medicine. An online questionnaire collecting quantitative and qualitative data was sent to 90 GP trainees of whom 65 responded. A phenomenological analysis method was applied to the data. The portfolio supported the trainees' ability to monitor their own clinical progress providing a better focus on learning objectives. It was helpful in the organization of the training programme and in the formation of individual personal knowledge. Reflection was stimulated, especially concerning complex and difficult clinical situations and it was used as a point of departure for trainee-trainer discussions. Trainees preferred an online portfolio to pen and paper. The degree of educational support was experienced differently. Obstacles were lack of time, lack of trainer support, inappropriate IT facilities, lack of proper introduction and lack of personal motivation.