Implementation of immunochemical faecal occult blood test in general practice: a study protocol using a cluster-randomised stepped-wedge design.

BACKGROUND: Colorectal cancer is a common malignancy and a leading cause of cancer-related death. Half of patients with colorectal cancer initially present with non-specific or vague symptoms. In the need for a safe low-cost test, the immunochemical faecal occult blood test (iFOBT) may be part of the evaluation of such patients in primary care. Currently, Danish general practitioners have limited access to this test. The aim of this article is to describe a study that will assess the uptake and clinical use of iFOBT in general practice. Furthermore, it will investigate the diagnostic value and the clinical implications of using iFOBT in general practice on patients presenting with non-alarm symptoms of colorectal cancer. METHODS/DESIGN: The study uses a cluster-randomised stepped-wedge design and is conducted in the Central Denmark Region among 836 GPs in 381 general practices. The municipalities of the Region and their appertaining general practitioners will be included sequentially in the study during the first 7 months of the 1-year study period. The following intervention has been developed for the study: a mandatory intervention providing all general practitioners with a starting package of 10 iFOBTs, a clinical instruction on iFOBT use in general practice and online information material from the date of inclusion, and an optional intervention consisting of a continuous medical education on colorectal cancer diagnostics and use of iFOBT. DISCUSSION: This study is among the first and largest trials to investigate the diagnostic use and the clinical value of iFOBT on patients presenting with non-alarm symptoms of colorectal cancer. The findings will be of national and international importance for the future planning of colorectal cancer diagnostics, particularly for 'low-risk-but-not-no-risk' patients with non-alarm symptoms of colorectal cancer. TRIAL REGISTRATION: A Trial of the Implementation of iFOBT in General Practice NCT02308384 . Date of registration: 26 November 2014.

The effect of an active implementation of a disease management programme for chronic obstructive pulmonary disease on healthcare utilization--a cluster-randomised controlled trial.

BACKGROUND: The growing population living with chronic conditions calls for efficient healthcare-planning and effective care. Implementing disease-management-programmes is one option for responding to this demand. Knowledge is scarce about the effect of implementation processes and their effect on patients; only few studies have reported the effectiveness of disease-management-programmes targeting patients with chronic obstructive pulmonary disease (COPD). The objective of this paper was to determine the effect on healthcare-utilization of an active implementation model for a disease-management-programme for patients with one of the major multimorbidity diseases, COPD. METHODS: The standard implementation of a new disease-management-programme for COPD was ongoing during the study-period from November 2008 to November 2010 in the Central Denmark Region. We wanted to test a strategy using Breakthrough Series, academic detailing and lists of patients with COPD. It targeted GPs and three hospitals serving approx. 60,000 inhabitants aged 35 or older and included interventions directed at professionals, organisations and patients. The study was a non-blinded block- and cluster-randomised controlled trial with GP-practices as the unit of randomisation. In Ringkoebing-Skjern Municipality, Denmark, 16 GP-practices involving 38 GPs were randomised to either the intervention-group or the control-group. A comparable neighbouring municipality acted as an external-control-group which included nine GP-practices with 25 GPs. An algorithm based on health-registry-data on lung-related contacts to the healthcare-system identified 2,736 patients who were alive at the end of the study-period. The population included in this study counted 1,372 (69.2%) patients who responded to the baseline questionnaire and confirmed their COPD diagnosis; 458 (33.4%) patients were from the intervention-group, 376 (27.4%) from the control-group and 538(39.2%) from the external-control-group. The primary outcome was adherence to the disease-management-programme measured at patient-level by use of specific services from general practice. Secondary outcomes were use of out-of-hours-services, outpatient-clinic, and emergency-department and hospital-admissions. RESULTS: The intervention practices provided more planned preventive consultations, additional preventive consultations and spirometries than non-intervention practices. A comparison of the development in the intervention practices with the development in the control-practices showed that the intervention resulted in more planned preventive-consultations, fewer conventional consultations and fewer patients admitted without a lung-related-diagnosis. CONCLUSIONS: Use of the active implementation model for the disease-management-programme for COPD changed the healthcare utilization in accordance with the programme. TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT01228708.

Use of hyperlinks in electronic test result communication: a survey study in general practice.

BACKGROUND: Information is essential in healthcare. Recording, handling and sharing healthcare information is important in order to ensure high quality of delivered healthcare. Information and communication technology (ICT) may be a valuable tool for handling these challenges. One way of enhancing the exchange of information could be to establish a link between patient-specific and general information sent to the general practitioner (GP). The aim of the present paper is to study GPs' use of a hyperlink inserted into electronic test result communication. METHODS: We inserted a hyperlink into the electronic test result communication sent to the patients' GPs who participated in a regional, systematic breast cancer screening program. The hyperlink target was a web-site with information on the breast cancer screening program and breast cancer in general. Different strategies were used to increase the GPs' use of this hyperlink. The outcome measure was the GPs' self-reported use of the link. Data were collected by means of a one-page paper-based questionnaire. RESULTS: The response rate was 73% (n=242). In total, 108 (45%) of the GPs reported to have used the link. In all, 22% (n=53) of the GPs used the web-address from a paper letter and 37% (n=89) used the hyperlink in the electronic test result communication (Δ = 15%[95%confidence int erval(CI) = 8 - 22%P < 0.001]). We found no statistically significant associations between use of the web-address/hyperlink and the GP's gender, age, or attitude towards mammography screening. CONCLUSIONS: The results suggest that hyperlinks in electronic test result communication could be a feasible strategy for combining and sharing different types of healthcare information.

Socioeconomic position and place of death of cancer patients.

OBJECTIVE: Most terminally ill patients and relatives prefer care and death to occur at home. However, in many cases patients die in hospital and the question arises whether social inequity in palliative care exists. The aim of this study was to analyse associations between dying at home and demographic and socioeconomic characteristics adjusted for healthcare utilisation among Danish cancer patients. METHOD: Population-based, cross-sectional register study in Aarhus County, Denmark. 599 deceased adults who died from cancer from 1 March to 30 November 2006 in a well-defined geographical area were identified. Based on unique personal identifier numbers, socioeconomic data and healthcare utilisation from different registers were retrieved and analysed. RESULTS: Multivariate analysis showed that dying at home was negatively associated with, first, being either 50-59 (prevalence ratio (PR): 0.67 (95% CI 0.45 to 0.99)) or 70-79 years of age (PR: 0.83 (95% CI 0.70 to 0.99)) compared with being 80 years or above; second, a middle personal income compared with a high income (PR: 0.86 (95% CI 0.75 to 1.00)); and, third, being employed or having a leadership position compared with being unemployed/student/receiving social security (PR: 0.72 (95% CI 0.53 to 0.98)). CONCLUSION: The found socioeconomic differences in whether death occurred at home or at institutions indicate that age, income and social class must be taken into account when palliative care services engage in fulfilling preferences of dying at home. This may lead to more equality in the possibility of dying at home, despite differences in socioeconomic level.

Complicated grief and need for professional support in family caregivers of cancer patients in palliative care: a longitudinal cohort study.

OBJECTIVES: There is little research on complicated grief (CG) in family caregivers in palliative care. The aim of the study was to assess the levels of complicated grief and depression in family caregivers after the death of a relative with cancer, to identify their need for support, to compare the palliative team staff's risk assessment of the relatives' grief reaction with measured levels of CG and depression, and to assess the use of bereavement support. METHODS: All 114 eligible family caregivers to deceased patients treated in a palliative care unit in the year 2006 were asked to participate in the study, and 87 (77%) accepted. The participants completed a postal questionnaire 2, 6, 13, and 18 months after the loss measuring complicated grief (Inventory of Complicated Grief, Revised), depression (Beck's Depression Inventory II), and their use of bereavement services. The palliative team staff completed a form 1 month post-loss with their clinical risk assessment of the family caregivers' levels of complicated grief and need for support. RESULTS: The prevalence of moderate to severe depression and CG was 15% and 40%, respectively, at 6 months post-loss. Professional risk assessment showed a sensitivity of 55% for CG and of 27% for depression and a specificity of 86% for depression and 63% for CG. The positive predictive value was 27% for depression and 21% for CG. Use of bereavement services was observed in 36% of the cases at 6 months after the loss. The proportion of bereaved with CG or depression at 6 months who had received bereavement services was 47% and 64%, respectively. CONCLUSIONS: The results suggest that a substantial number of family caregivers of diseased palliative care patients are at risk of developing CG and depression following their loss. While early identification of those at risk of developing CG could be helpful, the risk assessment of professionals may lack in precision. The results indicate that bereavement services could be utilized in a more targeted and perhaps more efficient manner. Guidelines for bereavement planning in palliative care are indicated.

Does the organizational structure of health care systems influence care-seeking decisions? A qualitative analysis of Danish cancer patients' reflections on care-seeking.

OBJECTIVE: The absence of a more significant improvement in cancer survival in countries such as the UK and Denmark may be partly rooted in delayed care-seeking among cancer patients. Past research on patient delay has mainly focused on patient characteristics (e.g. sociodemographic and psychological factors and symptom recognition) as causes of delayed care-seeking, while few studies have examined how the organizational structure of health care systems may influence patients' reflections on seeking care. The aim of this study was to explore this relationship. DESIGN: The analysis presented is based on semi-structured interviews with 30 cancer patients and their families. RESULTS: The article raises two hypotheses on the relationship between structural elements of a health care system and people's reflections on seeking health care: (1) Gatekeeping introduces an asymmetrical relationship between the patient and the GP which potentially results in self-restricting care-seeking, (2) Continuity in the doctor-patient relationship may negatively influence patient reflections on access to health care, as the focus shifts from the medical issues of the consultation to reflections on how to properly interact with the GP and the system in which she/he is situated. CONCLUSION: It is concluded that these hypotheses form a sound basis for further primary care research on how the organizational structure of health care systems influences patient reflections on access to medical care.

[Patients' assessment of their general practitioners--the significance of patient characteristics. General results from the DanPEP--part I]. / Patienternes vurdering af de praktiserende laeger. Overordnede resultater fra DanPEP-projektet--del I.

INTRODUCTION: Patients' experiences constitute a significant part of the quality assessment of general practice care. The aim of the present study was to examine the patients' assessment of their general practitioners (GPs) and to determine to which extent the assessments were associated with patient characteristics. MATERIAL AND METHODS: A survey among patients registered with the participating GPs assessing 23 aspects of the GP-patient relationship, medical care, information and support, organisation of care and accessibility. Analyses of associations between the assessments and patient characteristics. RESULTS: The most positively assessed aspect was confidentiality in the GPs' record keeping followed by aspects of empathy and precision, while the poorest evaluations were given to GP and practice availability by phone and amount of waiting time in the waiting room. Elderly patients, frequent attenders, patients who had a long history with the GP and patients with a good self-rated health were those who were most satisfied in general. The significance of patient gender and educational level was more complex. Patients suffering from chronic heart, endocrine or cancer diseases were more satisfied than patients without a chronic condition. CONCLUSION: Our results may be used for ongoing adjustment of care to the needs of groups of patients - while keeping in mind the individual patient's needs.

[Patients' assessment of their general practitioners--the significance of physician gender and age]. / Patienternes vurdering af de praktiserende laeger--sammenhaeng med laegens køn og alder.

INTRODUCTION: The aim of the present study was to examine to which extent the patients' assessment of their general practitioner was associated which the gender and age of the physician. MATERIAL AND METHODS: A survey among patients registered with the GPs assessing 23 aspects of the GP-patient relationship, medical care, information and support, organisation of care and accessibility. Analyses of associations between the assessments and the gender and age of the physicians. RESULTS: A total of 703 doctors participated in the study. Assessments from 56,652 patients were included in the analyses (response rate 73.1%). We found that patients perceived male physicians as more accessible than their female colleagues. The younger doctors were assessed more positively than their older colleagues on certain aspects, but the numeric differences between the groups were minor. CONCLUSION: Female general practitioners may benefit from paying more attention to the accessibility aspect. Older physicians may benefit from emphasizing their patients' need for participation, information and a sense of continuity.

[Patients' assessment of general practitioners. Association with type of practice]. / Patienternes vurdering af de praktiserende laeger: sammenhaeng med praksistype.

INTRODUCTION: This study aimed to examine if and how the patients' assessment of their general practitioner (GP) was associated with the organization of the practice, the number of listed patients and the number of staff members. MATERIAL AND METHODS: A survey among patients registered with the participating GPs assessing 23 aspects of the GP-patient relationship, medical care, information and support, organisation of care and accessibility. Analysis of the associations between the assessments and practice characteristics was performed. RESULTS: A total of 703 GPs partook in the study. Assessments from 56,652 patients were included in the analyses (response rate 67.6%). Solo practicing GPs, GPs with a short list of patients and GPs with a large staff were assessed more positively than their colleagues in other types of practices, GPs with many listed patients and GPs with a small staff. CONCLUSION: The study showed a complex association between the patient-experienced accessibility of general practice care and the number of listed patients and practice staff. Patients experienced the best accessibility in practices with few listed patients and in practices with a large staff. GPs in single-handed practices had far more positive assessments of accessibility than did GPs in partnership practices, especially availability by phone and waiting time prior to an appointment. Differences in patient list and staff between practices could not explain this finding.

Which is more important for outcome: the physician's or the patient's understanding of a health problem? A 2-year follow-up study in primary care.

OBJECTIVE: We sought to examine (1) whether the patients' and the family physicians' (FPs') beliefs about the nature of a health problem predict health outcomes and (2) whether the FPs were aware of their patients' beliefs. METHODS: A 2-year follow-up study of 38 FPs and 1131 patients presenting with well-defined physical disease (n=922) or medically unexplained symptoms (MUS) (n=209) according to the FPs was conducted. Before the consultation, patients categorized their health problem as being either physical or both physical and psychological. After the consultation, the FPs judged their patients' understanding of the health problem. Outcome measures were (1) patient satisfaction (seven-item Patient Satisfaction Consultation Questionnaire), (2) self-perceived mental and physical health (component summaries of the Medical Outcome Study's Short Form: SF-36) and (3) health care use extracted from patient registers. MAIN RESULTS: Patients with MUS according to the FPs and patients who believed that the nature of their health problem was both physical and psychological had higher health care use and worse self-rated health than patients in cases where both the FP and the patient had a physical understanding. Patients presenting MUS were more dissatisfied with the consultation than patients with well-defined physical disease. Overall, the FPs' perceptions of their patients' understanding were accurate in 82% of the consultations, but when the patients had a both physical and psychological understanding of their health problem, the FPs were right in only 26% of the consultations. CONCLUSIONS: Both FPs' diagnoses and patients' beliefs predict important health outcomes such as patient satisfaction, use of health care and self-rated health.

Qualitative description - the poor cousin of health research?

BACKGROUND: The knowledge and use of qualitative description as a qualitative research approach in health services research is limited.The aim of this article is to discuss the potential benefits of a qualitative descriptive approach, to identify its strengths and weaknesses and to provide examples of use. DISCUSSION: Qualitative description is a useful qualitative method in much medical research if you keep the limitations of the approach in mind. It is especially relevant in mixed method research, in questionnaire development and in research projects aiming to gain firsthand knowledge of patients', relatives' or professionals' experiences with a particular topic. Another great advantage of the method is that it is suitable if time or resources are limited. SUMMARY: As a consequence of the growth in qualitative research in the health sciences, researchers sometimes feel obliged to designate their work as phenomenology, grounded theory, ethnography or a narrative study when in fact it is not. Qualitative description might be a useful alternative approach to consider.

Cancer survivors' rehabilitation needs in a primary health care context.

BACKGROUND: Studies of cancer survivors' rehabilitation needs have mostly addressed specific areas of needs, e.g. physical aspects and/or rehabilitation needs in relation to specific cancer types. OBJECTIVE: To assess cancer survivors' perceived need for physical and psychosocial rehabilitation, whether these needs have been presented to and discussed with their GP. METHODS: A survey among a cohort of cancer survivors approximately 15 months after diagnosis. The questionnaire consisted of an ad hoc questionnaire on rehabilitation needs and the two validated questionnaires, the SF-12 and the Research and Treatment of Cancer quality of life questionnaire, the QLQ C-30 version 3. RESULTS: Among 534 eligible patients, we received 353 (66.1%) answers. Two-thirds of the cancer survivors had discussed physical rehabilitation needs with their GPs. Many (51%) feared cancer relapse, but they rarely presented this fear to the GP or the hospital staff. The same applied to social problems and problems within the family. Good physical and mental condition and low confidence in the GP were associated with no contact to the GP after hospital discharge. CONCLUSION: Cancer survivors have many psychosocial rehabilitation needs and intervention should effectively target these needs. If this task is assigned to the GPs, they need to be proactive when assessing psychosocial aspects.

Cancer rehabilitation: psychosocial rehabilitation needs after discharge from hospital?

OBJECTIVE: This study explores former cancer patients' psychosocial rehabilitation needs after hospital discharge. METHOD: Three focus-group interviews with 15 patients. RESULTS: Five main areas were identified: (1) Need for continuous support and information about rehabilitation opportunities; (2) Support to the family; (3) Psychological help also addressing fear of relapse of cancer; (4) Needs for social support; (5) Needs pertaining to how friends and acquaintances relate to the patients. CONCLUSION: Each of these aspects should be carefully considered for each patient, preferably by one assigned healthcare provider. Fear of cancer relapse prevails among the patients, the family and the social network and it is important in relation to psychosocial rehabilitation.

Cancer surviving patients' rehabilitation - understanding failure through application of theoretical perspectives from Habermas.

This study aims to analyze whether the rehabilitation of cancer surviving patients (CSPs) can be better organized. The data for this paper consists of focus group interviews (FGIs) with CSPs, general practitioners (GPs) and hospital physicians. The analysis draws on the theoretical framework of Jürgen Habermas, utilizing his notions of 'the system and the life world' and 'communicative and strategic action'. In Habermas' terminology, the social security system and the healthcare system are subsystems that belong to what he calls the 'system', where actions are based on strategic actions activated by the means of media such as money and power which provide the basis for other actors' actions. The social life, on the other hand, in Habermas' terminology, belongs to what he calls the 'life world', where communicative action is based on consensual coordination among individuals. Our material suggests that, within the hospital world, the strategic actions related to diagnosis, treatment and cure in the biomedical discourse dominate. They function as inclusion/exclusion criteria for further treatment. However, the GPs appear to accept the CSPs' previous cancer diagnosis as a precondition sufficient for providing assistance. Although the GPs use the biomedical discourse and often give biomedical examples to exemplify rehabilitation needs, they find psychosocial aspects, so-called lifeworld aspects, to be an important component of their job when helping CSPs. In this way, they appear more open to communicative action in relation to the CSPs' lifeworld than do the hospital physicians. Our data also suggests that the CSPs' lifeworld can be partly colonized by the system during hospitalization, making it difficult for CSPs when they are discharged at the end of treatment. This situation seems to be crucial to our understanding of why CSPs often feel left in limbo after discharge. We conclude that the distinction between the system and the lifeworld and the implications of a possible colonization during hospitalization offers an important theoretical framework for determining and addressing different types of rehabilitation needs.

[Palliation in the primary care sector--shared care]. / Palliation i primaersektoren--shared care.

Palliative homecare has been a primary care task for a long time. The introduction of palliative specialist teams has given patients with severe symptoms the possibility of getting qualified help, but has also resulted in a general tendency to exclude primary care from palliative care. Barriers to providing shared care are the organization of palliative care and the working culture of health professionals. Increased focus on shared care research is needed in order to optimise palliative home care.

A randomized controlled trial of brief training in the assessment and treatment of somatization in primary care: effects on patient outcome.

OBJECTIVE: Our aim was to evaluate the effect of an educational program designed to improve care for somatizing patients in primary care. METHOD: Evaluation was performed during routine clinical care in a cluster randomized controlled trial. Patients were included consecutively, and those with a high score on rating scales for somatization were selected for follow-up (n=911). Follow-up was conducted 3 months (response rate=0.74) and 12 months (response rate=0.69) after inclusion using questionnaires measuring quality of life (Medical Outcomes Study 36-Item Short Form), disability days (WHO's Disability Assessment Schedule), somatization (Whiteley-7 and Symptom Checklist Somatic Symptom Scale) and patient satisfaction (European Project on Patient Evaluation of General Practice Care). We analyzed differences from baseline to follow-up and compared these for intervention and control groups. RESULTS: Self-reported health improved in both intervention and control groups during follow-up for patients with a high score for somatization, but changes were small. We could not demonstrate any difference between the control group and the intervention group with regard to our primary outcome 'physical functioning.' Patients in the intervention group tended to be more satisfied at 12-month follow-up than those in the control group, but this difference fell short of statistical significance. CONCLUSION: Training of primary care physicians showed no statistically significant effect on clinical outcome and showed nonsignificant improvement in patient satisfaction with care for patients with a high score for somatization.

[The first HPV vaccine is now available]. / Nu kommer den første vaccine mod humant papillomvirus.

More than two thirds of carcinomas of the uterine cervix are caused by human papilloma virus (HPV) types 16 and 18, and 90% of all genital warts are caused by HPV 6 and 11. In June 2006, the US Food and Drug Administration accepted the first prophylactic HPV vaccine against HPV 6, 11, 16 and 18 to be offered to girls and young women. This new vaccine is also now available in Denmark. Questions concerning economics, ethics, organization, and vaccine monitoring need to be discussed in connection with the establishment of a vaccine program. In addition, information to the general population as well as to health care providers and decision-makers should have been given a high priority.

General practitioners' attitudes toward reporting and learning from adverse events: results from a survey.

OBJECTIVE: To investigate GPs' attitudes to and willingness to report and learn from adverse events and to study how a reporting system should function. DESIGN: Survey. SETTING: General practice in Denmark. MAIN OUTCOME MEASURES: GPs' attitudes to exchange of experience with colleagues and others, and circumstances under which such exchange is accepted. SUBJECTS: A structured questionnaire sent to 1198 GPs of whom 61% responded. RESULTS. GPs had a positive attitude towards discussing adverse events in the clinic with colleagues and staff and in their continuing medical education groups. The GPs had a positive attitude to reporting adverse events to a database if the system granted legal and administrative immunity to reporters. The majority preferred a reporting system located at a research institute. CONCLUSION: GPs have a very positive attitude towards discussing and reporting adverse events. This project encourages further research and pilot projects testing concrete reporting systems.