Defensive medicine in Danish general practice. Types of defensive actions and reasons for practicing defensively.

OBJECTIVE: To examine the occurrence of and types of defensive medicine (DM), and the reasons for practicing DM in general practice. DESIGN: Prospective survey registration of consecutive consultations regarding defensive medicine defined as: Actions that are not professionally well founded but are carried out due to demands and pressure. The GPs registered the degree of defensiveness, the type(s) of defensive action(s) and the reason(s) for acting defensively. SETTING: Danish general practice. SUBJECTS: A total of 26 GPs registered a total of 1,758 consultations. MAIN OUTCOME MEASURES: Defensive medical actions. RESULTS: Defensive actions were performed in 12% (210/1749) of all consultations. A fifth (46/210) of the defensive actions were characterised by the GPs as 'moderately' or 'highly' defensive. Frequent types of defensive actions were: blood tests, point-of-care-tests (POCTs) and referrals. Common reasons for defensive actions were: Influence from patients, 37% (78/210), concerns of overlooking severe disease, 32% (67/210) and influence from patient relatives, 12% (25/210). CONCLUSION: Danish GPs registered self-perceived defensive actions in a prospective survey. DM was carried out in one out of eight consultations, most often due to patient influence. The most frequent defensive actions were blood tests, POCTs and referrals.

Associations between degrees of task delegation and adherence to COPD guidelines on spirometry testing in general practice - a national cross-sectional study.

BACKGROUND: The healthcare systems in the western world have in recent years faced major challenges caused by demographic changes and altered patterns of diseases as well as political decisions influencing the organisation of healthcare provisions. General practitioners are encouraged to delegate more clinical tasks to their staff in order to respond to the changing circumstances. Nevertheless, the degree of task delegation varies substantially between general practices, and how these different degrees affect the quality of care for the patients is currently not known. Using chronic obstructive pulmonary disease (COPD) as our case scenario, the aim of the study was to investigate associations between degrees of task delegation in general practice and spirometry testing as a measure of quality of care. METHODS: We carried out a cross-sectional study comprising all general practices in Denmark and patients suffering from chronic obstructive pulmonary disease. General practitioners (GPs) were invited to participate in a survey investigating degrees of task delegation in their clinics. Data were linked to national registers on spirometry testing among patients with COPD. We investigated associations using multilevel mixed-effects logit models and adjusted for practice and patient characteristics. RESULTS: GPs from 895 practices with staff managing COPD-related tasks responded, and 61,223 COPD patients were linked to these practices. Hereof, 24,685 (40.3%) had a spirometry performed within a year. Patients had a statistically significant higher odds ratio (OR) of having an annual spirometry performed in practices with medium or maximal degrees of task delegation compared to practices with a minimal degree (OR = 1.27 and OR = 1.33, respectively). CONCLUSION: Delegating more complex tasks to practice staff implies that COPD-patients are more likely to be treated according to evidence-based recommendations on spirometry testing.

General practitioners' attitudes towards and experiences with referrals due to supplemental health insurance.

Background: Supplemental health insurances (SHI) cover 38% of the Danish population. SHI can give faster access to, and additional treatment from, private health providers. However, this is contingent on a referral from the general practitioner (GP), further complicating clinical decision-making. Objectives: To describe GPs' attitudes to SHI and their experiences with patients holding SHI. Moreover, we analysed associations between different GP characteristics; e.g. gender, age, practice type, own SHI status and their attitudes to and experiences with SHI. Methods: A questionnaire was mailed to 3321 GPs focusing on three issues: (i) Attitudes towards the public health care system. (ii) Perceptions of the impact of SHI. (iii) Experiences with patients holding SHIs. Results: The response rate was 64%. Overall, GPs found that SHIs contribute to inequality (83%) and overtreatment (90%). However, 46% often feel under pressure to refer SHI patients to specialist care, even though not medically indicated, while 11% always or often refer SHI patients unconditionally. Both groups perceive SHI patients more insistent on getting referrals than patients without SHI. Conclusion: Even though a majority of GPs associate SHI with overtreatment and inequality in health, many GPs feel under pressure to refer patients holding SHI for treatments or examinations that are not medically warranted. Some GPs even refer these patients without further examination or questioning. Insistent SHI patients may partly explain this paradox. Future research should illuminate SHI patients' courses in the private as well as the public healthcare system with regards to medical indications and health outcome measures focusing on inequality and overtreatment.

Work motivation, task delegation and job satisfaction of general practice staff: a cross-sectional study.

Background: Recent research has shown that a high degree of task delegation is associated with the practise staff's overall job satisfaction, and this association is important to explore since job satisfaction is related to medical as well as patient-perceived quality of care. Objectives: This study aimed: (1) to investigate associations between degrees of task delegation in the management of chronic disease in general practice, with chronic obstructive pulmonary disease (COPD) as a case and the staff's work motivation, (2) to investigate associations between the work motivation of the staff and their job satisfaction. Methods: The study was based on a questionnaire to which 621 members of the practice staff responded. The questionnaire consisted of a part concerning degree of task delegation in the management of COPD in their respective practice and another part being about their job satisfaction and motivation to work. Results: In the first analysis, we found that 'maximal degree' of task delegation was significantly associated with the staff perceiving themselves to have a large degree of variation in tasks, odds ratio (OR) = 4.26, confidence interval (CI) = 1.09, 16.62. In the second analysis, we found that this perceived large degree of variation in tasks was significantly associated with their overall job satisfaction, OR = 2.81, confidence interval = 1.71, 4.61. Conclusion: The results suggest that general practitioners could delegate highly complex tasks in the management of COPD to their staff without influencing the staff's work motivation, and thereby their job satisfaction, negatively, as long as they ensure sufficient variation in the tasks.

Associations between degrees of task delegation and job satisfaction of general practitioners and their staff: a cross-sectional study.

BACKGROUND: In recent years, the healthcare system in the western world has undergone a structural development caused by changes in demography and pattern of disease. In order to maintain the healthcare system cost-effective, new tasks are placed in general practice urging the general practitioners to rethink the working structure without compromising the quality of care. However, there is a substantial variation in the degree to which general practitioners delegate tasks to their staff, and it is not known how these various degrees of task delegation influence the job satisfaction of general practitioners and their staff. METHODS: We performed a cross-sectional study based on two electronic questionnaires, one for general practitioners and one for their staff. Both questionnaires were divided into two parts, a part exploring the degree of task delegation regarding management of patients with chronic obstructive pulmonary disease in general practice and a part concerning the general job satisfaction and motivation to work. RESULTS: We found a significant association between perceived "maximal degree" of task delegation in management of patients with chronic obstructive pulmonary disease and the staff's overall job satisfaction. The odds ratio of the staff's satisfaction with the working environment displayed a tendency that there is also an association with "maximal degree" of task delegation. In the analysis of the general practitioners, the odds ratios of the results indicate that there is a tendency that "maximal degree" of task delegation is associated with overall job satisfaction, satisfaction with the challenges in work, and satisfaction with the working environment. CONCLUSIONS: We conclude that a high degree of task delegation is significantly associated with overall job satisfaction of the staff, and that there is a tendency that a high degree of task delegation is associated with the general practitioners' and the staff's satisfaction with the working environment as well as with general practitioners' overall job satisfaction and satisfaction with challenges in work. To qualify future delegation processes within general practice, further research could explore the reasons for our findings.

Variation in general practitioners' information-seeking behaviour - a cross-sectional study on the influence of gender, age and practice form.

OBJECTIVE: To assess general practitioners' (GPs') information-seeking behaviour and perceived importance of sources of scientific medical information and to investigate associations with GP characteristics. DESIGN: A national cross-sectional survey was distributed electronically in December 2013. SETTING: Danish general practice. SUBJECTS: A population of 3440 GPs (corresponding to approximately 96% of all Danish GPs). MAIN OUTCOME MEASURES: GPs' use and perceived importance of information sources. Multilevel mixed-effects logit models were used to investigate associations with GP characteristics after adjusting for relevant covariates. RESULTS: A total of 1580 GPs (46.4%) responded to the questionnaire. GPs' information-seeking behaviour is associated with gender, age and practice form. Single-handed GPs use their colleagues as an information source significantly less than GPs working in partnership practices and they do not use other sources more frequently. Compared with their younger colleagues, GPs aged above 44 years are less likely to seek information from colleagues, guidelines and websites, but more likely to seek information from medical journals. Male and female GPs seek information equally frequently. However, whereas male GPs are more likely than female GPs to find that pharmaceutical sales representative and non-refundable CME meetings are important, they are less likely to find that colleagues, refundable CME meetings, guidelines and websites are important. CONCLUSION: Results from this study indicate that GP characteristics should be taken into consideration when disseminating scientific medical information, to ensure that patients receive medically updated, high-quality care. KEY POINTS Research indicates that information-seeking behaviour is associated with GP characteristics. Further insights could provide opportunities for targeting information dissemination strategies. Single-handed GPs seek information from colleagues less frequently than GPs in partnerships and do not use other sources more frequently. GPs aged above 44 years do not seek information as frequently as their younger colleagues and prefer other information sources. Male and female GPs seek information equally frequently, but do not consider information sources equally important in keeping medically updated.

Are formalised implementation activities associated with aspects of quality of care in general practice? A cross-sectional study.

BACKGROUND: There is a substantial variation in how different general practices manage knowledge implementation, including the degree to which activities are collectively and formally organised. Yet, it is unclear how these differences in implementation activities affect quality of care. AIM: To investigate if there are associations between specific formalised knowledge implementation activities and quality of care in general practices, exemplified by the use of spirometry testing. DESIGN & SETTING: A nationwide cross-sectional study combining survey and register data in Denmark. METHOD: An electronic questionnaire was distributed to GPs, and data on spirometry testing among first-time users of medication against obstructive lung diseases were obtained from national registers. Associations were investigated using multilevel mixed-effect logit models. RESULTS: GPs from 1114 practices (58%) responded, and 33 788 patients were linked to a responding practice. In partnership practices, the frequency of interdisciplinary and GP meetings affected the quality of care. Interdisciplinary and GP meetings held on a weekly basis were significantly associated with a higher level of quality of care and this was measured by the odds ratio (OR) of patients having spirometry. The development of practice protocols and standard recordings in the electronic medical record (EMR) for a range of disease areas compared with few or no areas at all also impacted the quality of care level provided. The effect of formalised implementation activities was not as evident in single-handed practices as in partnerships. CONCLUSION: This study provides valuable knowledge for GPs who aim to organise their practice in a way that supports implementation and quality improvement most effectively. Also, results may be useful for managers of implementation strategies and quality improvement initiatives when planning future activities.

Accreditation in general practice in Denmark: study protocol for a cluster-randomized controlled trial.

BACKGROUND: Accreditation is used increasingly in health systems worldwide. However, there is a lack of evidence on the effects of accreditation, particularly in general practice. In 2016 a mandatory accreditation scheme was initiated in Denmark, and during a 3-year period all practices, as default, should undergo accreditation according to the Danish Healthcare Quality Program. The aim of this study is primarily to evaluate the effects of a mandatory accreditation scheme. METHODS/DESIGN: The study is conducted as a cluster-randomized controlled trial among 1252 practices (clusters) with 2211 general practitioners in Denmark. Practices allocated to accreditation in 2016 serve as the intervention group, and practices allocated to accreditation in 2018 serve as controls. The selected outcomes should meet the following criteria: (1) a high degree of clinical relevance; (2) the possibility to assess changes due to accreditation; (3) availability of data from registers with no self-reporting data. The primary outcome is the number of prescribed drugs in patients older than 65 years. Secondary outcomes are changes in outcomes related to other perspectives of safe medication, good clinical practice and mortality. All outcomes relate to quality indicators included in the Danish Healthcare Quality Program, which is based on general principles for accreditation. DISCUSSION: The consequences of accreditation and standard-setting processes are generally under-researched, particularly in general practice. This is the largest study in general practice with a randomized implementation approach to evaluate the clinical effects of a nation-wide mandatory accreditation scheme in general practice. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02762240 . Registered on 24 May 2016.