Understanding older patients' willingness to have medications deprescribed in primary care: a protocol for a cross-sectional survey study in nine European countries.

INTRODUCTION: To reduce inappropriate polypharmacy, deprescribing should be part of patients' regular care. Yet deprescribing is difficult to implement, as shown in several studies. Understanding patients' attitudes towards deprescribing at the individual and country level may reveal effective ways to involve older adults in decisions about medications and help to implement deprescribing in primary care settings. In this study we aim to investigate older adults' perceptions and views on deprescribing in different European countries. Specific objectives are to investigate the patients' willingness to have medications deprescribed by medication type and to have herbal or dietary supplements reduced or stopped, the role of the Patient Typology (on medication perspectives), and the impact of the patient-GP relationship in these decisions. METHODS AND ANALYSIS: This cross-sectional survey study has two parts: Part A and Part B. Data collection for Part A will take place in nine countries, in which per country 10 GPs will recruit 10 older patients (≥65 years old) each (n = 900). Part B will be conducted in Switzerland only, in which an additional 35 GPs will recruit five patients each and respond to a questionnaire themselves, with questions about the patients' medications, their willingness to deprescribe those, and their patient-provider relationship. For both Part A and part B, a questionnaire will be used to assess the willingness of older patients with polypharmacy to have medications deprescribed and other relevant information. For Part B, this same questionnaire will have additional questions on the use of herbal and dietary supplements. DISCUSSION: The international study design will allow comparisons of patient perspectives on deprescribing from different countries. We will collect information about willingness to have medications deprescribed by medication type and regarding herbal and dietary supplements, which adds important information to the literature on patients' preferences. In addition, GPs in Switzerland will also be surveyed, allowing us to compare GPs' and patients' views and preferences on stopping or reducing specific medications. Our findings will help to understand patients' attitudes towards deprescribing, contributing to improvements in the design and implementation of deprescribing interventions that are better tailored to patients' preferences.

General practitioners' willingness to participate in research networks in Germany.

OBJECTIVES: To investigate general practitioners' (GPs') willingness to participate in long-term medical research and in research networks (RNs). DESIGN AND SETTING: Cross-sectional survey among German GPs around Halle-Wittenberg and Leipzig in 2020. SUBJECTS: Random sample of 905 GPs. MAIN OUTCOME MEASURES AND RESULTS: Response rate 37%, 69% female. Overall, 57% were interested in participating in medical research, 34% in an active role in a RN. Interest in RN participation was positively associated with male sex, younger age, previous experiences in medical research, being involved in teaching undergraduates, and having qualification in a further specialty. Main motivators were improving patient care, giving a more realistic picture of GP care, and carrying out research on topics within their own interest areas and a reliable contact person at the leading institution. Most GPs were not afraid of reduced earnings; however, time investment was the main barrier for participation. GPs were willing to dedicate twice as much time to research when remuneration was offered. High rated topics were polypharmacy, chronic diseases, drug safety and adverse drug reactions. CONCLUSION: GPs are interested to participate in practice-based research. The study results providing useful and generalizable insights in barriers and motivators should be considered when building and running GP-RNs.KEY POINTSThere is a difference between general practitioners' (GPs') overall interest in clinical research and their job and socio-demographic related readiness to participate in research networks (RNs).GPs are interested in RNs when it is a resource of and leading to enhanced patient-oriented care.GPs are willing to dedicate twice as much time to research when remunerated.GPs need a reliable counterpart within the leading institution.

General practitioners' deprescribing decisions in older adults with polypharmacy: a case vignette study in 31 countries.

BACKGROUND: General practitioners (GPs) should regularly review patients' medications and, if necessary, deprescribe, as inappropriate polypharmacy may harm patients' health. However, deprescribing can be challenging for physicians. This study investigates GPs' deprescribing decisions in 31 countries. METHODS: In this case vignette study, GPs were invited to participate in an online survey containing three clinical cases of oldest-old multimorbid patients with potentially inappropriate polypharmacy. Patients differed in terms of dependency in activities of daily living (ADL) and were presented with and without history of cardiovascular disease (CVD). For each case, we asked GPs if they would deprescribe in their usual practice. We calculated proportions of GPs who reported they would deprescribe and performed a multilevel logistic regression to examine the association between history of CVD and level of dependency on GPs' deprescribing decisions. RESULTS: Of 3,175 invited GPs, 54% responded (N = 1,706). The mean age was 50 years and 60% of respondents were female. Despite differences across GP characteristics, such as age (with older GPs being more likely to take deprescribing decisions), and across countries, overall more than 80% of GPs reported they would deprescribe the dosage of at least one medication in oldest-old patients (> 80 years) with polypharmacy irrespective of history of CVD. The odds of deprescribing was higher in patients with a higher level of dependency in ADL (OR =1.5, 95%CI 1.25 to 1.80) and absence of CVD (OR =3.04, 95%CI 2.58 to 3.57). INTERPRETATION: The majority of GPs in this study were willing to deprescribe one or more medications in oldest-old multimorbid patients with polypharmacy. Willingness was higher in patients with increased dependency in ADL and lower in patients with CVD.

Reorganisation of GP surgeries during the COVID-19 outbreak: analysis of guidelines from 15 countries.

BACKGROUND: General practitioners (GPs) play a key role in managing the COVID-19 outbreak. However, they may encounter difficulties adapting their practices to the pandemic. We provide here an analysis of guidelines for the reorganisation of GP surgeries during the beginning of the pandemic from 15 countries. METHODS: A network of GPs collaborated together in a three-step process: (i) identification of key recommendations of GP surgery reorganisation, according to WHO, CDC and health professional resources from health care facilities; (ii) collection of key recommendations included in the guidelines published in 15 countries; (iii) analysis, comparison and synthesis of the results. RESULTS: Recommendations for the reorganisation of GP surgeries of four types were identified: (i) reorganisation of GP consultations (cancelation of non-urgent consultations, follow-up via e-consultations), (ii) reorganisation of GP surgeries (area partitioning, visual alerts and signs, strict hygiene measures), (iii) reorganisation of medical examinations by GPs (equipment, hygiene, partial clinical examinations, patient education), (iv) reorganisation of GP staff (equipment, management, meetings, collaboration with the local community). CONCLUSIONS: We provide here an analysis of guidelines for the reorganisation of GP surgeries during the beginning of the COVID-19 outbreak from 15 countries. These guidelines focus principally on clinical care, with less attention paid to staff management, and the area of epidemiological surveillance and research is largely neglected. The differences of guidelines between countries and the difficulty to apply them in routine care, highlight the need of advanced research in primary care. Thereby, primary care would be able to provide recommendations adapted to the real-world settings and with stronger evidence, which is especially necessary during pandemics.

Precipitating factors of heart failure decompensation, short-term morbidity and mortality in patients attended in primary care.

OBJECTIVE: To evaluate the precipitating factors for heart failure decompensation in primary care and associations with short-term prognosis. Design Prospective cohort study with a 30-d follow-up from an index consultation. Regression models to determine independent factors associated with hospitalisation or death. SETTING: Primary care in ten European countries. Patients Patients with diagnosis of heart failure attended in primary care for a heart failure decompensation (increase of dyspnoea, unexplained weight gain or peripheral oedema). MAIN OUTCOME MEASURES: Potential precipitating factors for decompensation of heart failure and their association with the event of hospitalisation or mortality 30 d after a decompensation. RESULTS: Of 692 patients 54% were women, mean age 81 (standard deviation [SD] 8.9) years; mean left ventricular ejection fraction (LVEF) 55% (SD 12%). Most frequently identified heart failure precipitation factors were respiratory infections in 194 patients (28%), non-compliance of dietary recommendations in 184 (27%) and non-compliance with pharmacological treatment in 157 (23%). The two strongest precipitating factors to predict 30 d hospitalisation or death were respiratory infections (odds ratio [OR] 2.8, 95% confidence interval [CI] (2.4-3.4)) and atrial fibrillation (AF) > 110 beats/min (OR 2.2, CI 1.5-3.2). Multivariate analysis confirmed the association between the following variables and hospitalisation/death: In relation to precipitating factors: respiratory infection (OR 1.19, 95% CI 1.14-1.25) and AF with heart rate > 110 beats/min (OR 1.22, 95% CI 1.10-1.35); and regarding patient characteristics: New York Heart Association (NYHA) III or IV (OR 1.22, 95% CI 1.15-1.29); previous hospitalisation (OR 1.15, 95% CI 1.11-1.19); and LVEF < 40% (OR 1.14, 95% CI 1.09-1.19). CONCLUSIONS: In primary care, respiratory infections and rapid AF are the most important precipitating factors for hospitalisation and death within 30 d following an episode of heart failure decompensation. Key points Hospitalisation due to heart failure decompensation represents the highest share of healthcare costs for this disease. So far, no primary care studies have analysed the relationship between precipitating factors and short term prognosis of heart failure decompensation episodes. We found that in 692 patients with heart failure decompensation in primary care, the respiratory infection and rapid atrial fibrillation (AF) increased the risk of short-term hospital admission or death. Patients with a hospital admission the previous year and a decompensation episode caused by respiratory infection were even more likely to be hospitalized or die within 30 d.

Short-Term Effects of a Multimodal 3-Week Inpatient Pulmonary Rehabilitation Programme for Patients with Sarcoidosis: The ProKaSaRe Study.

BACKGROUND: Real-world data on the effects of a multicomponent pulmonary rehabilitation (PR) for patients with sarcoidosis are scarce. OBJECTIVE: To describe characteristics of patients with sarcoidosis referred for a 3-week inpatient PR, to assess the effects of PR on their quality of life (QoL) and clinical outcomes, and to investigate whether there are specific subgroups who particularly benefit from PR. METHODS: Using a prospective multicentre study design, data regarding 6-min walking distance (6MWD), QoL (Saint George's Respiratory Questionnaire, SGRQ), and the secondary outcomes of dyspnoea and psychological burden (fatigue, anxiety, and depression) were collected. RESULTS: We included 296 patients in the study (average age 49.1 ± 9.7 years, 47% female, average vital capacity 3.5 ± 1.0 L [87.0 ± 20.6 predicted]). The 6MWD improved by the end of the rehabilitation by 39.8 m on average (p < 0.0001; standardised response mean, SRM = 0.61), SGRQ showed significant improvements in all 3 domains, and the total score (p < 0.001) improved by 5.69-8.28 points (SRM 0.46-0.62). For the secondary outcomes, significant improvement (p < 0.001) was seen for all measured parameters, e.g., dyspnoea (modified Medical Research Council Scale, mMRC), fatigue (Fatigue Assessment Scale [FAS]; SRM = -0.71), anxiety and depression (Hospital Anxiety and Depression Scale [HADS]; SRM -0.58/-0.38), and generic QoL (measured by the SF-36 scales of physical and mental health; SRM 0.31/0.55). CONCLUSIONS: Our results provide the first documented evidence that PR is a promising complementary therapy option for sarcoidosis patients who remain subjectively symptomatic despite optimised outpatient medical treatment.

[Health Science Research with Primary Care Routine Data From Electronic Patient Records: the BeoNet Registry]. / Gesundheitswissenschaftliche Forschung mit primärärztlichen Routinedaten der elektronischen Patientenakte: das BeoNet-Register.

Reliable current information is needed for daily patient care and the health system, but comprehensive data, especially from primary care, are scarce and/or hard to access. The BeoNet Register-Database (BNR) aims to depict quality of medical care in Germany using routine data and with no additional documentation or costs for GPs. Registry design, data structure and database use will be demonstrated using chronic obstructive lung disease (COPD) as an example. The BNR is moving through pilot- and roll-out phases. Participating practices provide standardized information about (1) master data (2) practice profile (3) infrastructure and documentation systems. The routinely documented data will be pseudonymized before transmission via standardized secure interfaces to the registry database. Practices can participate in studies in cooperation with BNR if informed consent is obtained from the patients. The registry data will be linked with questionnaires on health care utilization, quality of life and disease-specific parameters. Researchers and physicians can access quasi anonymized data in specific datasets extracted from the registry. Regular automatic data quality checks and feedback from GPs, patients and researchers enhance the quality of the registry. Performance and data analysis are continuously optimized. The data security concept has been approved and ethical approval is on hand. GPs, pediatricians and pneumologists from Hanover, Munich and Heidelberg participated in the pilot phase. The registry database currently holds 98497 patient IDs and related information. BNR contains more than the standard billing data collected by health insurers. The data are applicable to a wide range of health practices, health care and economics and disease development questions. Questionnaires have been generated, tested and are being distributed. First descriptive analyses of prevalence, age and gender have been performed. Quality and validity checks have been implemented. 2016 marks the roll-out phase of the BNR. Further recruitment of practices throughout Germany, data linkage with additional questionnaires, recruitment of patients for health care research projects, quality checks and data analysis of disease-specific costs and health-related quality of life in COPD are progressing with the overall aim of improving pulmonary healthcare strategies. The floor is now open for retro- and prospective cross-sectional and longitudinal studies.

External validation of multidimensional prognostic indices (ADO, BODEx and DOSE) in a primary care international cohort (PROEPOC/COPD cohort).

BACKGROUND: Due to the heterogeneous and systemic nature of the chronic obstructive pulmonary disease (COPD), the new guidelines are oriented toward individualized attention. Multidimensional scales could facilitate its proper clinical and prognostic assessment, but not all of them were validated in an international primary care cohort, different from the original ones used for model development. Therefore, our main aim is to assess the prognostic capacity of the ADO, BODEx and DOSE indices in primary care for predicting mortality in COPD patients and to validate the models obtained in subgroups of patients, classified by revised Global Initiative for Chronic Obstructive Lung Disease (2011) and updated Spanish Guideline (2014). Besides, we want to confirm that the prognostic capacity of all indices increases if the number of exacerbations is substituted by the interval between them and to assess the impact on health of the patient's lifestyle, social network and adherence to treatment. METHODS: Design: External validation of scales, open and prospective cohort study in primary care. SETTING: 36 health centres in 6 European high, medium and low income countries. SUBJECTS: 477 patients diagnosed with COPD, captured in clinical visit by their General Practitioner/Nurse. PREDICTORS: Detailed patient history, exacerbations, lung function test and questionnaires at baseline. OUTCOMES: Exacerbations, all-cause mortality and specific mortality, within 5 years of recruitment. ANALYSIS: Multivariate logistic regression and Cox regression will be used. Possible non-linear effect of the indices will be studied by using Structured Additive Regression models with penalised splines. Subsequently, we will assess different aspects of the regression models: discrimination, calibration and diagnostic precision. Clinical variables modulated in primary care and the interval between exacerbations will be considered and incorporated into the analysis. DISCUSSION: The Research Agenda for General Practice/Family Medicine highlights that the evidence on predictive values of prognostic indices in primary care is scarce. A prospective cohort like that of PROEPOC/COPD provides good opportunities for research into COPD and make communication easier between family practitioners, nursing staff, pneumologists and other professionals, supporting a multi-disciplinary approach to the treatment of these patients. TRIAL REGISTRATION: ISRCTN52402811 . Date: 15/01/2015. Prospectively registered.

Asthma control and health-related quality of life one year after inpatient pulmonary rehabilitation: the ProKAR Study.

OBJECTIVES: Although pulmonary rehabilitation (PR) is commonly used for asthmatics in many countries, so far there are no studies addressing the question of whether and for how long an improvement in asthma control (AC) is seen after rehabilitation. The ProKAR study (Prospektive Katamnesestudie Asthma-Rehabilitation) was performed to provide data concerning the short- and long-term impact of PR on AC. METHODS: Two-hundred one adult patients with mild to severe persistent asthma were prospectively followed one year after completion of a 3-week PR program. AC, the primary outcome parameter, and health-related quality of life (HRQoL) were monitored using the Asthma Control Test (ACT) and St. George's Respiratory Questionnaire (SGRQ) at initiation (T0) and end of the PR (T1) and 3, 6 and 12 months thereafter. Pulmonary function, physical fitness (6MWD) and asthmatic inflammation (FENO) were measured at T0 and T1. RESULTS: The proportion of patients with well-controlled asthma (ACT score ≥20) increased from 33.2% to 67.3% after PR and was still at 51% after 12 months. Slight but statistically significant improvements in pulmonary functions and an increase in 6MWD of nearly 60 m were reported at T1. One year after discharge 55.8% of the patients still showed a clinically relevant improvement of at least 4 points in the total SGRQ score. CONCLUSIONS: The multidisciplinary inpatient PR program resulted in significant short and long-term improvement in AC and HRQoL in adult asthmatic patients.

Cross-Cultural Validation of the Definition of Multimorbidity in the Bulgarian Language.

INTRODUCTION: Multimorbidity is a health issue with growing importance. During the last few decades the populations of most countries in the world have been ageing rapidly. Bulgaria is affected by the issue because of the high prevalence of ageing population in the country with multiple chronic conditions. The AIM of the present study was to validate the translated definition of multimorbidity from English into the Bulgarian language. MATERIALS AND METHODS: The present study is part of an international project involving 8 national groups. We performed a forward and backward translation of the original English definition of multimorbidity using a Delphi consensus procedure. RESULTS: The physicians involved accepted the definition with a high percentage of agreement in the first round. The backward translation was accepted by the scientific committee using the Nominal group technique. DISCUSSION: Some of the GPs provided comments on the linguistic expressions which arose in order to improve understanding in Bulgarian. The remarks were not relevant to the content. The conclusion of the discussion, using a meta-ethnographic approach, was that the differences were acceptable and no further changes were required. CONCLUSIONS: A native version of the published English multimorbidity definition has been finalized. This definition is a prerequisite for better management of multimorbidity by clinicians, researchers and policy makers.

The Use of COVID-19 Mobile Apps in Connecting Patients with Primary Healthcare in 30 Countries: Eurodata Study.

BACKGROUND: The COVID-19 pandemic has necessitated changes in European healthcare systems, with a significant proportion of COVID-19 cases being managed on an outpatient basis in primary healthcare (PHC). To alleviate the burden on healthcare facilities, many European countries developed contact-tracing apps and symptom checkers to identify potential cases. As the pandemic evolved, the European Union introduced the Digital COVID-19 Certificate for travel, which relies on vaccination, recent recovery, or negative test results. However, the integration between these apps and PHC has not been thoroughly explored in Europe. OBJECTIVE: To describe if governmental COVID-19 apps allowed COVID-19 patients to connect with PHC through their apps in Europe and to examine how the Digital COVID-19 Certificate was obtained. METHODOLOGY: Design and setting: Retrospective descriptive study in PHC in 30 European countries. An ad hoc, semi-structured questionnaire was developed to collect country-specific data on primary healthcare activity during the COVID-19 pandemic and the use of information technology tools to support medical care from 15 March 2020 to 31 August 2021. Key informants belong to the WONCA Europe network (World Organization of Family Doctors). The data were collected from relevant and reliable official sources, such as governmental websites and guidelines. MAIN OUTCOME MEASURES: Patient's first contact with health system, governmental COVID-19 app (name and function), Digital COVID-19 Certification, COVID-19 app connection with PHC. RESULTS: Primary care was the first point of care for suspected COVID-19 patients in 28 countries, and 24 countries developed apps to complement classical medical care. The most frequently developed app was for tracing COVID-19 cases (24 countries), followed by the Digital COVID-19 Certificate app (17 countries). Bulgaria, Italy, Serbia, North Macedonia, and Romania had interoperability between PHC and COVID-19 apps, and Poland and Romania's apps considered social needs. CONCLUSIONS: COVID-19 apps were widely created during the first pandemic year. Contact tracing was the most frequent function found in the registered apps. Connection with PHC was scarcely developed. In future pandemics, connections between health system levels should be guaranteed to develop and implement effective strategies for managing diseases.

Exploring the accessibility of primary health care data in Europe's COVID-19 response: developing key indicators for managing future pandemics (Eurodata study).

BACKGROUND: Primary Health Care (PHC) plays a crucial role in managing the COVID-19 pandemic, with only 8% of cases requiring hospitalization. However, PHC COVID-19 data often goes unnoticed on European government dashboards and in media discussions. This project aims to examine official information on PHC patient care during the COVID-19 pandemic in Europe, with specific objectives: (1) Describe PHC's clinical pathways for acute COVID-19 cases, including long-term care facilities, (2) Describe PHC COVID-19 pandemic indicators, (3) Develop COVID-19 PHC activity indicators, (4) Explain PHC's role in vaccination strategies, and (5) Create a PHC contingency plan for future pandemics. METHODS: A mixed-method study will employ two online questionnaires to gather retrospective PHC data on COVID-19 management and PHC involvement in vaccination strategies. Validation will occur through focus group discussions with medical and public health (PH) experts. A two-wave Delphi survey will establish a European PHC indicators dashboard for future pandemics. Additionally, a coordinated health system action plan involving PHC, secondary care, and PH will be devised to address future pandemic scenarios. ANALYSIS: Quantitative data will be analysed using STATA v16.0 for descriptive and multivariate analyses. Qualitative data will be collected through peer-reviewed questionnaires and content analysis of focus group discussions. A Delphi survey and multiple focus groups will be employed to achieve consensus on PHC indicators and a common European health system response plan for future pandemics. The Eurodata research group involving researchers from 28 European countries support the development. DISCUSSION: While PHC manages most COVID-19 acute cases, data remains limited in many European countries. This study collects data from numerous countries, offering a comprehensive perspective on PHC's role during the pandemic in Europe. It pioneers the development of a PHC dashboard and health system plan for pandemics in Europe. These results may prove invaluable in future pandemics. However, data may have biases due to key informants' involvement and may not fully represent all European GP practices. PHC has a significant role in the management of the COVID-19 pandemic, as most of the cases are mild or moderate and only 8% needed hospitalization. However, PHC COVID-19 activity data is invisible on governments' daily dashboards in Europe, often overlooked in media and public debates.

Clinical pathway of COVID-19 patients in primary health care in 30 European countries: Eurodata study.

BACKGROUND: Most COVID-19 patients were treated in primary health care (PHC) in Europe. OBJECTIVES: To demonstrate the scope of PHC workflow during the COVID-19 pandemic emphasising similarities and differences of patient's clinical pathways in Europe. METHODS: Descriptive, cross-sectional study with data acquired through a semi-structured questionnaire in PHC in 30 European countries, created ad hoc and agreed upon among all researchers who participated in the study. GPs from each country answered the approved questionnaire. Main variable: PHC COVID-19 acute clinical pathway. All variables were collected from each country as of September 2020. RESULTS: COVID-19 clinics in PHC facilities were organised in 8/30. Case detection and testing were performed in PHC in 27/30 countries. RT-PCR and lateral flow tests were performed in PHC in 23/30, free of charge with a medical prescription. Contact tracing was performed mainly by public health authorities. Mandatory isolation ranged from 5 to 14 days. Sick leave certification was given exclusively by GPs in 21/30 countries. Patient hotels or other resources to isolate patients were available in 12/30. Follow-up to monitor the symptoms and/or new complementary tests was made mainly by phone call (27/30). Chest X-ray and phlebotomy were performed in PHC in 18/30 and 23/30 countries, respectively. Oxygen and low-molecular-weight heparin were available in PHC (21/30). CONCLUSION: In Europe PHC participated in many steps to diagnose, treat and monitor COVID-19 patients. Differences among countries might be addressed at European level for the management of future pandemics.

The role of primary health care in long-term care facilities during the COVID-19 pandemic in 30 European countries: a retrospective descriptive study (Eurodata study).

BACKGROUND AND AIM: Primary health care (PHC) supported long-term care facilities (LTCFs) in attending COVID-19 patients. The aim of this study is to describe the role of PHC in LTCFs in Europe during the early phase of the pandemic. METHODS: Retrospective descriptive study from 30 European countries using data from September 2020 collected with an ad hoc semi-structured questionnaire. Related variables are SARS-CoV-2 testing, contact tracing, follow-up, additional testing, and patient care. RESULTS: Twenty-six out of the 30 European countries had PHC involvement in LTCFs during the COVID-19 pandemic. PHC participated in initial medical care in 22 countries, while, in 15, PHC was responsible for SARS-CoV-2 test along with other institutions. Supervision of individuals in isolation was carried out mostly by LTCF staff, but physical examination or symptom's follow-up was performed mainly by PHC. CONCLUSION: PHC has participated in COVID-19 pandemic assistance in LTCFs in coordination with LTCF staff, public health officers, and hospitals.

Age- and gender-based comorbidity categories in general practitioner and pulmonology patients with COPD.

Chronic obstructive pulmonary disease (COPD) is a debilitating medical condition often accompanied by multiple chronic conditions. COPD is more frequent among older adults and affects both genders. The aim of the current cross-sectional survey was to characterize chronic comorbidities stratified by gender and age among patients with COPD under the care of general practitioners (GP) and pulmonologists, using real-world patient data. A total of 7966 COPD patients (women: 45%) with more than 5 years of the observation period in the practice were examined using 60 different Chronic comorbid conditions (CCC) and Elixhauser measures. More than 9 in 10 patients had at least one, and 51.7% had more than three comorbidities. No gender difference was found in the number of comorbidities. However, men had higher Elixhauser-van Walraven index scores than women, and the types of comorbidities differed by gender. An increasing number of comorbidities was seen with aging but the patients in their 30s and 40s also had a high number of comorbidities. Moreover, GP patients had a higher number and a wider array of documented comorbidities than pulmonology patients did. Psychological comorbidities were common in all patients, but particularly among younger patients. These findings around gender- and age-stratified comorbidities under the care of GPs and pulmonologists have implications for the choice of data provenience for decision-making analysis and treatment selection and success.

Risk stratification in heart failure decompensation in the community: HEFESTOS score.

AIMS: Because evidence regarding risk stratification predicting prognosis of patients with heart failure (HF) decompensation attended in primary care is lacking, we developed and externally validated a model to forecast death/hospitalization during the first 30 days after an episode of decompensation. The predictive model is based on variables easily obtained in primary care settings. METHODS AND RESULTS: HEFESTOS is a multinational study consisting of a derivation cohort of HF patients recruited in 14 primary healthcare centres in Barcelona and a validation cohort from primary healthcare in 9 other European countries. The derivation and validation cohorts included 561 and 250 patients, respectively. Percentages of women in the derivation and validation cohorts were 56.3% and 47.6% (P = 0.026), respectively. Mean age was 82.2 years (SD 8.03) in the derivation cohort, and 79.3 years (SD 10.3) in the validation one (P = 0.001). HF with preserved ejection fraction represented 72.1% in the derivation cohort and 58.8% in the validation one (P = 0.004). Mortality/hospitalization during the first 30 days after a decompensation episode was 30.5% and 26% (P = 0.225) for the derivation and validation cohorts, respectively. Multivariable logistic regression models were performed to develop a score of risk. The identified predictors were worsening of dyspnoea [odds ratio (OR): 2.5; P = 0.001], orthopnoea (OR: 2.16; P = 0.01), paroxysmal nocturnal dyspnoea (OR: 2.25; P = 0.01), crackles (OR: 2.35; P = 0.01), New York Heart Association functional class III/IV (OR: 2.11; P = 0.001), oxygen saturation ≤ 90% (OR: 4.98; P < 0.001), heart rate > 100 b.p.m. (OR: 2.72; P = 0.002), and previous hospitalization due to HF (OR: 2.45; P < 0.001). The model showed an area under the curve (AUC) of 0.807, 95% confidence interval (CI): [0.770; 0.845] in the derivation cohort and AUC 0.73, 95% CI: [0.660; 0.808] in the validation one. No significant differences between both cohorts were observed (P = 0.08). Regarding probability of hospitalization/death, three risk groups were defined: low <5%, medium 5-20%, and high >20%. Outcome incidence was 2.7% for the low-risk group, 12.8% for medium risk, and 46.2% for high risk in the derivation cohort, and 9.1%, 12.9%, and 39.6% in the validation one. CONCLUSIONS: The HEFESTOS score, based on variables easily accessible in a community setting and validated in an external European cohort, properly predicted the risk of death/hospitalization during the first 30 days after an HF decompensation episode.

Digital maturity and its determinants in General Practice: A cross-sectional study in 20 countries.

Background: The extent to which digital technologies are employed to promote the delivery of high-quality healthcare is known as Digital Maturity. Individual and systemic digital maturity are both necessary to ensure a successful, scalable and sustainable digital transformation in healthcare. However, digital maturity in primary care has been scarcely evaluated. Objectives: This study assessed the digital maturity in General Practice (GP) globally and evaluated its association with participants' demographic characteristics, practice characteristics and features of Electronic Health Records (EHRs) use. Methods: GPs across 20 countries completed an online questionnaire between June and September 2020. Demographic data, practice characteristics, and features of EHRs use were collected. Digital maturity was evaluated through a framework based on usage, resources and abilities (divided in this study in its collective and individual components), interoperability, general evaluation methods and impact of digital technologies. Each dimension was rated as 1 or 0. The digital maturity score was calculated as the sum of the six dimensions and ranged between 0 to 6 (maximum digital maturity). Multivariable linear regression was used to model the total score, while multivariable logistic regression was used to model the probability of meeting each dimension of the score. Results: One thousand six hundred GPs (61% female, 68% Europeans) participated. GPs had a median digital maturity of 4 (P25-P75: 3-5). Positive associations with digital maturity were found with: male gender [B = 0.18 (95% CI 0.01; 0.36)], use of EHRs for longer periods [B = 0.45 (95% CI 0.35; 0.54)] and higher frequencies of access to EHRs [B = 0.33 (95% CI 0.17; 0.48)]. Practicing in a rural setting was negatively associated with digital maturity [B = -0.25 (95%CI -0.43; -0.08)]. Usage (90%) was the most acknowledged dimension while interoperability (47%) and use of best practice general evaluation methods (28%) were the least. Shorter durations of EHRs use were negatively associated with all digital maturity dimensions (aOR from 0.09 to 0.77). Conclusion: Our study demonstrated notable factors that impact digital maturity and exposed discrepancies in digital transformation across healthcare settings. It provides guidance for policymakers to develop more efficacious interventions to hasten the digital transformation of General Practice.

General practitioners' perceptions of using virtual primary care during the COVID-19 pandemic: An international cross-sectional survey study.

With the onset of COVID-19, general practitioners (GPs) and patients worldwide swiftly transitioned from face-to-face to digital remote consultations. There is a need to evaluate how this global shift has impacted patient care, healthcare providers, patient and carer experience, and health systems. We explored GPs' perspectives on the main benefits and challenges of using digital virtual care. GPs across 20 countries completed an online questionnaire between June-September 2020. GPs' perceptions of main barriers and challenges were explored using free-text questions. Thematic analysis was used to analyse the data. A total of 1,605 respondents participated in our survey. The benefits identified included reducing COVID-19 transmission risks, guaranteeing access and continuity of care, improved efficiency, faster access to care, improved convenience and communication with patients, greater work flexibility for providers, and hastening the digital transformation of primary care and accompanying legal frameworks. Main challenges included patients' preference for face-to-face consultations, digital exclusion, lack of physical examinations, clinical uncertainty, delays in diagnosis and treatment, overuse and misuse of digital virtual care, and unsuitability for certain types of consultations. Other challenges include the lack of formal guidance, higher workloads, remuneration issues, organisational culture, technical difficulties, implementation and financial issues, and regulatory weaknesses. At the frontline of care delivery, GPs can provide important insights on what worked well, why, and how during the pandemic. Lessons learned can be used to inform the adoption of improved virtual care solutions and support the long-term development of platforms that are more technologically robust and secure.

Preferences of patients with asthma or COPD for treatments in pulmonary rehabilitation.

INTRODUCTION: Pulmonary rehabilitation (PR) aims to improve disease control in patients with chronic obstructive pulmonary disease (COPD) and asthma. However, the success of PR-programs depends on the patients' participation and willingness to cooperate. Taking the patients' preferences into consideration might improve both of these factors. Accordingly, our study aims to analyze patients' preferences regarding current rehabilitation approaches in order to deduce and discuss possibilities to further optimize pulmonary rehabilitation. METHODS AND ANALYSIS: At the end of a 3 weeks in-house PR, patients' preferences concerning the proposed therapies were assessed during two different time slots (summer 2015 and winter 2015/2016) in three clinics using a choice-based conjoint analysis (CA). Relevant therapy attributes and their levels were identified through literature search and expert interviews. Inclusion criteria were as follows: PR-inpatient with asthma and/or COPD, confirmed diagnosis, age over 18 years, capability to write and read German, written informed consent obtained. The CA analyses comprised a generalized linear mixed-effects model and a latent class mixed logit model. RESULTS: A total of 542 persons participated in the survey. The most important attribute was sport and exercise therapy. Rehabilitation preferences hardly differed between asthma and COPD patients. Health-related quality of life (HRQoL) as well as time since diagnosis were found to have a significant influence on patients' rehabilitation preferences. CONCLUSIONS: Patients in pulmonary rehabilitation have preferences regarding specific program components. To increase the adherence to, and thus, the effectiveness of rehabilitation programs, these results must be considered when developing or optimizing PR-programs.

Nine Forward-Backward Translations of the Hopkins Symptom Checklist-25 With Cultural Checks.

Introduction: The Hopkins Symptom Checklist-25 (HSCL-25) is an effective, reliable, and ergonomic tool that can be used for depression diagnosis and monitoring in daily practice. To allow its broad use by family practice physicians (FPs), it was translated from English into nine European languages (Greek, Polish, Bulgarian, Croatian, Catalan, Galician, Spanish, Italian, and French) and the translation homogeneity was confirmed. This study describes this process. Methods: First, two translators (an academic translator and an FP researcher) were recruited for the forward translation (FT). A panel of English-speaking FPs that included at least 15 experts (researchers, teachers, and practitioners) was organized in each country to finalize the FT using a Delphi procedure. Results: One or two Delphi procedure rounds were sufficient for each translation. Then, a different translator, who did not know the original version of the HSCL-25, performed a backward translation in English. An expert panel of linguists compared the two English versions. Differences were listed and a multicultural consensus group determined whether they were due to linguistic problems or to cultural differences. All versions underwent cultural check. Conclusion: All nine translations were finalized without altering the original meaning.