Person-centred medicine in the care home setting: development of a complex intervention.

BACKGROUND: Person-centred medicine is recommended in the care of older patients. Yet, involvement of care home residents and relatives in medication processes remains limited in routine care. Therefore, we aimed to develop a complex intervention focusing on resident and relative involvement and interprofessional communication to support person-centred medicine in the care home setting. METHODS: The development took place from October 2021 to March 2022 in the Municipality of Aarhus, Denmark. The study followed the Medical Research Council guidance on complex intervention development using a combination of theoretical, evidence-based, and partnership approaches. The patient involvement tool, the PREparation of Patients for Active Involvement in medication Review (PREPAIR), was included in a preliminary intervention model. Study activities included developing programme theory, engaging stakeholders, and exploring key uncertainties through interviews, co-producing workshops, and testing with end-users to develop the intervention and an implementation strategy. The Consolidated Framework for Implementation Research and the Interprofessional Shared Decision Making Model were used. Data were analysed using a rapid analysis approach. RESULTS: Before the workshops, six residents and four relatives were interviewed. Based on their feedback, PREPAIR was modified to the PREPAIR care home to fit the care home population. In total, ten persons participated in the co-producing workshops, including health care professionals and municipal managerial and quality improvement staff. The developed intervention prototype was tested for three residents and subsequently refined to the final intervention, including two fixed components (PREPAIR care home and an interprofessional medication communication template) delivered in a flexible three-stage workflow. Additionally, a multi-component implementation strategy was formed. In line with the developed programme theory, the intervention supported health care professionals´ awareness about resident and relative involvement. It provided a structure for involvement, empowered the residents to speak, and brought new insights through dialogue, thereby supporting involvement in medication-related decisions. The final intervention was perceived to be relevant, acceptable, and feasible in the care home setting. CONCLUSION: Our results indicate that the final intervention may be a viable approach to facilitate person-centred medicine through resident and relative involvement. This will be further explored in a planned feasibility study.

Point-of-care testing and antibiotics prescribing in out-of-hours general practice: a register-based study in Denmark.

BACKGROUND: Point-of-care testing may reduce diagnostic uncertainty in case of suspicion of bacterial infection, thereby contributing to prudent antibiotic prescribing. We aimed to study variations in the use of point-of-care tests (C-reactive protein test, rapid streptococcal antigen detection test, and urine dipstick) among general practitioners (GPs) and the potential association between point-of-care testing and antibiotic prescribing in out-of-hours general practice. METHODS: We conducted a population-based observational register-based study, based on patient contacts with out-of-hours general practice in the Central Denmark Region in 2014-2017. The tendency of GPs to use point-of-care testing was calculated, and the association between the use of point-of-care testing and antibiotic prescribing was evaluated with the use of binomial regression. RESULTS: Out-of-hours general practice conducted 794,220 clinic consultations from 2014 to 2017, of which 16.1% resulted in an antibiotic prescription. The GP variation in the use of point-of-care testing was largest for C-reactive protein tests, with an observed variation (p90/p10 ratio) of 3.0; this means that the GPs in the 90th percentile used C-reactive protein tests three times as often as the GPs in the 10th percentile. The observed variation was 2.1 for rapid streptococcal antigen detection tests and 1.9 for urine dipsticks. The GPs who tended to use more point-of-care tests prescribed significantly more antibiotics than the GPs who tended to use fewer point-of-care tests. The GPs in the upper quintile of the tendency to use C-reactive protein test prescribed 22% more antibiotics than the GPs in the lowest quintile (21% for rapid streptococcal antigen detection tests and 8% for urine dipsticks). Up through the quintiles, this effect exhibited a positive linear dose-response correlation. CONCLUSION: The GPs varied in use of point-of-care testing. The GPs who tended to perform more point-of-care testing prescribed more antibiotics compared with the GPs who tended to perform fewer of these tests.

Temporal capital and unaligned times as inequality mechanisms: A case study of chronic care in general practice.

Addressing persistent health inequality is one of the most critical challenges in public health. Structural features of 'time' may provide new perspectives on the link between social inequality and time in a healthcare context. Drawing on the case of chronic care in Danish general practice, we aim to use temporal capital as a theoretical frame to unfold how patients' social positions are interlinked with their medical treatment. We followed patients with multimorbidity and polypharmacy in general practice. Data were collected from interviews, observations, informal conversations, and medical records. We used the concept temporal capital to illuminate the mechanism of inequality in healthcare. We suggest understanding temporal capital as patients' abilities and possibilities to understand, navigate, negotiate, and manage the temporal rhythms of healthcare. Unaligned times, i.e. the mismatch between patients' temporal capital and healthcare organisations and/or professionals' rhythms, are unfolded in five themes: unaligned schedules (scheduling the consultation to fit everyday life and institutional rhythms and attending the consultation), sequences (preparing activities in a specific order to accommodate clinical linearity), agendas (timing the agenda to the clinical workflow), efficiency (ensuring efficiency in the consultation and balancing on-task and off-task content), and pace (conducting the consultation to accommodate fixed durations). Differences in temporal capital and hence abilities and possibilities for aligning with the temporal rhythms of healthcare may be facilitated or restrained by the individual patient's social position, thereby defining and establishing temporal mechanisms of social inequality in medical treatment. In conclusion, social inequality in medical treatment has several temporal references, resulting from pre-existing inequalities and causing new ones. Notions of temporal capital and temporal unalignment provide a useful lens for exploring social inequality in healthcare encounters.

Interprofessional team-based collaboration between designated GPs and care home staff: a qualitative study in an urban Danish setting.

BACKGROUND: Being a general practitioner for residents in many care homes may challenge communication with residents, relatives, and care home staff, and potentially lead to lower quality of care. Several countries have therefore introduced different solutions to reduce the number of general practitioners at each care home. In 2017, the designated general practitioner model was introduced at many Danish care homes. This study aimed to evaluate experiences from the interprofessional team-based collaboration between designated general practitioners and care home staff with regular contact with the designated general practitioners in an urban Danish setting. METHODS: A qualitative design was applied using semi-structured interviews. Eight interviews (three group interviews and five individual interviews) were conducted with four designated general practitioners and seven care home staff members at four care homes in an urban setting of Central Denmark Region, Denmark. The interviews were transcribed verbatim, and data were analysed using content analysis with inspiration from the theory of relational coordination. The study followed the guidelines addressed in the COREQ (Consolidated Criteria for Reporting Qualitative Research) framework. RESULTS: The initiation of the designated general practitioner model was experienced to contribute to more clear, precise, and timely communication between care homes and the general practitioner. An improved mutual acknowledgement of roles and competencies was experienced between designated general practitioners, care home nurses, and sometimes also social and health care assistants. The more frequent visits by the general practitioners at the care homes, as a result of the designated general practitioner model, resulted in more face-to-face communication between care home staff and designated general practitioners. Professional differences in the interpretation of the patient's needs were still present, which at times caused a frustrating compromise of own professional competencies. An important reason for the overall perception of improved collaboration was attributed to the more frequent dialogue in which the care homes staff and the designated general practitioners exchanged knowledge that could be applied in future patient encounters. CONCLUSION: The designated general practitioner model implied an improved collaboration between general practitioners and care homes staff. Clear, precise, and timely communication between care homes and the general practitioners, as well as mutual trust and acknowledgement was experienced to be essential for the collaboration. An important reason for the overall perception of an improved collaboration was attributed to the more frequent dialogue (more frequent general practitioner visits at the care homes) in which the care homes staff and the designated general practitioners exchange knowledge which again could be applied in future patient encounters.

What GPs do to meet accreditation standards - implementation activities and perceived improvements attributed to general practice accreditation.

BACKGROUND: Healthcare accreditation is a widely implemented tool used to enhance the quality of care and underpin quality control. However, research is sparse on the accreditation process in general practice. The aim of this study was to explore how team-based implementation activities preceding accreditation were associated with self-perceived improvements in emergency preparedness (preparedness for urgent disease and cardiac arrest) and handling of prescription renewals in Danish general practice. METHODS: GPs (general practitioners) completed a questionnaire exploring practice-team activities conducted to implement two specific accreditation standards and the related improvements as perceived by the GPs. The following implementation activities were selected, inspired by Normalization Process Theory: Common understanding (obtaining a common understanding of the purpose of implementing changes according to the accreditation standard), key person (assigning a key person responsible for working with the standard), and easy integration (finding it easy to integrate changes into existing working procedures). Data were analysed with logistic regression, and adjusted analyses included practice type, number of GP partners, number of staff, training site for junior GPs and administrative region. RESULTS: The total response rate was 74% (n = 920). Around 80% of the clinics reported having conducted team-based implementation activities. Almost half of the clinics (48%) reported perceived improvements in the emergency preparedness, and 30% reported perceived improvements in the handling of prescription renewals. Obtaining a common understanding was found to have a strong, significant association with perceived improvements in the emergency preparedness (OR = 5.07 (3.06-8.40)) and handling of prescription renewals (OR = 3.66 (2.07-6.46)). Easy integration of changes was also significantly associated with improvements in both emergency preparedness (OR = 1.88 (1.24-2.85)) and handling of prescription renewals (OR = 2.34 (1.44-3.79)), whereas assigning a key person was only significantly associated with improved emergency preparedness (OR = 1.95 (1.19-3.19)). CONCLUSION: Clinical quality initiatives that involve collaboration within a practice team are more likely to cause improvements if specific team-based implementation activities are conducted. It is particularly important to facilitate a common understanding of the purpose of the initiative. Therefore, external support for quality initiatives aiming at the practice level in general practice should facilitate such team-based activities.

[Clinical implementation of complex interventions].

Intervention research is rapidly evolving and the updated Medical Research Council's framework from 2021 recommends a number of elements to consider when developing, adapting and evaluating complex interventions. We aimed to introduce the framework into the Danish language, and it is now ready for use in the efforts to developing and evaluating interventions that can help closing the evidence-practice gap. Using the framework systematically is expected to optimise evidence-based decisions of implementing new or settle obsolete interventions targeted patients, providers or healthcare organisations. This review gives a brief summary of the updated recommendations.

Variation of GP antibiotic prescribing tendency for contacts with out-of-hours primary care in Denmark - a cross-sectional register-based study.

OBJECTIVE: To study variation in antibiotic prescribing rates among general practitioners (GP) in out-of-hours (OOH) primary care and to explore GP characteristics associated with these rates. DESIGN: Population-based observational registry study using routine data from the OOH primary care registration system on patient contacts and antibiotic prescriptions combined with national register data. SETTING: OOH primary care of the Central Denmark Region. SUBJECTS: All patient contacts in 2014-2017. MAIN OUTCOME MEASURES: GPs' tendency to prescribe antibiotics. Excess variation (not attributable to chance). RESULTS: We included 794,220 clinic consultations (16.1% with antibiotics prescription), 281,141 home visits (11.6% antibiotics), and 1,583,919 telephone consultations (5.8% antibiotics). The excess variation in the tendency to prescribe antibiotics was 1.56 for clinic consultations, 1.64 for telephone consultations, and 1.58 for home visits. Some GP characteristics were significantly correlated with a higher tendency to prescribe antibiotics, including 'activity level' (i.e. number of patients seen in the past hour) for clinic and telephone consultations, 'familiarity with OOH care' (i.e. number of OOH shifts in the past 180 days), male sex, and younger age for home visits. Overall, GP characteristics explained little of the antibiotic prescribing variation seen among GPs (Pseudo r2: 0.008-0.025). CONCLUSION: Some variation in the GPs' tendency to prescribe antibiotics was found for OOH primary care contacts. Available GP characteristics, such as GPs' activity level and familiarity with OOH care, explained only small parts of this variation. Future research should focus on identifying factors that can explain this variation, as this knowledge could be used for designing interventions.KEY POINTSCurrent awareness:Antibiotic prescribing rates seem to be higher in out-of-hours than in daytime primary care.Most important results:Antibiotic prescribing rates varied significantly among general practitioners after adjustment for contact- and patient-characteristics.This variation remained even after accounting for variation attributable to chance.General practitioners' activity level and familiarity with out-of-hours care were positively associated with their tendency to prescribe antibiotics.

Involving patients in medicines optimisation in general practice: a development study of the "PREparing Patients for Active Involvement in medication Review" (PREPAIR) tool.

BACKGROUND: Many patients have multiple health conditions and take multiple medications (polypharmacy). Active patient involvement may improve treatment outcomes and ensure patient-centred care. Yet, patient involvement remains a challenge in clinical practice. We aimed to develop and pilot test a questionnaire-based preparation and dialogue tool, the PREparing Patients for Active Involvement in medication Review (PREPAIR) tool, to encourage the involvement of patients with polypharmacy in medicines optimisation in general practice. METHODS: We conducted a literature review followed by a co-production process to develop the tool: a workshop with six GPs and pilot testing, including observations and interviews, with 22 patients, three GPs and three practice staff. During this process, we made continuous adaptations to the prototype. We analysed the qualitative data thematically, focusing on the development process and mechanisms of impact. FINDINGS: The final PREPAIR tool included five items concerning the patient's experience of 1) adverse drug reactions, 2) excess medication, 3) unnecessary medication, 4) medication satisfaction and 5) medication-related topics to discuss with the GP (open-ended question). The applied workflow during testing was as follows; the patient completed the PREPAIR tool at home, to encourage reflection on the medication, and brought it to the GP consultation. During the consultation, the GP and the patient reviewed the patient's responses and discussed potential medication-related problems. For some patients, the increased reflection led to worries about the medications. Still, the pilot testing showed that, when using the PREPAIR tool, the patients arrived at the clinic well prepared and empowered to speak. From the PREPAIR-supported dialogue, the GPs obtained a better understanding of patients' perspectives and provided a more patient-centred consultation. For the patients, the PREPAIR-supported dialogue ultimately promoted an increased sense of security, satisfaction and insight into their medication, despite initial worries for some patients. CONCLUSIONS: We developed a brief tool to support active patient involvement in medication review in general practice. The PREPAIR-tool was well received by both patients and GPs and fitted well into the existing clinical practice. Our findings suggest that the PREPAIR-tool can support patient involvement during consultations and facilitate patient-centred care.

Chronic care services and variation between Danish general practices: a nationwide cohort study.

BACKGROUND: Little is known about variations in the provision of chronic care services in primary care. AIM: To describe the frequency of chronic care services provided by GPs and analyse the extent of non-random variation in service provision. DESIGN AND SETTING: Nationwide cohort study undertaken in Denmark using data from 2016. METHOD: Information on chronic care services was obtained from national health registers, including annual chronic care consultations, chronic care procedures, outreach home visits, and talk therapy. The associations between services provided, patient morbidity, and socioeconomic factors were estimated. Service variations were analysed, and excess variation related to practice-specific factors was estimated while accounting for random variation. RESULTS: Chronic care provision was associated with increasing patient age, increasing number of long-term conditions, and indicators of low socioeconomic status. Variation across practices ranged from 1.4 to 128 times more than expected after adjusting for differences in patient population and random variation. Variation related to practice-specific factors was present for all the chronic care services that were investigated. Older patients with lower socioeconomic status and multimorbidity were clustered in practices with low propensity to provide certain chronic care services. CONCLUSION: Chronic care was provided to patients typically in need of health care, that is, older adults, those with multimorbidity, and those with low socioeconomic status, but service provision varied more than expected across practices. GPs provided slightly fewer chronic care services than expected in practices where many patients with multimorbidity and low socioeconomic status were clustered, suggesting inverse care law mechanisms.

Potentially inappropriate medications (PIMs): frequency and extent of GP-related variation in PIMs: a register-based cohort study.

OBJECTIVES: Potentially inappropriate medications (PIMs) pose an increasing challenge in the ageing population. We aimed to assess the extent of PIMs and the prescriber-related variation in PIM prevalence. DESIGN: Nationwide register-based cohort study. SETTING: General practice. PARTICIPANTS: The 4.2 million adults listed with general practitioner (GP) clinics in Denmark (n=1906) in 2016. MAIN OUTCOME MEASURES: We estimated the patients' time with PIMs by using 29 register-operationalised STOPP criteria linking GP clinics and redeemed prescriptions. For each criterion and each GP clinic, we calculated ratios between the observed PIM time and that predicted by multivariate Poisson regressions on the patients. The observed variation was measured as the 90th/10th percentile ratios of these ratios. The extent of expectable random variation was assessed as the 90th/10th percentile ratios in randomly sampled GP populations (ie, the sampled variation). The GP-related excess variation was calculated as the ratio between the observed variation and sampled variation. The linear correlation between the observed/expected ratio for each of the criteria and the observed/expected ratio of total PIM time (for each clinic) was measured by Pearson's rho. RESULTS: Overall, 294 542 individuals were exposed to 1 44 117 years of PIMs. The two most prevalent PIMs were long-term use (>3 months) of non-steroidal anti-inflammatory drugs (51 074 years of PIMs) or benzodiazepines (48 723 years of PIMs). These two criteria showed considerable excess variation of 2.33 and 3.05, respectively; for total PIMs, this figure was 1.65. For more than half of the criteria, we observed a positive correlation between the specific PIM and the sum of remaining PIMs. CONCLUSIONS: This study documents considerable variations in the prescribing practice of GPs for certain PIMs. These findings highlight a need for exploring the causal explanations for such variations, which could be markers of suboptimal GP-prescribing strategies.

External validation of the Medication Risk Score in polypharmacy patients in general practice: A tool for prioritizing patients at greatest risk of potential drug-related problems.

Drug-related problems are important causes of patient harm and increased healthcare costs. To assist general practitioners in prioritizing patients in need of a critical medication review, we aimed to assess the ability of the Medication Risk Score (MERIS) to stratify patients with polypharmacy in general practice according to their risk of drug-related problems. We conducted a cross-sectional multi-centre external validation study. Patients receiving more than five concomitant medications (polypharmacy) were eligible. The outcome was potentially serious drug-related problems as evaluated by expert consensus. Performance was assessed in terms of calibration and discrimination indices. Of 497 patients, 489 were included in the main analysis. The median age (interquartile range) was 70.5 years (60-79). In total, 372 potentially serious drug-related problems were observed in 253 patients (52%). The MERIS was well calibrated above a score level of 10. The area under the receiver operating characteristic curve was 0.70 (95% confidence interval: 0.65-0.74). The performance of the MERIS was fair in patients with polypharmacy in general practice. Given the scale of drug-related problems and the lack of efficient prioritization tools in this setting, the MERIS could be a useful risk indicator to complement usual practice.

Implementation of healthcare accreditation in Danish general practice: a questionnaire study exploring general practitioners' perspectives on external support.

OBJECTIVE: To describe the use and perceived usefulness of implementation support provided to general practice during an accreditation process and to explore potential variations across clinic characteristics. DESIGN: Cross-sectional questionnaire study. SETTING AND SUBJECTS: All Danish general practice clinics undergoing an accreditation survey from 27 September 2016 to 15 December 2017 (n = 608). MAIN OUTCOME MEASURES: Use and perceived usefulness of seven types of implementation support as reported by general practitioners (GPs). Clinic characteristics included practice type, number of GP partners and staff and employment of GP trainees. RESULTS: The total response rate was 74% (n = 447). Most clinics (99.5%) used some type of implementation support (average: 4.8 different types). The most used types of support were peer support (80-92%) and various accreditation documents (85-92%). Support tailored to the individual clinic was most often considered useful (91-97%). However, this type of support was used relatively infrequently (16-40%). In most cases, clinic characteristics were neither significantly associated with the use of support nor with the perceived usefulness of the available support. CONCLUSION: During the accreditation processes, each clinic used a broad variety of implementation support. Support tailored to the individual clinic was highly appreciated and should be promoted in future quality interventions in general practice. Discussions with peers were widely used, and it should be investigated further how peer discussions are best facilitated. The study calls for a multifactorial approach to future quality interventions in general practice to target the needs and capacities of the individual clinics.

Exploring implementation processes in general practice in a feedback intervention aiming to reduce potentially inappropriate prescribing: a qualitative study among general practitioners.

BACKGROUND: Potentially inappropriate prescribing (PIP) has been linked with adverse health outcomes and increased healthcare costs. Feedback interventions targeting PIP have shown promising results. However, translation from research to everyday practice remains a challenge. With the Normalisation Process Theory (NPT) as overarching framework, we aimed to explore the implementation processes performed by general practices in a real-life, quality improvement intervention using feedback on practice-level prescribing. METHODS: All 376 general practices in the Central Denmark Region received a prescribing feedback intervention targeting selected types of PIP. Six months later, they received an evaluation questionnaire, to which 45% responded. Among 102 practices reporting to have made changes in response to the intervention, we conducted individual, semi-structured interviews with ten GPs. Maximum variation was sought in terms of baseline prescribing status, implementation activities, practice type and geographical location. The interviews were analysed thematically using NPT. RESULTS: The implementation processes in general practice reflected the four NPT constructs. Key motivators for implementation included the GPs' professional values and interests, but pragmatic considerations were also of importance (coherence). A collective versus an individual approach to the engagement and planning of the implementation process (cognitive participation) was observed. Similarly, a distinction was evident between practice-level actions involving the entire practice team as opposed to individual-level actions performed by the individual GP (collective action). Several challenges to the implementation processes were identified, including patient influences and competing priorities at multiple levels (reflexive monitoring). Additionally, internal evaluation and normalisation of new practices occurred in varying degrees. CONCLUSION: NPT provided a useful framework for understanding implementation processes in general practice. Our results emphasise that clear professional aims and feasible content of interventions are key for GP motivation. This may be ensured through cooperation with GPs' professional organisation, which may strengthen intervention legitimacy and uptake. Two main implementation strategies were identified: practice-level and GP-level strategies. Intervention developers need to recognise both strategies to deliver intervention content and implementation support that promote sustainable improvements in prescribing practice. Competing demands and patient influences remain important challenges that need to be addressed in future studies to further facilitate the reduction of PIPs.

A genetic risk assessment for prostate cancer influences patients' risk perception and use of repeat PSA testing: a cross-sectional study in Danish general practice.

BACKGROUND: Prostate cancer (PC) is the most common cancer among men in the western world. Genetic lifetime risk assessment could alleviate controversies about prostate specific antigen (PSA) testing for early diagnosis. AIM: To determine how men interpret information about their lifetime risk for PC and how this can affect their choice of having a repeated PSA test. DESIGN & SETTING: A genetic test was offered for assessment of individual PC lifetime risk in general practices in Denmark, with the purpose of promoting appropriate use of PSA testing. METHOD: Participants had a genetic lifetime risk assessment for PC diagnosis (either high or normal risk). A month after receiving the result, participants answered a questionnaire about their perceived risk of getting or dying from PC compared with other men, as well as their intentions for repeated PSA testing. RESULTS: Nearly half (44.7%) of 555 participants who received the genetic risk assessment were not aware they had a genetic test. Nevertheless, compared with men with a normal genetic risk, those with high genetic risk reported higher perceived risk for PC (mean difference of 0.74 [95% confidence interval {CI} = 0.56 to 0.96] on a 5-point scale), higher perceived risk of dying from PC (mean difference of 0.48 [95% CI = 0.29 to 0.66] on a 5-point scale), and increased intention for repeated PSA testing (mean difference of 0.48 [95% CI = 0.30 to 0.65] on a 4-point scale). CONCLUSION: Despite low awareness and/or understanding of the test result, a high genetic risk for PC made participants more aware of their risk, and it increased their intention and probability for repeated PSA testing.

Higher patient assessed quality of chronic care is associated with lower diabetes distress among adults with early-onset type 2 diabetes: Cross-sectional survey results from the Danish DD2-study.

AIM: Among adults aged 20-45 years with type 2 diabetes mellitus, we examined the perceived quality of chronic care, and its associations with (i) sociodemographic and clinical characteristics, and (ii) diabetes distress. METHODS: In total, 216/460 (47%) completed a self-administered survey assessing sociodemographic characteristics, patient assessed chronic illness care (PACIC-20, scale of 1-5) and diabetes distress (PAID-20, scale of 0-100), and 197 had full quality of care data for assessment. We obtained clinical data from national registers and used linear and logistic regression models to examine associations. RESULTS: The mean (SD) PACIC score was 2.6 (0.9) (score range 1-5). Lower PACIC scores were associated with female sex and current unemployment, and with receiving diabetes care in general practice compared with hospital outpatient clinics [mean difference: -0.4 (95% confidence interval (CI) (-0.7 to -0.2)]. People with upper quartile PACIC scores were less likely to report high diabetes distress compared with people with lower quartile PACIC scores [odds Ratio 0.3 95%CI (0.1-0.8)]. CONCLUSION: Higher quality of care was associated with lower diabetes distress among adults with early onset type 2 diabetes mellitus, but respondents reported less than optimal quality in several core areas of chronic care.

Communication quality in telephone triage conducted by general practitioners, nurses or physicians: a quasi-experimental study using the AQTT to assess audio-recorded telephone calls to out-of-hours primary care in Denmark.

OBJECTIVES: To compare the quality of communication in out-of-hours (OOH) telephone triage conducted by general practitioners (GPs), nurses using a computerised decision support system and physicians with different medical specialities, and to explore the association between communication quality and efficiency, length of call and the accuracy of telephone triage. DESIGN: Natural quasi-experimental cross-sectional study. SETTING: Two Danish OOH services using different telephone triage models: a GP cooperative and the medical helpline 1813. PARTICIPANTS: 1294 audio-recorded randomly selected OOH telephone triage calls from 2016 conducted by GPs (n=423), nurses using CDSS (n=430) and physicians with different medical specialities (n=441). MAIN OUTCOME MEASURES: Twenty-four physicians assessed the calls. The panel used a validated assessment tool (Assessment of Quality in Telephone Triage, AQTT) to measure nine aspects of communication, overall perceived communication quality, efficiency and length of call. RESULTS: The risk of poor quality was significantly higher in calls triaged by GPs compared with calls triaged by nurses regarding 'allowing the caller to describe the situation' (GP: 13.5% nurse: 9.8%), 'mastering questioning techniques' (GP: 27.4% nurse: 21.1%), 'summarising' (GP: 33.0% nurse: 21.0%) and 'paying attention to caller's experience' (GP: 25.7% nurse: 17.0%). The risk of poor quality was significantly higher in calls triaged by physicians compared with calls triaged by GPs in five out of nine items. GP calls were significantly shorter (2 min 57 s) than nurse calls (4 min 44 s) and physician calls (4 min 1 s). Undertriaged calls were rated lower than optimally triaged calls for overall quality of communication (p<0.001) and all specific items. CONCLUSIONS: Compared with telephone triage by GPs, the communication quality was higher in calls triaged by nurses and lower in calls triaged by physicians with different medical specialities. However, calls triaged by nurses and physicians were longer and perceived less efficient. Quality of communication was associated with accurate triage.

The effect of assessing genetic risk of prostate cancer on the use of PSA tests in primary care: A cluster randomized controlled trial.

BACKGROUND: Assessing genetic lifetime risk for prostate cancer has been proposed as a means of risk stratification to identify those for whom prostate-specific antigen (PSA) testing is likely to be most valuable. This project aimed to test the effect of introducing a genetic test for lifetime risk of prostate cancer in general practice on future PSA testing. METHODS AND FINDINGS: We performed a cluster randomized controlled trial with randomization at the level of general practices (73 in each of two arms) in the Central Region (Region Midtjylland) of Denmark. In intervention practices, men were offered a genetic test (based on genotyping of 33 risk-associated single nucleotide polymorphisms) in addition to the standard PSA test that informed them about lifetime genetic risk of prostate cancer and distinguished between "normal" and "high" risk. The primary outcome was the proportion of men having a repeated PSA test within 2 years. A multilevel logistic regression model was used to test the association. After applying the exclusion criteria, 3,558 men were recruited in intervention practices, with 1,235 (34.7%) receiving the genetic test, and 4,242 men were recruited in control practices. Men with high genetic risk had a higher propensity for repeated PSA testing within 2 years than men with normal genetic risk (odds ratio [OR] = 8.94, p < 0.01). The study was conducted in routine practice and had some selection bias, which is evidenced by the relatively large proportion of younger and higher income participants taking the genetic test. CONCLUSIONS: Providing general practitioners (GPs) with access to a genetic test to assess lifetime risk of prostate cancer did not reduce the overall number of future PSA tests. However, among men who had a genetic test, knowledge of genetic risk significantly influenced future PSA testing. TRIAL REGISTRATION: This study is registered with ClinicalTrials.gov, number NCT01739062.

Mental well-being and job satisfaction in general practitioners in Denmark and their patients' change of general practitioner: a cohort study combining survey data and register data.

OBJECTIVES: Low job satisfaction and poor well-being (eg, stress and burnout) among physicians may have negative consequences for patient experienced healthcare quality. In primary care, this could manifest in patients choosing another general practitioner (GP). The objective of this study was to examine change of GP (COGP) (unrelated to change of address) among patients in relation to their GPs' job satisfaction, well-being and self-assessed work-ability. DESIGN AND SETTING: Data from a nationwide questionnaire survey among Danish GPs in May 2016 was combined with register data on their listed patients. Associations between patients' COGP in the 6-month study period (from May 2016) and the job satisfaction/well-being of their GP were estimated as risk ratios (RRs) at the individual patient level using binomial regression analysis. Potential confounders were included for adjustment. PARTICIPANTS: The study cohort included 569 776 patients aged ≥18 years listed with 409 GPs in single-handed practices. RESULTS: COGP was significantly associated with occupational distress (burnout and low job satisfaction) in the GP. This association was seen in a dose-response like pattern. For burnout, associations were found for depersonalisation and reduced sense of personal accomplishment (but not for emotional exhaustion). The adjusted RR was 1.40 (1.10-1.72) for patients listed with a GP with the lowest level of job satisfaction and 1.24 (1.01-1.52) and 1.40 (1.14-1.72) for patients listed with a GP in the most unfavourable categories of depersonalisation and sense of personal accomplishment (the most favourable categories used as reference). COGP was not associated with self-assessed work-ability or domains of well-being related to life in general. CONCLUSIONS: Patients' likelihood of changing GP increased with GP burnout and decreasing job satisfaction. These findings indicate that patients' evaluation of care as measured by COGP may be influenced by their GPs' work conditions and occupational well-being.

Implementing Integrated Community-Based Primary Healthcare: Applying the iCoach-Approach to Case Selection to Denmark.

BACKGROUND: The iCoach approach to case selection focuses on innovative models of community-based primary healthcare (CBPHC) and their contexts. The aim of this study was to assess the possibilities and limitations of the approach based on Denmark, which differs in significant ways from the jurisdictions initially included. THEORY AND METHODS: Case study research suggests the approach is an interesting attempt to standardise case selection based on literal replication. The study reviewed the national grey literature and interviewed key informants at national and local levels. RESULTS: Applying the approach to Denmark required redefining selection criteria related to collaboration and context to capture its specific institutional and policy context. Selecting cases at the organisational level also required assessing how the system level contexts compared to those of the initial three jurisdictions included in iCoach. DISCUSSION: The iCoach approach allows collecting broadly comparable cases of innovative models of CBPHC across jurisdictions. However, the analysis of underlying conditions of implementing innovative models requires a more interactive approach to case selection. CONCLUSION: Researchers need to be clearer about the specific purpose of the case selection. This is also highly relevant for practitioners to ensure that insights are applicable in specific local and national contexts.

Mental well-being, job satisfaction and self-rated workability in general practitioners and hospitalisations for ambulatory care sensitive conditions among listed patients: a cohort study combining survey data on GPs and register data on patients.

BACKGROUND: Physicians' work conditions and mental well-being may affect healthcare quality and efficacy. Yet the effects on objective measures of healthcare performance remain understudied. This study examined mental well-being, job satisfaction and self-rated workability in general practitioners (GPs) in relation to hospitalisations for ambulatory care sensitive conditions (ACSC-Hs), a register-based quality indicator affected by referral threshold and prevention efforts in primary care. METHODS: This is an observational study combining data from national registers and a nationwide questionnaire survey among Danish GPs. To ensure precise linkage of each patient with a specific GP, partnership practices were not included. Study cases were 461 376 adult patients listed with 392 GPs. Associations between hospitalisations in the 6-month study period and selected well-being indicators were estimated at the individual patient level and adjusted for GP gender and seniority, list size, and patient factors (comorbidity, sociodemographic characteristics). RESULTS: The median number of ACSC-Hs per 1000 listed patients was 10.2 (interquartile interval: 7.0-13.7). All well-being indicators were inversely associated with ACSC-Hs, except for perceived stress (not associated). The adjusted incidence rate ratio was 1.26 (95% CI 1.13 to 1.42) for patients listed with GPs in the least favourable category of self-rated workability, and 1.19 (95% CI 1.05 to 1.35), 1.15 (95% CI 1.04 to 1.27) and 1.14 (95% CI 1.03 to 1.27) for patients listed with GPs in the least favourable categories of burn-out, job satisfaction and general well-being (the most favourable categories used as reference). Hospitalisations for conditions not classified as ambulatory care sensitive were not equally associated. CONCLUSIONS: ACSC-H frequency increased with decreasing levels of GP mental well-being, job satisfaction and self-rated workability. These findings imply that GPs' work conditions and mental well-being may have important implications for individual patients and for healthcare expenditures.