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

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

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

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

Barriers for continuous medical education: cross-sectional questionnaire study among danish general practitioners.

BACKGROUND: General practitioners' (GPs') participation in continuous medical education (CME) is essential for patientcare, wellbeing of the GPs, and healthcare expenditures. A quarter of the Danish GPs did not use their reimbursement for CME in 2022. Knowledge of barriers for participating in CME is limited. AIM: To analyse GPs' barriers for participation in CME and patterns in perceived barriers. DESIGN & SETTING: The study population comprised all 3257 GPs in Denmark, who in May 2023 were registered as entitled to reimbursement for CME. METHOD: The response rate was 1303/3257 (40%). Based on a question about use of CME, the respondents were divided into frequent, partial, and seldom users. Partial and seldom users answered questions about barriers related to CME (n=726). The presence of barriers was quantified, and a Latent class analysis (LCA) was used to stratify GPs according to their barrier patterns. RESULTS: Most frequent barriers were: Too busy (68%), fully booked courses (47%), and no substitute (41%). Based on the LCA, we found three distinctive patterns, clustering around: GPs from clinics with no tradition for CME (17%), GPs who used time on professional work outside clinic (teaching, organisational work) (43%), and GPs who were personally or professionally affected (40%). Singled-handed and male GPs were slightly overrepresented among seldom-users. CONCLUSIONS: We have identified barriers for CME. We found three different profiles of GPs who perceived different patterns of barriers. Identified patters in barriers should be considered in future CME initiatives.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

A new comprehensive model for Continuous Professional Development.

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

Collaborative engagement with colleagues may provide better care for 'heart-sink' patients.

INTRODUCTION: In this article we show how a group of general practitioners' (GPs') professionalism was enhanced through collaborative engagement. Complexity, uncertainty and so-called 'heart-sink' patients are naturally embedded in clinical practice. GPs need to deal with, and even embrace, uncertainty, enabling them to provide patient-centred care. METHODS: A relatively fixed group of Danish GPs have met regularly for more than 14 years, discussing difficult and complex cases. Their experiences were researched through two focus group interviews using semi-structured interviews comprising open and closed questions, which were audiotaped and transcribed. The qualitative findings were analysed employing grounded theory principles. RESULTS: Participation in the GP group was perceived to have had a positive impact on participants' personal and professional lives by reducing the number of 'heart-sink' patients, by strengthening their ability to reflect and deal with uncertainty, by boosting self-confidence by improved professional selfawareness, by providing them with a safe environment and by enhancing their working enjoyment and professional motivation. A number of features of the group's structure and ways of working, which appear to have secured the long-lasting sustainability of the group, have been identified. DISCUSSION AND CONCLUSION: This group of Danish GPs experienced personal and professional growth through collaborative engagement. They have apparently learned to embrace and even value the fundamental uncertain and complex nature of primary care, which seems to benefit their 'heart-sink' patients. The features, which have ensured the long-lasting sustainability of this group, could perhaps inspire other younger GPs to work in such reflective groups.

[Visits of postgraduate medical lecturers can improve the postgraduate medical education in common acute admissions].

A new hospital organization for receiving emergency patients has been introduced in Denmark. This qualitative study reviews eight reports from the visits of postgraduate medical lecturers regarding the educational environment in this new organization in the Region of Southern Denmark. The study summarizes a number of recommendations on how to improve the educational environment in new-established organizations. Repeated visits are expected to facilitate the educational environment.

Semi-structured interview is a reliable and feasible tool for selection of doctors for general practice specialist training.

INTRODUCTION: In order to optimise the selection process for admission to specialist training in family medicine, we developed a new design for structured applications and selection interviews. The design contains semi-structured interviews, which combine individualised elements from the applications with standardised behaviour-based questions. This paper describes the design of the tool, and offers reflections concerning its acceptability, reliability and feasibility. MATERIAL AND METHODS: We used a combined quantitative and qualitative evaluation method. Ratings obtained by the applicants in two selection rounds were analysed for reliability and generalisability using the GENOVA programme. Applicants and assessors were randomly selected for individual semi-structured in-depth interviews. The qualitative data were analysed in accordance with the grounded theory method. RESULTS: Quantitative analysis yielded a high Cronbach's alpha of 0.97 for the first round and 0.90 for the second round, and a G coefficient of the first round of 0.74 and of the second round of 0.40. Qualitative analysis demonstrated high acceptability and fairness and it improved the assessors' judgment. Applicants reported concerns about loss of personality and some anxiety. The applicants' ability to reflect on their competences was important. CONCLUSION: The developed selection tool demonstrated an acceptable level of reliability, but only moderate generalisability. The users found that the tool provided a high degree of acceptability; it is a feasible and useful tool for -selection of doctors for specialist training if combined with work-based assessment. Studies on the benefits and drawbacks of this tool compared with other selection models are relevant. FUNDING: not relevant. TRIAL REGISTRATION: not relevant.

Doctors applying for Danish postgraduate medical specialist training are getting younger.

INTRODUCTION: It was previously shown that applicants for postgraduate medical specialist training in Denmark were old. In order to prevent potential shortage of specialists, the Danish health authorities have passed legislation to speed up the output of new specialists. The aim of this study was to highlight the present characteristics of young doctors who entered specialist training. METHODS: Data include 443 doctors who were enrolled in a formalized postgraduate medical training programme in the Region of Southern Denmark from 2009 to 2011. RESULTS: 41% of the recruited young doctors were men and 59% were women. The average age for doctors recruited for residency training was 35 years and the average time from graduation to initiation of specialist training (candidate age) was 70 months. If foreign graduates were excluded, the average age was 34 years and average candidate age was 58 months. 6% of the recruited doctors had a PhD. 61% of the doctors were graduates from the University of Southern Denmark. 14% graduated from the University of Copenhagen and 12% from Aarhus University. Finally, 13% graduated from a foreign university. CONCLUSION: Applicants accepted for specialist training are becoming younger at a faster rate than the new legislation can explain. The gender distribution seems to have been stable for more than a decade. The number of doctors who had a PhD seemed low; however, there was a variation between specialties.

Improved education after implementation of the Danish postgraduate medical training reform.

INTRODUCTION: A reform of educational postgraduate medical training was launched in Denmark in 2004. The reform was based on a report by the Danish Medical Specialist Commission and consisted of a number of initiatives that were all aimed at improving the quality of medical training. Since 1998, all junior doctors in Denmark have been requested to rate the quality of their training on a Danish standardized questionnaire (DSQ) comprising 24 questions. In this study, we examined how junior doctors in hospitals rated their postgraduate medical training before and six years after the reform was implemented. MATERIAL AND METHODS: This study is a cross-sectional register study of DSQ ratings of the postgraduate training in the region of Southern Denmark in 2002-2004 and in 2010. The ratings were extracted from the official database: www.evaluer.dk. RESULTS: For comparison, a total of 1,028 ratings from before the reform and 686 ratings from after the reform were extracted. 70% of junior doctors filled in a DSQ in 2010. The doctors' perceptions of the training improved from 2002-2004 to 2010 as far as educational outcome and the department's educational effort were concerned. However, no change was evident in several questions targeting educational management. CONCLUSION: Based on the junior doctors' DSQ ratings, the quality of postgraduate training has improved in several areas from 2002-2004 to 2010. But there is still room for improvement. Developing a new, validated questionnaire should be considered in order to ensure a high credibility in future work on quality.o. FUNDING: not relevant. TRIAL REGISTRATION: not relevant.

[Clinical junior doctors' initial experiences with the joint interdisciplinary ward for acute admissions]. / Kliniske basislægers første erfaringer med den fælles akutmodtagelse som uddannelsessted.

A new hospital organisation for receiving acute patients has been introduced in Denmark. All patients with acute problems are to be received in an interdisciplinary ward (IW). This study examines how junior doctors evaluate training in the IW. A questionnaire was sent to 558 doctors who went through postgraduate basic training in 2009 and 2010. The response rate was 63%. Sixty-eight doctors had been trained in IW. The responders found that training in IW had a high educational potential. They appreciated the broad training in acute conditions from several specialities. However, the educational management could be improved.

The benefits of educational release of hospital-based general practice specialist training registrars into general practice.

In Denmark, specialist training for family medicine consists of 2.5 years training in general practice and 2.5 years training in specific hospital departments. The hospital training programme contains mandatory release time (return days) whereby GP trainees leave their hospitals in order to work with patients in their teaching GP surgeries for one day every month. The goals are to develop and maintain a family medicine perspective during the hospital training and to maintain contact with the family medicine environment. In order to explore the benefits of going back to general practice for one day per month during hospital training, we carried out a qualitative study comprising three focus group interviews with trainees and one focus group with trainers. Return days are important for the development of a professional identity and they can ensure the provision of a useful/necessary breathing space in a turbulent education. If properly organised, return days have the potential to strengthen professional competences due to a stronger focus on the family medicine perspective during training. The process strengthens transferability of skills. A focus on better educational management is needed. Trainers' commitment and trainees' ownership of and responsibility for the educational process are prerequisites for success.

The role of general practice in postgraduate basic training.

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