Factors associated with statin discontinuation near end of life in a Danish primary health care cohort.

BACKGROUND: Long-term preventive treatment such as treatment with statins should be reassessed among patients approaching end of life. The aim of the study was to describe the rate of discontinuation of statin treatment and factors associated with discontinuation in the 6 months before death. METHODS: This study is a retrospective cohort study using national registers and blood test results from primary health care patients. Patients in the Copenhagen municipality, Denmark who died between 1997 and 2018 and were statin users during the 10-year period before death were included. We calculated the proportion who remained statin users in the 6-month period before death. Factors associated with discontinuation were tested using logistic regression. RESULTS: A total of 55,591 decedents were included. More patients continued treatment (64%, n = 35,693) than discontinued (36%, n = 19,898) the last 6 months of life. The 70 and 80 age groups had the lowest odds of discontinuing compared to the 90 (OR 1.59, 95% CI 0.93-2.72) and 100 (OR 3.11, 95% CI 2.79-3.47) age groups. Increasing comorbidity score (OR 0.89, 95% CI 0.87; 0.90 per 1-point increase) and use of statins for secondary prevention (OR 0.89, 95% CI 0.85; 0.93) reduced the likelihood of discontinuation as did a diagnosis of dementia, heart failure, or cancer. CONCLUSION: A substantial portion of patients continued statin treatment near end of life. Efforts to promote rational statin use and discontinuation are required among patients with limited life expectancy, including establishing clear, practical recommendations about statin discontinuation, and initiatives to translate recommendations into clinical practice.

Health alliance for prudent prescribing and yield of antibiotics in a patient-centred perspective (HAPPY PATIENT): a before-and-after intervention and implementation study protocol.

BACKGROUND: Excessive and inappropriate use of antibiotics is the most important driver of antimicrobial resistance. The aim of the HAPPY PATIENT project is to evaluate the adaptation of European Union (EU) recommendations on the prudent use of antimicrobials in human health by evaluating the impact of a multifaceted intervention targeting different categories of healthcare professionals (HCPs) on common community-acquired infectious diseases, especially respiratory and urinary tract infections. METHODS/DESIGN: HAPPY PATIENT was initiated in January 2021 and is planned to end in December 2023. The partners of this project include 15 organizations from 9 countries. Diverse HCPs (doctors, nurses, pharmacists, and pharmacy technicians) will be audited by the Audit Project Odense (APO) method before and after an intervention in four different settings: general practice, out of hours services, nursing homes and community pharmacies in four high antibiotic prescribing countries (France, Poland, Greece, and Spain) and one low prescribing country (Lithuania). About 25 individuals from each professional group will be recruited in each country, who will register at least 25 patients with community-acquired infections during each audit period. Shortly before the second registration participants will undertake a multifaceted intervention and will receive the results from the first registration to allow the identification of possible quality problems. At these meetings participants will receive training courses on enhancement of communication skills, dissemination of clinical guidelines with recommendations for diagnosis and treatment, posters for the waiting rooms, and leaflets for patients. The results of the second registration will be compared with those obtained in the first audit. DISCUSSION: HAPPY PATIENT is an EU-funded project aimed at contributing to the battle against antibiotic resistance through improvement of the quality of management of common community-acquired infections based on interventions by different types of HCPs. It is hypothesized that the use of multifaceted strategies combining active intervention will be effective in reducing inappropriate prescribing and dispensing of antibiotics. STUDY REGISTRATION: EU Health programmes project database https://webgate.ec.europa.eu/chafea_pdb/health/projects/900024/summary ; date of registration: 1 January 2021.

Insomnia in the elderly: reported reasons and their associations with medication in general practice in Denmark.

Objective: The aim of this study was to investigate reasons for insomnia symptoms and their associations with sleep medication prescription in elderly patients in general practice.Design: Over a period of 20 weekdays, general practitioners (GPs) recorded reasons and treatment for insomnia symptoms. Patient characteristics and outcomes were analysed using descriptive statistics. Logistic regression was used to analyse the associations between reasons for insomnia symptoms and prescription.Setting: General practices in the Region of Southern Denmark.Subjects: Consultations (n = 405) with patients older than 65 years presenting with insomnia symptoms.Main outcome measures: Reasons for insomnia symptoms and sleep medication prescription.Results: The most commonly reported reasons for insomnia symptoms were somatic illness (34%) and psychiatric diagnosis (29%). Having a psychiatric diagnosis or multiple reported reasons for insomnia increased the odds for prescription (odds ratio (OR) 4.60, 95% confidence interval (CI) 2.41-9.90 and OR 2.10, CI 1.03-4.28), whereas being first consultation regarding insomnia symptoms decreased the odds (OR 0.17, CI 0.10-0.30). A total of 80% received a prescription, most frequently of Z-hypnotics (49%). About half (52%) of the patients consulting their GP for the first time with insomnia symptoms received a prescription.Conclusion: Somatic and psychiatric diseases were the most commonly reported reasons for insomnia symptoms in the elderly, suggesting a high prevalence of comorbid insomnia. Regardless of reason, a majority of the consultations resulted in prescription of sleep medication with potential serious adverse effects. This indicates that there is still room for improving the management of insomnia among older adults. Key PointsAlthough insomnia is common in the elderly, little is known about its reasons and their associations with prescription patterns. The most commonly reported reasons for insomnia symptoms in the elderly are psychiatric diagnosis and somatic illness. According to guidelines, sleep medication with potential serious adverse effects is prescribed too frequently to elderly patients. An effort should be made to identify and optimally treat comorbid insomnia, which appears to be prevalent in older adults.

Cross-cultural adaptation of the medical engagement scale into Danish general practice setting.

Introduction: The need to involve doctors in healthcare leadership has long been recognized by clinical staff and policymakers. A Medical Engagement Scale has been designed in England to evaluate levels of medical engagement in leadership and management. Objective: The aim of this study was to translate and adapt the scale and to test the translated version for comprehension and suitability in Danish general practice setting. Design and method: The process involved forward translation, backward translation, and field tests. The field tests included cognitive debriefing interviews. In all 30 general practitioners and 5 non-general practitioners participated in the process of translation. After using the scale among 1652 general practitioners statistical analysis was carried out to test internal consistency. Setting: The study was carried out in general practice in Denmark. Results: Several changes made during the process in order to achieve a Danish version that is acceptable, understandable and still capable of measuring medical engagement comparable of the original English version. Analysis of scale internal consistency using Cronbach's alpha revealed acceptable reliability for all three meta-scales, which ranged from 0.69 to 0.81. The overall tool achieved a Cronbach's alpha of 0.89. Conclusion: The Danish version of the Medical Engagement Scale is a valid and reliable tool that is acceptable and relevant for general practice in Denmark. Key points This study describes the cross-cultural adaptation of the Medical Engagement Scale from a UK primary healthcare setting to a Danish primary healthcare setting. The process produced a relevant and acceptable questionnaire measuring medical engagement. Internal consistency revealed acceptable reliability The translation of the scale provides the possibility to use this scale for practical and academic purposes.

Variation in Point-of-Care Testing of HbA1c in Diabetes Care in General Practice.

Background: Point-of-care testing (POCT) of HbA1c may result in improved diabetic control, better patient outcomes, and enhanced clinical efficiency with fewer patient visits and subsequent reductions in costs. In 2008, the Danish regulators created a framework agreement regarding a new fee-for-service fee for the remuneration of POCT of HbA1c in general practice. According to secondary research, only the Capital Region of Denmark has allowed GPs to use this new incentive for POCT. The aim of this study is to use patient data to characterize patients with diabetes who have received POCT of HbA1c and analyze the variation in the use of POCT of HbA1c among patients with diabetes in Danish general practice. Methods: We use register data from the Danish Drug Register, the Danish Health Service Register and the National Patient Register from the year 2011 to define a population of 44,981 patients with diabetes (type 1 and type 2 but not patients with gestational diabetes) from the Capital Region. The POCT fee is used to measure the amount of POCT of HbA1c among patients with diabetes. Next, we apply descriptive statistics and multilevel logistic regression to analyze variation in the prevalence of POCT at the patient and clinic level. We include patient characteristics such as gender, age, socioeconomic markers, health care utilization, case mix markers, and municipality classifications. Results: The proportion of patients who received POCT was 14.1% and the proportion of clinics which were "POCT clinics" was 26.9%. There were variations in the use of POCT across clinics and patients. A part of the described variation can be explained by patient characteristics. Male gender, age differences (older age), short education, and other ethnicity imply significantly higher odds for POCT. High patient costs in general practice and other parts of primary care also imply higher odds for POCT. In contrast, high patient costs for drugs and/or morbidity in terms of the Charlson Comorbidity index mean lower odds for POCT. The frequency of patients with diabetes per 1000 patients was larger in POCT clinics than Non-POCT clinics. A total of 22.5% of the unexplained variability was related to GP clinics. Conclusions: This study demonstrates variation in the use of POCT which can be explained by patient characteristics such as demographic, socioeconomic, and case mix markers. However, it appears relevant to reassess the system for POCT. Further studies are warranted in order to assess the impacts of POCT of HbA1c on health care outcomes.

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

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

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

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

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

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

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

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

Relations between task delegation and job satisfaction in general practice: a systematic literature review.

BACKGROUND: It has for years been discussed whether practice staff should be involved in patient care in general practice to a higher extent. The research concerning task delegation within general practice is generally increasing, but the literature focusing on its influence on general practitioners' and their staff's job satisfaction appears to be sparse even though job satisfaction is acknowledged as an important factor associated with both patient satisfaction and medical quality of care. Therefore, the overall aim of this study was 1) to review the current research on the relation between task delegation and general practitioners' and their staff's job satisfaction and, additionally, 2) to review the evidence of possible explanations for this relation. METHODS: A systematic literature review. We searched the four databases PubMed, Cinahl, Embase, and Scopus systematically. The immediate relevance of the retrieved articles was evaluated by title and abstract by the first author, and papers that seemed to meet the aim of the review were then fully read by first author and last author independently judging the eligibility of content. RESULTS: We included four studies in the review. They explored views and attitudes of the staff, encompassing nurses as well as practice managers. Only one of the included studies also explored general practitioners' views and attitudes, hence making it impossible to establish any syntheses on this relation. According to the studies, the staff's overall attitude towards task delegation was positive and led to increased job satisfaction, probably because task delegation comprised a high degree of work autonomy. CONCLUSIONS: The few studies included in our review suggest that task delegation within general practice may be seen by the staff as an overall positive issue contributing to their job satisfaction, primarily due to perceived autonomy in the work. However, because of the small sample size comprising only qualitative studies, and due to the heterogeneity of these studies, we cannot draw unambiguous conclusions although we point towards tendencies.

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

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

Medical engagement and organizational characteristics in general practice.

BACKGROUND: Medical engagement is a mutual concept of the active and positive contribution of doctors to maintaining and enhancing the performance of their health care organization, which itself recognizes this commitment in supporting and encouraging high quality care. A Medical Engagement Scale (MES) was developed by Applied Research Ltd (2008) on the basis of emerging evidence that medical engagement is critical for implementing radical improvements. OBJECTIVES: To study the importance of medical engagement in general practice and to analyse patterns of association with individual and organizational characteristics. DESIGN AND SETTING: A cross-sectional study using a sampled survey questionnaire and the official register from the Danish General Practitioners' Organization comprising all registered Danish GPs. METHOD: The Danish version of the MES Questionnaire was distributed and the survey results were analysed in conjunction with the GP register data. RESULTS: Statistically adjusted analyses revealed that the GPs' medical engagement varied substantially. GPs working in collaboration with colleagues were more engaged than GPs from single-handed practices, older GPs were less engaged than younger GPs and female GPs had higher medical engagement than their male colleagues. Furthermore, GPs participating in vocational training of junior doctors were more engaged than GPs not participating in vocational training. CONCLUSION: Medical engagement in general practice varies a great deal and this is determined by a complex interaction between both individual and organizational characteristics. Working in collaboration, having staff and being engaged in vocational training of junior doctors are all associated with enhanced levels of medical engagement among GPs.

How GPs implement clinical guidelines in everyday clinical practice--a qualitative interview study.

BACKGROUND: Clinical guidelines are considered to be essential for improving quality and safety of health care. However, interventions to promote implementation of guidelines have demonstrated only partial effectiveness and the reasons for this apparent failure are not yet fully understood. OBJECTIVE: To investigate how GPs implement clinical guidelines in everyday clinical practice and how implementation approaches differ between practices. METHODS: Individual semi-structured open-ended interviews with seven GPs who were purposefully sampled with regard to gender, age and practice form. Interviews were recorded, transcribed verbatim and then analysed using systematic text condensation. RESULTS: Analysis of the interviews revealed three different approaches to the implementation of guidelines in clinical practice. In some practices the GPs prioritized time and resources on collective implementation activities and organized their everyday practice to support these activities. In other practices GPs discussed guidelines collectively but left the application up to the individual GP whilst others again saw no need for discussion or collective activities depending entirely on the individual GP's decision on whether and how to manage implementation. CONCLUSION: Approaches to implementation of clinical guidelines vary substantially between practices. Supporting activities should take this into account.