Optimising a clinical decision support tool to improve chronic kidney disease management in general practice.

BACKGROUND: Early identification and treatment of chronic disease is associated with better clinical outcomes, lower costs, and reduced hospitalisation. Primary care is ideally placed to identify patients at risk of, or in the early stages of, chronic disease and to implement prevention and early intervention measures. This paper evaluates the implementation of a technological intervention called Future Health Today that integrates with general practice EMRs to (1) identify patients at-risk of, or with undiagnosed or untreated, chronic kidney disease (CKD), and (2) provide guideline concordant recommendations for patient care. The evaluation aimed to identify the barriers and facilitators to successful implementation. METHODS: Future Health Today was implemented in 12 general practices in Victoria, Australia. Fifty-two interviews with 30 practice staff were undertaken between July 2020 and April 2021. Practice characteristics were collected directly from practices via survey. Data were analysed using inductive and deductive qualitative analysis strategies, using Clinical Performance - Feedback Intervention Theory (CP-FIT) for theoretical guidance. RESULTS: Future Health Today was acceptable, user friendly and useful to general practice staff, and supported clinical performance improvement in the identification and management of chronic kidney disease. CP-FIT variables supporting use of FHT included the simplicity of design and delivery of actionable feedback via FHT, good fit within existing workflow, strong engagement with practices and positive attitudes toward FHT. Context variables provided the main barriers to use and were largely situated in the external context of practices (including pressures arising from the COVID-19 pandemic) and technical glitches impacting installation and early use. Participants primarily utilised the point of care prompt rather than the patient management dashboard due to its continued presence, and immediacy and relevance of the recommendations on the prompt, suggesting mechanisms of compatibility, complexity, actionability and credibility influenced use. Most practices continued using FHT after the evaluation phase was complete. CONCLUSIONS: This study demonstrates that FHT is a useful and acceptable software platform that provides direct support to general practice in identifying and managing patients with CKD. Further research is underway to explore the effectiveness of FHT, and to expand the conditions on the platform.

[Integrative medicine for patients suffering from addictive disorders alongside other pathologies in general practice]. / Clinique intégrative des addictions coexistant avec d'autres pathologies en médecine générale.

People suffering from substance use disorders frequently suffer from concomitant affections such as other addictions, psychiatric, somatic or social problems. Clarifying objectives and priorities with the patient and coordination of care are the priority in the follow up suggested in this article. We present a clinical example in which the modality of care is adapted depending on the evolution of the patient's needs. The follow up by a general practitioner can be pursued in parallel to specialized care. The modality of this collaboration will have to adapt to the patients' and healthcare workers' needs. This follow-up aims to provide good quality health care all the while supporting the healthcare providers who can, sometimes, feel helplessness.

Les personnes souffrant d'un trouble de l'utilisation de substances présentent fréquemment plusieurs affections parallèles telles que d'autres problématiques addictologiques, psychiatriques, somatiques ou sociales. La clarification des objectifs et priorités avec le patient ainsi que la coordination des soins sont au premier plan de la prise en charge proposée dans cet article. Nous présentons, au travers d'une vignette clinique, un exemple de suivi pour lequel la modalité de prise en charge s'adapte aux besoins changeants du patient au cours du temps. Le suivi par un médecin généraliste peut être combiné à un suivi spécialisé. Le mode de collaboration devra s'adapter aux besoins des soignants et du patient. Ce suivi visera à assurer des soins de qualité tout en soutenant les soignants face à un possible sentiment d'impuissance.

Feasibility and acceptability of general practitioners using sit-stand desks: a feasibility trial.

OBJECTIVES: The primary aim of this study was to investigate the feasibility and acceptability of general practitioners (GPs) using sit-stand desks to facilitate standing during consultations. A further aim was to examine the views of patients about GPs standing for their consultations. DESIGN: A pre-post single-group experimental trial design. SETTING: General practices in England, UK. PARTICIPANTS: 42 GPs (working a minimum of five clinical sessions per week) and 301 patients (aged ≥18 years). INTERVENTIONS: The intervention consisted of each GP having a sit-stand desk (Opløft Sit-Stand Platform) installed in their consultation room for 4 working weeks. Sit-stand desks allow users to switch, in a few seconds, between a sitting and standing position and vice versa, by adjusting the height of the desk. MAIN OUTCOME MEASURES: To test feasibility and acceptability, GPs reported their views about using sit-stand desks at work at baseline and follow-up. Sitting time and physical activity were also measured via accelerometer at baseline and follow-up. Patients who attended a consultation where their GP was standing were asked to complete an exit questionnaire about the perceived impact on the consultation. RESULTS: Most GPs reported using their sit-stand desk daily (n=28, 75.7%). 16 GPs (44.4%) used their sit-stand desk during face-to-face consultations every day. Most GPs and patients did not view that GPs standing during face-to-face consultations impacted the doctor-patient relationship (GPs; 73.5%, patients; 83.7%). GPs' sitting time during work was 121 min per day lower (95% CI: -165 to -77.58) at follow-up compared with baseline. CONCLUSIONS: Use of sit-stand desks is acceptable within general practice and may reduce sitting time in GPs. This may benefit GPs and help reduce sitting time in patients. TRIAL REGISTRATION NUMBER: ISRCTN76982860.

Guide to shave procedures in general practice.

BACKGROUND: General practitioners manage a significant proportion of inflammatory and neoplastic skin conditions on a daily basis. Various surgical techniques can be employed to aid in diagnosis, including punch biopsies, shave biopsy, shave excision, incisional biopsy, curettage and formal excision with closure. Requiring minimal equipment, shave procedures are quick to perform, produce good cosmetic outcomes and minimise costs. OBJECTIVE: Our aim is to discuss shave procedures in detail and highlight the difference between shave biopsies and shave excisions, as well as the role they each have in diagnosing an array of benign, inflammatory and malignant skin conditions, including melanocytic lesions. DISCUSSION: Shave procedures performed on suitable lesions by trained practitioners can be used for sampling or removing suspect lesions. Where the intent is complete removal, margin involvement is rare given good lesion selection and technique.

Assessment and management of sleep disorders in shift workers: Challenges and considerations for general practice.

BACKGROUND: Shift work is characterised by displaced sleep opportunities and associated sleep disturbance. Shift workers often report sleepiness and other wake time symptoms associated with poor sleep. However, clinical sleep disorders are also prevalent in shift workers. Although prevalence rates are similar or higher in shift workers compared with the general population, help seeking in shift workers with sleep disorders is low. OBJECTIVE: This article aims to provide general practitioners with a contemporary overview of the prevalence rates for sleep disorders in shift workers, to clarify the existing evidence relating to mental and physical health consequences of sleep disorders in shift workers and to highlight the need to consider undiagnosed sleep disorders before attributing sleep-related symptoms solely to work schedules. DISCUSSION: Symptoms of sleep loss associated with shift work overlap with symptoms experienced by individuals living with sleep disorders. Although >40% of middle-aged Australians live with a sleep disorder that requires investigation and management, symptoms in shift workers are often attributed to the work schedule and, as a result, might not be investigated for appropriate diagnosis and treatment. We argue that screening for sleep disorders in shift workers with sleep complaints should be a priority.

Heavy drinkers' expectations and experiences when discussing alcohol use during a general practice visit in Australia: A qualitative study.

BACKGROUND AND OBJECTIVES: Our understanding of community members' expectations and experiences of discussing alcohol use in general practice settings is limited, particularly for people with heavy alcohol use. METHOD: Qualitative interviews were conducted with people with heavy alcohol use to explore their experiences of discussing alcohol use with their general practitioner (GP). Interviews were audio-recorded and transcribed, and data were analysed using an inductive thematic approach. RESULTS: Three themes were identified: (1) patient perceptions of alcohol discussions in primary care; (2) the importance of the doctor-patient relationship; and (3) consequences of unmet health needs and expectations. Patients expect their GPs to initiate conversations about alcohol use. Positive interactions are characterised by GPs' caring, non-judgemental and collaborative approach, whereas negative interactions focus on a perceived lack of knowledge or ability to manage excessive alcohol use. DISCUSSION: Alcohol harm reduction efforts should include strategies for bolstering the therapeutic relationship between GPs and their patients.

Impact of COVID-19 on asthma management in general practice: A qualitative study.

BACKGROUND AND OBJECTIVES: The COVID-19 pandemic catalysed unprecedented changes to healthcare delivery in Australia, leading to a rapid transformation of asthma management, to which healthcare providers and patients have had to adapt. Understanding the impact of these changes is critical as we emerge from pandemic-affected workflows. METHOD: A qualitative study using semistructured interviews was conducted with 19 general practitioners across Sydney and regional New South Wales. Reflexive thematic analysis of interview data was undertaken. RESULTS: Four key themes were identified: disorganised asthma care before COVID­19; chaotic asthma care during the pandemic; adapting to non-guideline-driven telehealth asthma care; and widening health agenda misalignment. DISCUSSION: This study highlights the triumphs and gaps in asthma management during the pandemic and the vulnerability of existing asthma care systems to disruption. These lessons can be used to re-evaluate how we deliver asthma care and inform future models of care as we transition towards a 'post-COVID' landscape.

Assisting young people aged 12-25 years to cease e-cigarette use in general practice.

BACKGROUND: Increasing numbers of young people (adolescents aged 12-17 years and young adults aged 18-25 years) are using e-cigarettes. Although the extent of the health effects is currently unknown, young people are at risk of developing nicotine dependence and, as a result, find it difficult to cease use of e-cigarettes. They might seek help from their general practitioner (GP) to do so. OBJECTIVE: This article summarises the available evidence for e-cigarette cessation in young people and suggests a rational approach to assist GPs seeing young people seeking help for e-cigarette cessation. DISCUSSION: There is limited evidence to support best treatment options for e-cigarette cessation in young people. An approach based on the experience from tobacco cessation in adults and adapted for young people might assist. Management that supports family and school engagement, with behavioural interventions, nicotine replacement therapy, other pharmacological interventions and ongoing review as appropriate for the young person's age and developmental milestones, might help successful e-cigarette cessation.

Electronic health record-based behaviour change interventions aimed at general practitioners in the UK: a mixed methods systematic review using behaviour change theory.

OBJECTIVES: Electronic health record (EHR) systems are used extensively in healthcare; their design can influence clinicians' behaviour. We conducted a systematic review of EHR-based interventions aimed at changing the clinical practice of general practitioners in the UK, assessed their effectiveness and applied behaviour change theory to identify lessons for other settings. DESIGN: Mixed methods systematic review. DATA SOURCES: MEDLINE, EMBASE, CENTRAL and APA PsycINFO were searched up to March 2023. ELIGIBILITY CRITERIA: Quantitative and qualitative findings from randomised controlled trials (RCTs) controlled before-and-after studies and interrupted time series of EHR-based interventions in UK general practice were included. DATA EXTRACTION AND SYNTHESIS: Quantitative synthesis was based on Cochrane's Synthesis without Meta-analysis. Interventions were categorised using the Behaviour Change Wheel and MINDSPACE frameworks and effectiveness determined by vote-counting using direction of effect. Inductive thematic synthesis was used for qualitative studies. RESULTS: Database searching identified 3824 unique articles; 10 were included (from 2002 to 2021), comprising eight RCTs and two associated qualitative studies. Four of seven quantitative studies showed a positive effect on clinician behaviour and three on patient-level outcomes. Behaviour change techniques that may trigger emotions and required less cognitive engagement appeared to have positive effects. Qualitative findings indicated that interventions reassured clinicians of their decisions but were sometimes ignored. CONCLUSION: Despite widespread use, there is little high quality, up-to-date experimental evidence evaluating the effectiveness of EHR-based interventions in UK general practice. The evidence suggested EHR-based interventions may be effective at changing behaviour. Persistent, simple action-oriented prompts appeared more effective than complex interventions requiring greater cognitive engagement. However, studies lacked detail in intervention design and theory behind design choices. Future research should seek to optimise EHR-based behaviour change intervention design and delineate limitations, providing theory-based justification for interventions. This will be of increasing importance with the growing use of EHRs to influence clinicians' decisions. PROSPERO REGISTRATION NUMBER: CRD42022341009.

The feasibility, acceptability and appropriateness of screening for frailty in Australians aged 75 years and over attending Australian general practice.

Background Globally, frailty is associated with a high prevalence of avoidable hospital admissions and emergency department visits, with substantial associated healthcare and personal costs. International guidelines recommend incorporation of frailty identification and care planning into routine primary care workflow to support patients who may be identified as pre-frail/frail. Our study aimed to: (1) determine the feasibility, acceptability, appropriateness and determinants of implementing a validated FRAIL Scale screening Tool into general practices in two disparate Australian regions (Sydney North and Brisbane South); and (2) map the resources and referral options required to support frailty management and potential reversal. Methods Using the FRAIL Scale Tool, practices screened eligible patients (aged ≥75years) for risk of frailty and referred to associated management options. The percentage of patients identified as frail/pre-frail, and management options and referrals made by practice staff for those identified as frail/pre-frail were recorded. Semi-structured qualitative interviews were conducted with practice staff to understand the feasibility, acceptability, appropriateness and determinants of implementing the Tool. Results The Tool was implemented by 19 general practices in two Primary Health Networks and 1071 consenting patients were assessed. Overall, 80% of patients (n =860) met the criterion for frailty: 33% of patients (n =352) were frail, and 47% were pre-frail (n =508). They were predominantly then referred for exercise prescription, medication reviews and geriatric assessment. The Tool was acceptable to staff and patients and compatible with practice workflows. Conclusions This study demonstrates that frailty is identified frequently in Australians aged ≥75years who visit their general practice. It's identification, linked with management support to reverse or reduce frailty risk, can be readily incorporated into the Medicare-funded annual 75+ Health Assessment.

Optimising personal continuity for older patients in general practice: a cluster randomised stepped wedge pragmatic trial.

AIM: To evaluate the effectiveness, feasibility and acceptability of a multicomponent intervention for improving personal continuity for older patients in general practice. DESIGN: A cluster randomised three-wedged, pragmatic trial during 18 months. SETTING: 32 general practices in the Netherlands. PARTICIPANTS: 221 general practitioners (GPs), practice assistants and other practice staff were included. Practices were instructed to include a random sample of 1050 patients aged 65 or older at baseline and 12-month follow-up. INTERVENTION: The intervention took place at practice level and included opTimise persOnal cOntinuity for oLder (TOOL)-kit: a toolbox containing 34 strategies to improve personal continuity. OUTCOMES: Data were collected at baseline and at six 3-monthly follow-up measurements. Primary outcome measure was experienced continuity of care at the patient level measured by the Nijmegen Continuity Questionnaire (NCQ) with subscales for personal continuity (GP knows me and GP shows commitment) and team/cross-boundary continuity at 12-month follow-up. Secondary outcomes were measured in GPs, practice assistants and other practice staff and included work stress and satisfaction and perceived level of personal continuity. In addition, a process evaluation was undertaken among GPs, practice assistants and other practice staff to assess the acceptability and feasibility of the intervention. RESULTS: No significant effect of the intervention was observed on NCQ subscales GP knows me (adjusted mean difference: 0.05 (95% CI -0.05 to 0.15), p=0.383), GP shows commitment (0.03 (95% CI -0.08 to 0.14), p=0.668) and team/cross-boundary (0.01 (95% CI -0.06 to 0.08), p=0.911). All secondary outcomes did not change significantly during follow-up. Process evaluation among GPs, practice assistants and other practice staff showed adequate acceptability of the intervention and partial implementation due to the COVID-19 pandemic and a high perceived workload. CONCLUSION: Although participants viewed TOOL-kit as a practical and accessible toolbox, it did not improve personal continuity as measured with the NCQ. The absence of an effect may be explained by the incomplete implementation of TOOL-kit into practice and the choice of general outcome measures instead of outcomes more specific for the intervention. TRIAL REGISTRATION NUMBER: International Clinical Trials registry Platform (ICTRP), trial NL8132 (URL: ICTRP Search Portal (who.int).

Access and triage in contemporary general practice: A novel theory of digital candidacy.

To access contemporary healthcare, patients must find and navigate a complex socio-technical network of human and digital actors linked in multi-modal pathways. Asynchronous, digitally-mediated triage decisions have largely replaced synchronous conversations between humans. In this paper, we draw on a large qualitative dataset from a multi-site study of remote and digital technologies in general practice to understand widening inequities of access. We theorise our data by bringing together traditional candidacy theory (in particular, concepts of self-assessment, help-seeking, adjudication and negotiation) and socio-technical and technology structuration theories (in particular, concepts of user configuration, articulation, distanciation, disembedding, and recursivity), thus producing a novel theory of digital candidacy. We propose that both human and technological actors (in different ways) embody social structures which affect how they 'act' in social situations. Digital technologies contain inbuilt assumptions about users' capabilities, needs, rights, and skills. Patients' ability to self-assess as sick, access digital platforms, self-advocate, and navigate multiple stages in the pathway, including adapting to and compensating for limitations in the technology, vary widely and are markedly patterned by disadvantage. Not every patient can craft an accurate digital facsimile on which the subsequent adjudication decision will be made; those who create incomplete, flawed or unpersuasive digital facsimiles may be deprioritised or misdirected. Staff who know about such patients may use articulation measures to ensure a personalised and appropriate access package, but they cannot identify or fully mitigate all such cases. The decisions and actions of human and technological agents at the time of an attempt to access care can significantly influence, disrupt, and reconstitute candidacy both immediately and recursively over time, and also recursively shape the system itself. These findings underscore the need for services to be (co-)designed with attention to the exclusionary tendencies of digital technologies and technology-supported processes and pathways.

Collective Intelligence Increases Diagnostic Accuracy in a General Practice Setting.

BACKGROUND: General practitioners (GPs) work in an ill-defined environment where diagnostic errors are prevalent. Previous research indicates that aggregating independent diagnoses can improve diagnostic accuracy in a range of settings. We examined whether aggregating independent diagnoses can also improve diagnostic accuracy for GP decision making. In addition, we investigated the potential benefit of such an approach in combination with a decision support system (DSS). METHODS: We simulated virtual groups using data sets from 2 previously published studies. In study 1, 260 GPs independently diagnosed 9 patient cases in a vignette-based study. In study 2, 30 GPs independently diagnosed 12 patient actors in a patient-facing study. In both data sets, GPs provided diagnoses in a control condition and/or DSS condition(s). Each GP's diagnosis, confidence rating, and years of experience were entered into a computer simulation. Virtual groups of varying sizes (range: 3-9) were created, and different collective intelligence rules (plurality, confidence, and seniority) were applied to determine each group's final diagnosis. Diagnostic accuracy was used as the performance measure. RESULTS: Aggregating independent diagnoses by weighing them equally (i.e., the plurality rule) substantially outperformed average individual accuracy, and this effect increased with increasing group size. Selecting diagnoses based on confidence only led to marginal improvements, while selecting based on seniority reduced accuracy. Combining the plurality rule with a DSS further boosted performance. DISCUSSION: Combining independent diagnoses may substantially improve a GP's diagnostic accuracy and subsequent patient outcomes. This approach did, however, not improve accuracy in all patient cases. Therefore, future work should focus on uncovering the conditions under which collective intelligence is most beneficial in general practice. HIGHLIGHTS: We examined whether aggregating independent diagnoses of GPs can improve diagnostic accuracy.Using data sets of 2 previously published studies, we composed virtual groups of GPs and combined their independent diagnoses using 3 collective intelligence rules (plurality, confidence, and seniority).Aggregating independent diagnoses by weighing them equally substantially outperformed average individual GP accuracy, and this effect increased with increasing group size.Combining independent diagnoses may substantially improve GP's diagnostic accuracy and subsequent patient outcomes.

Translating evidence into practice in primary care management of adolescents and women with polycystic ovary syndrome: a mixed-methods study.

BACKGROUND: The international guideline on polycystic ovary syndrome (PCOS) provides evidence-based recommendations on the management of PCOS. Guideline implementation tools (GItools) were developed for general practitioner (GP) use to aid rapid translation of guidelines into practice. This mixed-methods study aimed to evaluate barriers and enablers of the uptake of PCOS GItools in general practice. DESIGN AND SETTING: A cross-sectional survey was distributed through professional networks and social media to GPs and GPs in training in Australia. Survey respondents were invited to contribute to semi-structured interviews. Interviews were audio-recorded and transcribed verbatim. Qualitative data were thematically analysed and mapped deductively to the Theoretical Domains Framework and Capability, Opportunity, Motivation and Behaviour model. RESULTS: The study engaged 146 GPs through surveys, supplemented by interviews with 14 participants. A key enabler to capability was reflective practice. Barriers relating to opportunity included limited awareness and difficulty locating and using GItools due to length and lack of integration into practice software, while enablers included ensuring recommendations were relevant to GP scope of practice. Enablers relevant to motivation included co-use with patients, and evidence of improved outcomes with the use of GItools. DISCUSSION: This study highlights inherent barriers within the Australian healthcare system that hinder GPs from integrating evidence for PCOS. Findings will underpin behaviour change interventions to assist GPs in effectively utilising guidelines in clinical practice, therefore minimising variations in care. While our findings will have a direct influence on guideline translation initiatives, changes at organisational and policy levels are also needed to address identified barriers.

Expectations of general practitioners on a practice based research network in Germany- a qualitative study within the Bavarian Research Practice Network (BayFoNet).

BACKGROUND: Despite general practitioners' (GPs') key role in Germany`s primary health care, clinical research in general practice is scarce. Clinical research is mainly conducted at inpatient facilities, although their results are rarely transferable. German GPs have no extra time or funding for research, as well as limited research training. To support clinical research in German primary health care, practice-based research networks (PBRNs) are developed. As they will be based on an active involvement of GPs, we need more information on GPs` participation-readiness. The aim of this study was to explore facilitators and barriers to participation in the Bavarian Research Practice Network (BayFoNet) from the GPs`perspective before clinical trials will be performed. METHODS: We have performed semi-structured qualitative interviews with a purposive sample of 20 Bavarian GPs in 2022 under the application of the consolidated framework for implementation research (CFIR). Transcriptions were analysed according to Kuckartz` qualitative content analysis. The five domains of the CFIR framework served as initial deductive codes. RESULTS: N = 14 interviewees already agreed to participate in BayFoNet, whereas n = 6 interviewees opted not to participate in BayFoNet at the time of data collection. Main facilitators to conduct clinical research within BayFoNet were the motivation to contribute to evidence strength and quality in general practice, professional development and training of practice staff, as well as networking. Barriers for an active participation were bad experiences with previous clinical studies and lack of resources. CONCLUSIONS: PBRNS in Germany have to be promoted and the entire practice team has to be involved at an early stage of development. Professional training of general practice staff and a living network might enhance engagement. Participatory approaches could help to develop acceptable and feasible study designs. Furthermore, PBRNs should support patient recruitment and data collection in general practices and disseminate the results of their research projects regularly to maintain GPs` engagement. TRIAL REGISTRATION: DRKS00028805, NCT05667207.

Childhood obesity prevention in general practice: supporting implementation through co-ideation.

BACKGROUND: Childhood obesity is associated with physical and psychological complications thus the prevention of excess weight gain in childhood is an important health goal. Relevant to the prevention of childhood obesity, Australian general practice-specific, preventive care guidelines recommend General Practitioners (GPs) conduct growth monitoring and promote a number of healthy behaviours. However, challenges to providing preventive care in general practice may impact implementation. In October and November, 2022, a series of three workshops focusing on the prevention of childhood obesity were held with a group of Australian GPs and academics. The objective of the workshops was to determine practical ways that GPs can be supported to address barriers to the incorporation of obesity-related prevention activities into their clinical practice, for children with a healthy weight. METHODS: This paper describes workshop proceedings, specifically the outcomes of co-ideation activities that included idea generation, expansion of the ideas to possible interventions, and the preliminary assessment of these concepts. The ecological levels of the individual, interpersonal, and organisation were considered. RESULTS: Possible opportunities to support childhood obesity prevention were identified at multiple ecological levels within the clinic. The preliminary list of proposed interventions to facilitate action included GP education and training, clinical audit facilitation, readily accessible clinical guidelines with linked resources, a repository of resources, and provision of adequate growth monitoring tools in general practice. CONCLUSIONS: Co-ideation with GPs resulted in a number of proposed interventions, informed by day-to-day practicalities, to support both guideline implementation and childhood obesity prevention in general practice.

Changes in work tasks and organization of general practice in Norway during the COVID-19 pandemic: results from a comparative international study.

BACKGROUND: The COVID-19 pandemic led to huge and rapid changes in general practice in Norway as in the rest of Europe. This paper aims to explore to what extent the COVID-19 pandemic changed the work tasks and organization of Norwegian general practice. MATERIAL AND METHOD: We analysed data from the Norwegian part of the international, cross-sectional PRICOV-19 study, collecting data from general practice via an online self-reported questionnaire. We included 130 Norwegian general practices, representing an estimated 520 Norwegian general practitioners (GPs). All Norwegian GPs were invited to participate. In the analyses, we focused on items related to the use of alternatives to face-to-face consultations, changes in the workload, tasks and delegated responsibilities of both the GPs and other personnel in the GP offices, adaptations in routines related to hygiene measures, triage of patients, and how the official rules and recommendations affected the practices. RESULTS: There was a large and significant increase in the use of all forms of alternative consultation forms (digital text-based, video- and telephone consultations). The use of several different infection prevention measures were significantly increased, and the provision of hand sanitizer to patients increased from 29.6% pre-pandemic to 95.1% since the pandemic. More than half of the GPs (59.5%) reported that their responsibilities in the practice had increased, and 41% were happy with the task shift. 27% felt that they received adequate support from the government; however, 20% reported that guidelines from the government posed a threat to the well-being of the practice staff. We found no associations with the rurality of the practice location or size of the municipalities. CONCLUSION: Norwegian GPs adapted well to the need for increased use of alternatives to face-to-face consultations, and reported a high acceptance of their increased responsibilities. However, only one in four received adequate support from the government, which is an important learning point for similar situations in the future.

Interconception care in Australian general practice: a qualitative study.

BACKGROUND: GPs provide care for women across the lifespan. This care currently includes preconception and postpartum phases of a woman's life. Interconception care (ICC) addresses women's health issues between pregnancies that then have impact on maternal and infant outcomes, such as lifestyle and biomedical risks, interpregnancy intervals, and contraception provision. However, ICC in general practice is not well established. AIM: To explore GP perspectives about ICC. DESIGN AND SETTING: Qualitative interviews were undertaken with GPs between May and July 2018. METHOD: Eighteen GPs were purposively recruited from South-Eastern Australia. Audiorecorded semi- structured interviews were transcribed verbatim and analysed thematically using the Framework Method. RESULTS: Most participants were unfamiliar with the concept of ICC. Delivery was mainly opportunistic, depending on the woman's presenting need. Rather than a distinct and required intervention, participants conceptualised components of ICC as forming part of routine practice. GPs described many challenges including lack of clarity about recommended ICC content and timing, lack of engagement and perceived value from mothers, and time constraints during consultations. Facilitators included care continuity and the availability of patient education material. CONCLUSION: Findings indicate that ICC is not a familiar concept for GPs, who feel that they have limited capacity to deliver such care. Further research to evaluate patient perspectives and potential models of care is required before ICC improvements can be developed, trialled, and evaluated. These models could include the colocation of multidisciplinary services and services in combination with well-child visits.

"You're stuck in the middle here": a qualitative study of GPs' experiences of managing knee pain attributed to a degenerative meniscal tear.

BACKGROUND: Exercise is the recommended first-line therapy for a degenerative meniscal tear (DMT). Despite this, knee pain attributed to DMTs are a common presentation to specialist orthopaedic clinics. In the primary care setting, the general practitioner (GP) plays a central role in managing patients with knee pain, but to date their perspective has not been explored in relation to DMTs. This study explored GPs' experiences of managing people with knee pain attributed to a DMT. METHODS: A qualitative research design was adopted and practices in the South and Mid-West of Ireland were contacted via recruitment emails circulated through professional and research networks. Interested GPs contacted the researchers via email, and purposive and snowball sampling was used for recruitment. Semi-structured interviews were conducted online or over the telephone. Interviews were digitally recorded and transcribed. Data was analysed using an inductive approach to thematic analysis. Ethical approval was granted by the Irish College of General Practitioners (ICGP_REC_21_0031). RESULTS: Seventeen semi-structured one-on-one interviews were conducted. Three main themes were identified with related subthemes: (1) GPs' experiences of relational aspects of care, (2) GP beliefs about what constitutes best care for patients with a DMT, and (3) how GP practice is enacted within the current healthcare setting. GPs described the challenge of maintaining a strong clinical alliance, while managing perceived patient expectations of a 'quick fix' and advanced imaging. They reported slowing down clinical decisions and feeling 'stuck' with limited options when conservative treatment had failed. GPs believed that exercise should be the core treatment for DMTs and emphasised engaging patients in an active approach to recovery. Some GPs believed arthroscopy had a role in circumstances where patients didn't improve with physiotherapy. Limited access to public physiotherapy and orthopaedic services hampered GPs' management plans and negatively impacted patient outcomes. CONCLUSIONS: GP beliefs around what constitutes best care for a DMT generally aligned with the evidence base. Nonetheless, there was sometimes tension between these beliefs and the patient's own treatment expectations. The ability to enact their beliefs was hampered by limited access to conservative management options, sometimes leading to early escalation of care.