Reducing long-term use of benzodiazepine receptor agonists: In-depth interview study with primary care stakeholders.

AIMS: To increase our understanding of which factors contribute to long-term benzodiazepine receptor agonist (BZRA) use for insomnia in primary care, from a patients', general practitioners' (GP) and pharmacists' perspective. DESIGN: Qualitative research following a grounded theory approach. SETTING: Primary care in Belgium. PARTICIPANTS: Twenty-four participants were interviewed, including nine patients, six GPs and nine pharmacists. MEASUREMENTS: In-depth, semistructured interviews with iterative cycles of data collection and analysis. Transcripts were analysed using the framework method. Thematic findings were interpreted in the context of the Theoretical Domains Framework. FINDINGS: A reflexive relation was identified between views about hypnotic use at the level of society, healthcare and patients. Behaviour change appeared to depend strongly on context and social influence, including a need for supporting relationships by all stakeholders. Six key messages captured factors that contribute to long-term BZRA use for insomnia in primary care: societal beliefs as a game changer, the opportunity of nonpharmacological treatment, collaborative primary care, patient-centred goals, informed consent and self-management. CONCLUSIONS: Long-term BZRA use for insomnia is a complex and multifaceted public health problem that is not adequately addressed in primary care at this time. Although primary care professionals in this study found discontinuation of long-term BZRA use relevant to the patient's health, many organisational and personal barriers were reported. Moreover, the current social and healthcare context is not empowering patients and professionals to reduce long-term BZRA use for insomnia. Specifically, for primary care, all stakeholders reported the need for a nonmedicalised relationship between the patient and GP to lower prescribing rates. PATIENT OR PUBLIC CONTRIBUTION: The Flemish Patient Platform, a patient representative organisation, assisted with recruitment by launching a call for participants in their newsletter and volunteered to disseminate the results. The call for recruitment was also published online in social media groups regarding insomnia and via posters in public pharmacies. Patients or public were not involved in designing or conducting the interview study.

Development of TOEKAN, a 360° evaluation tool for the clinical learning environment in General Practice postgraduate training.

BACKGROUND: The General Practice (GP) postgraduate program exists for 80% out of workplace learning. The quality of the clinical learning environment (CLE) has a direct effect on the quality of training and the professional development of GP trainees. METHODOLOGY: Participatory research was used to involve all stakeholders in the development process of a 360° evaluation tool that should improve the average quality of GP training practices, guide GP trainees towards the best training practices and detect and remediate GP trainers of lower quality. RESULTS: TOEKAN (Tool for Communication and Evaluation of Quality Standards) was developed, which consists of a 72-item questionnaire for GP trainees and GP trainers and an 18-item questionnaire for those who coach and remediate GP trainers. The outcomes of the TOEKAN questionnaires are visualized in an online dashboard. DISCUSSION: TOEKAN is the first 360° evaluation tool for CLE in GP education. All stakeholders will complete the survey on a regular basis and have access to the results. By creating intrinsic and extrinsic motivation as well as mediation measures, the quality of CLE will improve. Continuous monitoring of the use and outcomes of TOEKAN will allow to critically review and improve this new evaluation tool as well as support the broader implementation.

A Qualitative Exploration of Multiple Perspectives on Transfer of Learning Between Classroom and Clinical Workplace.

Phenomenon: Transfer of learning between classroom and workplace appears to be difficult. Various conceptions about learning in either the classroom or the workplace exist among stakeholders, yet little is known about their conceptions of the transfer of learning between both settings. This study explored stakeholders' conceptions about transfer of learning between classroom-based learning and workplace practice. APPROACH: Homogeneous focus groups with students, medical teachers, and workplace supervisors were conducted using a constructivist grounded theory approach. FINDINGS: The 54 participants' conceptions mainly related to their beliefs about who was responsible for (a) preparing for transfer of learning, (b) being at the workplace and connecting back to classroom-based learning, and (c) reflecting on transfer of learning and continuing the process. A continuum was recognized between those who held medical teachers/workplace supervisors responsible and those who held students responsible. Insights: There appears to be a variety of conceptions about who is responsible for enabling the transfer process. These conceptions may influence learning and instructional activities. Hence, it may be necessary to make these beliefs explicit in order to better align stakeholders' conceptions. To this end, the conceptual framework created in this study may be a useful tool.

"At the time I only wanted to relieve stress": Exploring motivation for behaviour change in long-term hypnotic users.

Background: Motivating patients to discontinue long-term benzodiazepine receptor agonist (BZRA) use for insomnia remains an important challenge in primary care because of the medication's unfavourable risk-benefit profile. Previous studies have shown that understanding the complexity of patients' motivation is crucial to the primary care physician for providing effective interventions efficiently. Theoretical frameworks about behaviour change show that motivation is a multi-layered concept that interacts with other concepts, which aligns with a holistic perspective or implementation of the biopsychosocial model. Aim: Exploring primary care patients' views and ideas on what factors helped or hindered them in discontinuing long-term BZRA use, in relation to motivation as conceptualised in the Behaviour Change Wheel, and associated domains of the Theoretical Domains Framework. Design and setting: A qualitative study with semi-structured interviews in primary care in Belgium between September 2020 and March 2021. Method: Eighteen interviews with long-term hypnotic users were audio recorded, transcribed and thematically analyzed, using the Framework Method. Results: The success of discontinuation interventions does not solely rely on patients' spontaneous sense of striving for improvement. Reinforcement and identity were found to be important domains for motivation. Beliefs about personal capabilities, and about consequences of both BZRA intake and discontinuation, differed between previous and current users. Conclusion: Motivation is a multi-layered concept which is not fixed in time. Patient empowerment and goal setting could help long-term BZRA users to lower their intake. As well as public health interventions that might change social attitudes towards the use of hypnotic medication.

Implementing Blended Care to Discontinue Benzodiazepine Receptor Agonist Use for Insomnia: Process Evaluation of a Pragmatic Cluster Randomized Controlled Trial.

BACKGROUND: Long-term use of benzodiazepine receptor agonists (BZRAs) remains common despite European guidelines advising that these drugs be used in the lowest possible dose and for the shortest possible duration. Half of all BZRAs are prescribed in family practice. This creates a window of opportunity for discontinuation in primary care. Therefore, the effectiveness of blended care for the discontinuation of long-term BZRA use in adult primary care patients with chronic insomnia disorder was tested in a multicenter, pragmatic, and cluster randomized controlled superiority trial in Belgium. In the literature, information on implementing blended care in a primary care setting is scarce. OBJECTIVE: The study aimed to contribute to a framework for the successful implementation of blended care in a primary care setting by increasing our understanding of this complex intervention through an evaluation of e-tool use and views and ideas of participants in a BZRA discontinuation trial. METHODS: Based on a theoretical framework, this study evaluated the processes of recruitment, delivery, and response using 4 components: a survey on recruitment (n=76), semistructured in-depth interviews with patients (n=18), web-based asynchronous focus groups with general practitioners (GPs; n=19), and usage data of the web-based tool. Quantitative data were analyzed descriptively, and qualitative data were analyzed thematically. RESULTS: For recruitment, the most common barriers were refusal by the patient and the lack of digital literacy, while facilitators were starting the conversation and the curiosity of patients. The delivery of the intervention to the patients was diverse, ranging from GPs who never informed the patient about their access to the e-tool to GPs consulting the e-tool in between consultations to have discussion points when the patient visited. Concerning response, patients' and GPs' narratives also showed much variety. For some GPs, daily practice changed because they received more positive reactions than expected and felt empowered to talk more often about BZRA discontinuation. Conversely, some GPs reported no changes in practice or among patients. In general, patients found follow-up by an expert to be the most important component in blended care, whereas GPs deemed the intrinsic motivation of patients to be the key element of success. An important barrier to implementation by the GP was time. CONCLUSIONS: Overall, the participants who had used the e-tool were positive about its structure and content. Nevertheless, many patients desired a more tailored application with feedback from an expert and personal tapering schedules. Strict pragmatic implementation of blended care seems to only reach GPs with an interest in digitalization. Although not superior to usual care, blended care could be a complementary tool that allows tailoring the discontinuation process to the personal style of the GP and the needs of the patient. TRIAL REGISTRATION: ClinicalTrials.gov NCT03937180; https://clinicaltrials.gov/ct2/show/NCT03937180.

Does it make sense to use written instruments to assess communication skills? Systematic review on the concurrent and predictive value of written assessment for performance.

OBJECTIVES: To evaluate possible associations between learners' results in written and performance-based assessments of communication skills (CS), either in concurrent or predictive study designs. METHODS: Search included four databases for peer-reviewed studies containing both written and performance-based CS assessment. Eleven studies met the inclusion criteria. RESULTS: Included studies predominantly assessed undergraduate medical students. Studies reported mainly low to medium correlations between written and performance-based assessment results (Objective Structured Clinical Examinations or encounters with simulated patients), and gave correlation coefficients ranging from 0.13 to 0.53 (p < 0.05). Higher correlations were reported when specific CS, like motivational interviewing were assessed. Only a few studies gave sufficient reliability indicators of both assessment formats. CONCLUSIONS: Written assessment scores seem to predict performance-based assessments to a limited extent but cannot replace them entirely. Reporting of assessment instruments' psychometric properties is essential to improve the interpretation of future findings and could possibly affect their predictive validity for performance. PRACTICE IMPLICATIONS: Within longitudinal CS assessment programs, triangulation of assessment including written assessment is recommended, taking into consideration possible limitations. Written assessments with feedback can help students and trainers to elaborate on procedural knowledge as a strong support for the acquisition and transfer of CS to different contexts.

Trends in the registration of anxiety in Belgian primary care from 2000 to 2021: a registry-based study.

BACKGROUND: Anxiety is frequently encountered in general practice, but figures regarding prevalence and incidence in this healthcare setting remain scarce. AIM: To provide insight about the trends in prevalence and incidence of anxiety in Belgian general practice, as well as the comorbidities and treatment of anxiety in this context. DESIGN AND SETTING: Retrospective cohort study using the INTEGO morbidity registration network, with clinical data from over 600 000 patients in Flanders, Belgium. METHOD: Trends in age-standardised prevalence and incidence of anxiety from 2000 to 2021 as well as prescriptions in patients with prevalent anxiety were analysed with joinpoint regression. Comorbidity profiles were analysed using the Cochran-Armitage test and the Jonckheere-Terpstra test. RESULTS: During the 22-year study period, 8451 unique patients with anxiety were identified. The prevalence of anxiety diagnoses rose significantly during this period, from 1.1% in 2000 to 4.8% in 2021. The overall incidence rate rose from 1.1/1000 patient-years (PY) in 2000 to 9.9/1000 PY in 2021. The average chronic disease count per patient increased significantly during the study period, from 1.5 to 2.3 chronic conditions. The most frequent comorbidities in patients with anxiety in 2017-2021 were malignancy (20.1%), hypertension (18.2%), and irritable bowel syndrome (13.5%). The proportion of patients treated with psychoactive medication rose from 25.7% to almost 40% over the study period. CONCLUSION: A significantly increasing prevalence and incidence of physician-registered anxiety was found in the study. Patients with anxiety tend to become more complex, with more comorbidities. Treatment for anxiety in Belgian primary care is very dependent on medication.

Blended care to discontinue benzodiazepine receptor agonists use in patients with chronic insomnia disorder: a pragmatic cluster randomized controlled trial in primary care.

STUDY OBJECTIVES: International guidelines recommend using benzodiazepine receptor agonists (BZRA) for maximally four weeks. Nevertheless, long-term use for chronic insomnia disorder remains a common practice. This study aimed to test the effectiveness of blended care for discontinuing long-term BZRA use in general practice. METHODS: A pragmatic cluster randomized controlled superiority trial compared blended care to usual care through urine toxicology screening. In the intervention, care by the general practitioner (GP) was complemented by an interactive e-learning program, based on cognitive behavioral therapy for insomnia. Adults using BZRA daily for minimally 6 months were eligible. Participants were clustered at the level of the GP surgery for allocation (1:1). Effectiveness was measured as the proportion of patients who had discontinued at one-year follow-up. Data analysis followed intention-to-treat principles. RESULTS: In total, 916 patients in 86 clusters, represented by 99 GPs, were randomized. Primary outcome data was obtained from 727 patients (79%). At one-year follow-up, 82 patients (18%) in blended care, compared to 91 patients (20%) in usual care, had discontinued. There was no statistically significant effect for the intervention (OR: 0.924; 95% CI: 0.60; 1.43). No adverse events were reported to the research team. CONCLUSIONS: The findings did not support the superiority of blended care over usual care. Both strategies showed clinical effectiveness, with an average of 19% of patients having discontinued at one-year follow-up. Further research is important to study the effect of structurally implementing digital interventions in general practice. CLINICAL TRIAL: Big Bird trial; KCE-17016. This trial is registered at clinicaltrials.gov (NCT03937180).

Co-design to increase implementation of insomnia guidelines in primary care.

BACKGROUND: Sleep disorders, including insomnia, are widespread problems, which have increased during the COVID-19 pandemic. Guidelines for the treatment of insomnia prioritize non-pharmacological interventions. Nevertheless, primary care professionals lack well-developed material for patient education, that could help implement the treatment guidelines in Flanders, Belgium. OBJECTIVE: This project's purpose is to develop complementary, written educational material, grounded in the principles of evidence-based practice, for primary care. PATIENT INVOLVEMENT: This co-design project involved patients and health professionals. Special attention was given to including patients with low health literacy, and empowering patients when designing in mixed groups. METHODS: Based on the framework of Sanders and Stappers (2014), data were collected and analyzed in four phases. Pre-design, needs were explored using think-aloud studies and focus groups. Next, for generative purposes, the design studio method was used. Then, evaluation of the prototype happened with another series of think-aloud studies. Finally, post-design, implementation of the product was evaluated with a short survey. RESULTS: Twenty-five participants (10 patients and 15 healthcare professionals) contributed to the development of an educational patient leaflet called Sssssst. How do you sleep (at night)? Out of 30 professionals who received the printed leaflet for use in practice, 17 provided feedback after six months. Generally, the leaflet was well received. Visual design aspects stimulated use in practice. DISCUSSION: Written and visual materials aid primary care professionals to educate patients on sleep and insomnia. This supporting tool also stimulates self-management in patients. Although inspiring and educational for all stakeholders, a co-design approach is no guarantee for the product to "fit all".

Evolution of benzodiazepine receptor agonist prescriptions in general practice: A registry-based study.

Background: Contrary to most European guidelines, benzodiazepine receptor agonists (BZRA) are often used continuously at a low dosage, being the most common form of long-term use. In Belgium, BZRA use is monitored by analyzing self-report data about medication use in the last 24 h. This method provides insufficient insight into the terms of use of these psychoactive drugs. Aim: To describe trends in BZRA prescribing in Flanders, Belgium, between 2000 and 2019. Design and setting: Population-based trend analysis and a case-control study for the year 2019 were done with data from a morbidity registry in general practice. Methods: Repeated cross-sectional and joinpoint regression analyses revealed trends in sex- and age-standardized prescription rates among adult patients (18+). Results: Overall, BZRA prescriptions increased. The highest overall increase was found among male patients 18-44 years old, with an average annual percentage change of 2.5 (95% CI: 0.9, 4.3). Among 65+ female patients, a decrease was found since 2006, with an annual percentage change of -0.7 (95% CI: -1.3, -0.1). In 2019, 12% of registered patients received minimally one prescription, long-term use was observed in 5%, back pain was the most common morbidity significantly associated with a rise in BZRA prescriptions, and zolpidem was the most prescribed BZRA (22%). Conclusion: Despite some statistically significant decreasing trends, an overall increase in BZRA prescriptions was observed throughout the 19-year study period, especially among long-term users of 18-44 years and 65-plus. Zolpidem became the most prescribed BZRA and warrants more attention.

Trends in the epidemiology of depression and comorbidities from 2000 to 2019 in Belgium.

BACKGROUND: Depression is a common mental disorder in family practice with an impact on global health. The aim of this study is to provide insight in the trends of epidemiological measures as well as pharmacological treatments and comorbidities of depression. METHODS: A study using data from INTEGO, a family practice registration network in Flanders, Belgium. Trends in age-standardized prevalence and incidence of depression from 2000 to 2019 as well as antidepressant prescriptions in prevalent depression cases were analyzed with join point regression. Comorbidity profiles were explored using the Cochran-Armitage test and the Jonckheere-Terpstra test. RESULTS: We identified 538 299 patients older than 15 years during the study period. We found an increasing trend in the age-standardized prevalence of depression from 6.73 % in 2000 to 9.20 % in 2019. For the incidence of depression, a decreasing trend was observed from 2000 to 2015 with an incidence of 9.42/1000 in 2000 and 6.89/1000 in 2015, followed by an increasing trend from 2015 to 2019 (incidence of 13.64/1000 in 2019). The average number of chronic diseases per patient with depression increased significantly during the study period (from 1.2 to 1.8), and the proportion of patients relative to the whole study population that received at least one antidepressant prescription per year increased between 2000 and 2019 from 26.44% to 40.16%. CONCLUSIONS: The prevalence of depression increases while the incidence sharply rises, but only in recent years. Patients with depression tend to have more comorbidities, making a multi-faceted approach to these patients more important.

What do we know about written assessment of health professionals' communication skills? A scoping review.

OBJECTIVE: The aim of this scoping review was to investigate the published literature on written assessment of communication skills in health professionals' education. METHODS: Pubmed, Embase, Cinahl and Psychnfo were screened for the period 1/1995-7/2020. Selection was conducted by four pairs of reviewers. Four reviewers extracted and analyzed the data regarding study, instrument, item, and psychometric characteristics. RESULTS: From 20,456 assessed abstracts, 74 articles were included which described 70 different instruments. Two thirds of the studies used written assessment to measure training effects, the others focused on the development/validation of the instrument. Instruments were usually developed by the authors, often with little mention of the test development criteria. The type of knowledge assessed was rarely specified. Most instruments included clinical vignettes. Instrument properties and psychometric characteristics were seldom reported. CONCLUSION: There are a number of written assessments available in the literature. However, the reporting of the development and psychometric properties of these instruments is often incomplete. Practice implications written assessment of communication skills is widely used in health professions education. Improvement in the reporting of instrument development, items and psychometrics may help communication skills teachers better identify when, how and for whom written assessment of communication should be used.

Community involvement facilitating the discussion of alcohol use in primary care: A nominal group study.

BACKGROUND: Hazardous alcohol use significantly affects health and wellbeing in society. General practitioners (GPs) are uniquely positioned to address this problem by integrating early identification and brief intervention (EIBI) in daily practice. Unfortunately, EIBI implementation remains low. Community-oriented strategies (COS), defined as public health activities directed to the general population, are suggested to address this implementation gap. COS aim to increase the understanding, engagement and empowerment within the population to facilitate EIBI delivery. However, no consensus on what COS should contain exists. OBJECTIVES: To obtain insight in the stakeholders' perspectives and create consensus with them on COS with the highest potential to facilitate EIBI delivery. METHODS: Four nominal group sessions were conducted with 31 stakeholders representing 12 different stakeholder groups from Leuven (Belgium). Stakeholders generated ideas, reflected on them in group and prioritised them anonymously, creating four separate lists. Merging these lists with their relative scores resulted in a master list, which was checked for accuracy through a member check. Qualitative content analysis on the stakeholder's notes provided an in-depth exploration of their perspectives. RESULTS: Twenty-one strategies were identified, nine of which were COS. Highlighting the GPs' proactive role was considered most relevant. Other foci included creating awareness on the effects of alcohol use and normalising discussing alcohol use within the community. A holistic approach, exceeding the sole focus on COS, combining community, healthcare and government was accentuated. CONCLUSION: Stakeholders emphasise addressing the proactive role of GPs as most promising COS, though it should be delivered within a holistic multi-component approach.

Effectiveness of a blended care programme for the discontinuation of benzodiazepine use for sleeping problems in primary care: study protocol of a cluster randomised trial, the Big Bird trial.

INTRODUCTION: Problematic benzodiazepine use is a global health issue. Although the adverse side effects of long-term use of benzodiazepines are well known, it remains difficult to implement interventions for discontinuation in primary care. Considering the success of blended care for the treatment of sleeping disorders and the support of substance use disorders, evidence suggests that a blended care approach, combining face-to-face consultations with the general practitioner with web-based self-learning by the patient, is beneficial for the discontinuation of chronic benzodiazepine use for primary insomnia in general practice. Therefore, the aim of this study is to evaluate the effectiveness of such an approach for the discontinuation of benzodiazepine and zolpidem, zopiclone and zaleplon drugs ((z-)BZD) use in the long term and evaluate the implementation process. METHODS AND ANALYSIS: This study is a multicentre, pragmatic, cluster randomised controlled trial with 1200 patients, included by 120 general practitioners. Allocation to usual or blended care happens at the level of the general practice in a 1:1 ratio using a block randomisation system stratified per language. The study population consists of adult primary care patients who have been using (z-)BZD for primary insomnia on a daily basis for at least 6 months. Primary outcome measure is the proportion of patients that discontinued (z-)BZD at 12 months assessed by toxicological screening for (z-)BZD in urine. Secondary outcomes include discontinuation of (z-)BZD at 6 months, quality of life and the number of defined daily doses of (z-)BZD prescribed. Data will be collected using a study-specific online platform and analysed using the intention-to-treat approach. The process of implementing blended care will be evaluated in a nested study. ETHICS AND DISSEMINATION: This trial was approved by the Ethics Committee for Research of UZ/KU Leuven (ref. S61194). Study results will be disseminated via open-access, peer-reviewed publications and conference presentations. TRIAL REGISTRATION NUMBER: NCT03937180.

General principles to consider when designing a clinical communication assessment program.

OBJECTIVES: Assessment of clinical communication helps teachers in healthcare education determine whether their learners have acquired sufficient skills to meet the demands of clinical practice. The aim of this paper is to give input to educators when planning how to incorporate assessment into clinical communication teaching by building on the authors' experience and current literature. METHODS: A summary of the relevant literature within healthcare education is discussed, focusing on what and where to assess, how to implement assessment and how to choose appropriate methodology. RESULTS: Establishing a coherent approach to teaching, training, and assessment, including assessing communication in the clinical context, is discussed. Key features of how to implement assessment are presented including: establishing a system with both formative and summative approaches, providing feedback that enhances learning and establishing a multi-source and longitudinal assessment program. CONCLUSIONS: The implementation of a reliable, valid, credible, feasible assessment method with specific educational relevance is essential for clinical communication teaching. PRACTICE IMPLICATIONS: All assessment methods have strengths and limitations. Since assessment drives learning, assessment should be aligned with the purpose of the teaching program. Combining the use of different assessment formats, multiple observations, and independent measurements in different settings is advised.

Optimizing the utility of communication OSCEs: omit station-specific checklists and provide students with narrative feedback.

OBJECTIVE: To evaluate how the utility (reliability, validity, acceptability, feasibility, cost and educational impact) of a communication-OSCE was influenced by whether or not station-specific (StSp) checklists were used together with a generic instrument and whether or not narrative feedback was provided to students. METHODS: At ten stations, faculty members rated standardized patient-student interactions using the common ground (CG) instrument (at all stations) and StSp-checklists. Both raters and patients provided written feedback. The impact of changing the design on the various utility parameters was assessed: reliability by means of a generalizability study, cost using the Reznick model and the other utility parameters by means of a survey. RESULTS: Use of the generic instrument (CG) proved more reliable (G coefficient=0.67) than using the StSp-checklists (G=0.47) or both (G=0.65) while there was a high correlation between both scale scores (Pearsons'r=0.86). The cost was 6.5% higher when StSp-checklists were used and 5% higher when narrative feedback was provided. CONCLUSION: The utility of a communication OSCE can be enhanced by omitting StSp-checklists and by providing narrative feedback to students. PRACTICE IMPLICATIONS: The same generic assessment scale can be used in all stations of a communication OSCE. Providing feedback to students is promising but it increases the costs.

Vocational trainees' views and experiences regarding the learning and teaching of communication skills in general practice.

OBJECTIVE: To explore the views and experiences of general practice (GP) vocational trainees regarding communication skills (CS) and the teaching and learning of these skills. METHODS: A purposive sample of second and third (final) year GP trainees took part in six focus group (FG) discussions. Transcripts were coded and analysed in accordance with a grounded theory approach by two investigators using Alas-ti software. Finally results were triangulated by means of semi-structured telephone interviews. RESULTS: The analysis led to three thematic clusters: (1) trainees acknowledge the essential importance of communication skills and identified contextual factors influencing the learning and application of these skills; (2) trainees identified preferences for learning and receiving feedback on their communication skills; and (3) trainees perceived that the assessment of communication skills is subjective. These themes are organised into a framework for a better understanding of trainees' communication skills as part of their vocational training. CONCLUSIONS: The framework helps in leading to a better understanding of the way in which trainees learn and apply communication skills. PRACTICE IMPLICATIONS: The unique context of vocational training should be taken into account when trainees' communication skills are assessed. The teaching and learning should be guided by a learner-centred approach. The framework is valuable for informing curricular reform and future research.

Patients' ideas, concerns, and expectations (ICE) in general practice: impact on prescribing.

BACKGROUND: Although studies are available on patients' ideas, concerns, and expectations in primary care, there is a scarcity of studies that explore the triad of ideas, concerns, and expectations (ICE) in general practice consultations and the impact on medication prescribing. AIM: To evaluate the presence of ICE and its relation to medication prescription. DESIGN OF STUDY: Cross-sectional study. SETTING: Thirty-six GP teaching practices affiliated with the University of Ghent, in Flanders, Belgium. METHOD: Participants were all patients consulting on 30 May 2005, and their doctors. Reasons for an encounter (consultation or home visit) with new and follow-up contacts, the identification of ICE, and the prescription of medication were recorded by 36 trainee GPs undergoing observational training. The study included 613 consultations. RESULTS: One, two, or three of the ICE components were expressed in 38.5%, 24.4%, and 20.1% (n = 236, 150, 123) of contacts respectively. On the other hand, in 17.0% (104/613) of all contacts, and in 22% (77/350) of the new contact reasons, no ICE was voiced, and the GPs operated without knowing this information about the patients. Mean number of ICE components per doctor and per contact was 1.54 (standard deviation = 0.54). A logistic regression analysis of the 350 new contacts showed that the presence of concerns (P = 0.037, odds ratio [OR] 1.73, 95% confidence interval [CI] = 1.03 to 2.9), and expectations (P = 0.009, OR = 2.0, 95% CI = 1.2 to 3.4) was associated with not prescribing new medication (dichotomised into the categories present/absent); however, other patient, doctor, and student variables were not significantly associated with medication prescription. CONCLUSION: An association was found between the presence of concerns and/or expectations, and less medication prescribing. The data suggest that exploring ICE components may lead to fewer new medication prescriptions.

Comparison of two instruments for assessing communication skills in a general practice objective structured clinical examination.

OBJECTIVE: In recent decades, there has been increased interest in tools for assessing and improving the communication skills of general practice trainees. Recently, experts in the field rated the older Maas Global (MG) and the newer Common Ground (CG) instruments among the better communication skills assessment tools. This report seeks to establish their cross-validity. METHODS: Eighty trainees were observed by 2 raters for each instrument in 2 standardised patient stations from the final year objective structured clinical examination for Belgian trainee general practitioners. Each instrument was assigned 6 raters. RESULTS: Trainees showed the lowest mean scores for evaluating the consultation (MG7), summarising (MG11), addressing emotions (MG9) and addressing feelings (CG5). Inter-rater kappa statistics revealed fair-to-moderate agreement for the MG and slight-to-fair agreement for the CG. Cronbach's alpha was 0.78 for the MG and 0.89 for the CG. A generalisability study was only feasible for the MG: it was more helpful to increase the number of cases than the number of raters. Agreement between the instruments was examined using kappa statistics, Bland-Altman plots and multi-level analysis. Ranking the trainees for each instrument revealed similar results for the least competent trainees. Variances between and within trainees differed between instruments, whereas case specificity was comparable. Multi-level analysis also revealed a rater-item interaction effect. CONCLUSIONS: The 2 instruments have convergent validity, but the drawbacks of the CG, which has fewer items to be scored, include lower inter-rater reliability and score variance within trainees.