Patient safety in general practice during COVID-19: a descriptive analysis in 38 countries (PRICOV-19).

BACKGROUND: This article aims to examine patient safety in general practice during COVID-19. METHODS: In total, 5489 GP practices from 37 European countries and Israel filled in the online self-reported PRICOV-19 survey between November 2020 and December 2021. The outcome measures include 30 patient safety indicators on structure, process, and outcome. RESULTS: The data showed that structural problems often impeded patient safety during COVID-19, as 58.6% of practices (3209/5479) reported limitations related to their building or infrastructure. Nevertheless, GP practices rapidly changed their processes, including the appointment systems. Implementation proved challenging as, although 76.1% of practices (3751/4932) developed a protocol to answer calls from potential COVID patients, only 34.4% (1252/3643) always used it. The proportion of practices reported having sufficient protected time in general practitioners' schedules to review guidelines remained consistent when comparing the pre-COVID (34.2%,1647/4813) with the COVID period (33.2%,1600/4813). Overall, 42.8% of practices (1966/4590) always informed home care services when patients were diagnosed with COVID-19, while this decreased to 30.1% for other major infectious diseases (1341/4458). Most practices reported at least one incident of delayed care in patients with an urgent condition, most often because the patient did not come to the practice sooner (60.4%, 2561/4237). Moreover, 31.1% of practices (1349/4199) always organized a team discussion when incidents happened. Overall, large variations were found across countries and patient safety indicators. CONCLUSIONS: The results demonstrated that European GP practices adopted numerous measures to deliver safe care during COVID-19. However, multilayered interventions are needed to improve infection control and GP practice accessibility in future pandemics.

Developing a competency framework for training with simulations in healthcare: a qualitative study.

BACKGROUND: Simulation is a technique used to create an experience without going through the real event. Competency-based medical education focuses on outcomes and ensures professionals have the necessary knowledge, skills, and attitudes. The purpose of this study was to develop a set of competencies for the instructors providing basic and advanced levels of simulation-based training in healthcare. METHODS: We conducted a qualitative study in three steps, with each next step building on and influenced by the previous one. First, we conducted a literature review, then a consensus development panel, and finally a three-step Delphi process. The participants were experts in the fields of healthcare, education, and simulations. RESULTS: The six main competencies identified for the instructor providing simulation-based training at the basic level in healthcare include knowledge of simulation training, education/training development, education/training performance, human factors, ethics in simulation, and assessment. An instructor providing simulation-based training at an advanced level in healthcare should also possess the following five competencies: policies and procedures, organisation and coordination, research, quality improvement, and crisis management. CONCLUSION: The identified competencies can serve as a valuable resource for simulation educators and organisations involved in simulation education, to plan curriculum and implement a continuous train-the-trainers programme.

Evaluation of a specialist nurse-led structured self-management training for peer supporters with type 2 diabetes mellitus with or without comorbid hypertension in Slovenia.

BACKGROUND: The training of peer supporters is critical because the success of the entire peer support intervention depends on the knowledge and experience that peer supporters can share with other patients. The objective of this study was to evaluate the pilot implementation of a specialist nurse-led self-management training programme for peer supporters with type 2 diabetes mellitus (T2DM) with or without comorbid hypertension (HTN) at the primary healthcare level in Slovenia, in terms of feasibility, acceptability, and effectiveness. METHODS: A prospective pre-post interventional pilot study was conducted in two Community Health Centres (CHC) in Slovenia from May 2021 to August 2022. Purposive sampling was employed to recruit approximately 40 eligible volunteers to become trained peer supporters. A specialist nurse-led structured training lasting 15 h over a 2-month period was delivered, comprising four group and two individual sessions. The comprehensive curriculum was based on interactive verbal and visual learning experience, utilising the Diabetes Conversation Maps™. Data were collected from medical records, by clinical measurements, and using questionnaires on sociodemographic and clinical data, the Theoretical Framework of Acceptability, knowledge of T2DM and HTN, and the Appraisal of Diabetes Scale, and evaluation forms. RESULTS: Of the 36 participants, 31 became trained peer supporters (retention rate of 86.1%). Among them, 21 (67.7%) were women, with a mean age of 63.9 years (SD 8.9). The training was evaluated as satisfactory and highly acceptable. There was a significant improvement in knowledge of T2DM (p < 0.001) and HTN (p = 0.024) among peer supporters compared to baseline. Six months post-training, there was no significant improvement in the quality of life (p = 0.066), but there was a significant decrease in body mass index (BMI) (p = 0.020) from 30.4 (SD 6.2) at baseline to 29.8 (SD 6.2). CONCLUSION: The pilot implementation of a specialist nurse-led self-management training for peer supporters was found to be feasible, acceptable, and effective (in the study group). It led to improvements in knowledge, maintained disease control, and promoted positive self-management behaviours among peer supporters, as evidenced by a decrease in their BMI over six months. The study emphasises the need for effective recruitment, training, and retention strategies. TRIAL REGISTRATION: The research is part of the international research project SCUBY: Scale up diabetes and hypertension care for vulnerable people in Cambodia, Slovenia and Belgium, which is registered in ISRCTN registry ( https://www.isrctn.com/ISRCTN41932064 ).

Cytisine Versus Varenicline for Smoking Cessation in a Primary Care Setting: A Randomized Non-inferiority Trial.

INTRODUCTION: A smoking-cessation program was implemented as a randomized non-inferiority trial in primary care practices in Croatia and Slovenia to investigate whether a standard 4-week treatment with cytisine was at least as effective and feasible as a standard 12-week treatment with varenicline in helping smokers quit. AIMS AND METHODS: Out of 982 surveyed smokers, 377 were recruited to the non-inferiority trial: 186 were randomly assigned to cytisine and 191 to varenicline treatment. The primary cessation outcome was 7-day abstinence after 24 weeks, while the primary feasibility outcome was defined by adherence to the treatment plan. We also compared the rates of adverse events between the two treatment groups. RESULTS: The cessation rate after 24 weeks was 32.46% (62/191) in the varenicline group and 23.12% (43/186) in the cytisine group (odds ratio [OR]: 95%, credible interval [CI]: 0.39 to 0.98). Of 191 participants assigned to varenicline treatment 59.16% (113) were adherent, while 70.43% (131 of 186) were adherent in the cytisine group (OR: 1.65, 95% CI: 1.07 to 2.56). Participants assigned to cytisine experienced fewer total (incidence rate ratio [IRR]: 0.59, 95% CI: 0.43 to 0.81) and fewer severe or more extreme adverse events (IRR: 0.72, 95% CI: 0.35 to 1.47). CONCLUSIONS: This randomized non-inferiority trial (n = 377) found the standard 4-week cytisine treatment to be less effective than the standard 12-week varenicline treatment for smoking cessation. However, adherence to the treatment plan, ie, feasibility, was higher, and the rate of adverse events was lower among participants assigned to cytisine treatment. IMPLICATIONS: The present study found the standard 12 weeks of varenicline treatment to be more effective than the standard 4 weeks of cytisine treatment for smoking cessation in a primary care setting in Croatia and Slovenia. Participants assigned to cytisine, however, had a higher adherence to the treatment plan and a lower rate of adverse events. Estimates from the present study may be especially suitable for generalizations to high-smoking prevalence populations in Europe. Given the much lower cost of cytisine treatment, its lower rate of adverse events, and higher feasibility (but its likely lower effectiveness with the standard dosage regimen), future analyses should assess the cost-effectiveness of the two treatments for health policy considerations.

Cross-sectional study examining psychometric properties of the Slovenian version of the 14-item Resilience Scale (RS-14-SL).

PURPOSE: Resilience has become an important concept in health research, addressing mental health outcomes. The purpose of this study was to translate, adapt, and evaluate psychometric properties of the Slovenian version of the 14-item Resilience Scale (RS-14), using a sample of general population and cancer survivors. METHODS: The original version of the RS-14 was first back-translated and pilot tested. The factor structure was assessed with an exploratory analysis and confirmed with a confirmatory analysis. To assess reliability, internal consistency (Cronbach's alpha) and test-retest (ICC, t student test) were determined. Measurement validity was assessed with demographic (age and gender) and psychological characteristics (symptoms of anxiety and depression and health-related quality of life). RESULTS: An exploratory factor analysis revealed one-factor solution in both samples and the fit indexes showed an acceptable model fit. Internal consistency showed excellent values (0.91-0.96), and test-retest reliability was found to be acceptable (ICC = 0.89). Significant correlations were found between RS-14 and anxiety and depression HADS subscales in Sample 1 (r = - 0.62, - 0.72 for anxiety and depression) and Sample 2 (r = - 0.43, r = - 0.51 for anxiety and depression) and the majority of EQ-5D subscales (usual activities, pain, anxiety/depression). CONCLUSION: The study showed that the Slovenian version of the RS-14 test scores is valid and stable. TRIAL REGISTRATION NUMBER: 0120-25/2019/6.

Perceptions of the primary health care team about the implementation of integrated care of patients with type 2 diabetes and hypertension in Slovenia: qualitative study.

BACKGROUND: Integrated care involves good coordination, networking, and communication within health care services and externally between providers and patients or informal caregivers. It affects the quality of services, is more cost-effective, and contributes to greater satisfaction among individuals and providers of integrated care. In our study, we examined the implementation and understanding of integrated care from the perspective of providers - the health care team - and gained insights into the current situation. METHODS: Eight focus groups were conducted with health care teams, involving a total of 48 health care professionals, including family physicians, registered nurses, practice nurses, community nurses, and registered nurses working in a health education center. Prior to conducting the focus groups, a thematic guide was developed based on the literature and contextual knowledge with the main themes of the integrated care package. The analysis was conducted using the NVivo program. RESULTS: We identified 12 main themes with 49 subthemes. Health care professionals highlighted good accessibility and the method of diagnostic screening integrated with preventive examinations as positive aspects of the current system of integrated care in Slovenia. They mentioned the good cooperation within the team, with the involvement of registered nurses and community nurses being a particular advantage. Complaints were made about the high workload and the lack of workforce. They feel that patients do not take the disease seriously enough and that patients as teachers could be useful. CONCLUSION: Primary care teams described the importance of implementing integrated care for diabetes and hypertension patients at four levels: Patient, community, care providers, and state. Primary care teams also recognized the importance of including more professionals from different health care settings on their team.

An innovative approach to educating primary health care teams about medical emergencies.

Management of emergencies is an integral part of primary care. However, the wide range of symptoms and the rarity of the situations make it difficult for primary care workers to be continually updated and competent in providing life support. In Ljubljana Community Health Centre, we use innovative approaches and modern teaching techniques to educate primary health care teams on how to manage medical emergencies.The three-level educational approach described here enables comprehensive education in managing and recognising dangerous medical situations. It also provides a safe way of learning how to manage difficult, uncommon and serious clinical situations.This comprehensive educational approach is oriented towards continuous improvement in quality and the safety of patients at the primary health care level.

The 14-item Resilience scale as a potential screening tool for depression/anxiety and quality of life assessment: a systematic review of current research.

BACKGROUND: Due to the expensive and time-consuming diagnostics, most general physicians do not use a standardized psychodiagnostic tool to detect depression and anxiety and often rely on their own judgment. This often leads to inaccuracy of identification of patients with mental disorders. OBJECTIVE: To systematically review the literature of the 14-item resilience scale (RS-14) and offer directions for future studies. METHODS: Fourteen studies that included a translated/validated RS-14 regardless of the sample were included through Medline and CINAHL databases and the following questions were addressed: (i) What are the factor structure, internal consistency and repeatability of the RS-14? (ii) Is RS-14 concordant with other scales for measuring resilience, and what is the concurrent validity of this instrument? (iii) What are the critiques, conclusions and limitations of previous studies? RESULTS: Most factor analyses demonstrated a one-factor solution and confirmed 14-item scale. Cronbach's α for was high (M = 0.88); the test-retest reliability was satisfactory in three (0.70 < r > 0.83) out of four studies (r = 0.49). Results of concurrent validity showed positive correlation with some variables, including quality of life and a negative correlation with depression and anxiety. Among other limitations, the biggest drawback was a non-representative sample. CONCLUSIONS: RS-14 was found to perform well in clinical and non-clinical sample. Due to its wide use of population, time efficiency and good results on concurrent validity, we suggest future studies to examine whether RS-14 has a potential to serve as a first distress and quality of life screening tool in the family medicine practices.

Prevalence and factors associated with unmet needs in post-treatment cancer survivors: A systematic review.

Cancer survivors may experience unmet needs beyond the end of their treatment. This paper aimed to explore the prevalence and most frequently found unmet needs and to identify factors associated with higher levels of total unmet needs and with each domain separately. Five databases were searched using the keywords neoplasms, survivors, needs assessment, health services' needs and demands. The results were presented based on the strength of the evidence (strong, moderate and weak association) and the categorisation of the pooled prevalence of at least one unmet need (high, moderate, low). Twenty-six studies were included in the review. A higher prevalence of at least one reported unmet need was observed in survivors with less time since treatment and in women with breast cancer. The most frequently reported unmet needs were fear of cancer recurrence and requesting up to date information. Strong evidence was found for an association between a higher number of unmet needs and younger age, higher anxiety and poorer quality of life. Future studies on unmet needs should report how unmet needs are associated with each domain separately. This might solve the inconclusive evidence found for the stage of the disease at diagnosis and depression.

Transition from a traditional to a comprehensive quality assurance system in Slovenian family medicine practices.

In Slovenia, quality of care at the primary healthcare level is formally a priority, but the legislation to ensure quality in this area is proceeding very slowly. The first steps towards a systematic quality control system in Slovenian family medicine were implemented with the initiation of an ongoing project of renewed family medicine practices in 2011 and the introduction of quality indicators. In 2017, an initiative by the Ministry of Health and the Department of Family Medicine at the Faculty of Medicine, the University of Ljubljana, aimed to develop a new approach to quality assurance and an improvement. It comprises four main parts: the family medicine practice team, a quality control group, a quality control office and the Ministry of Health. In this plan, quality is controlled and improved at the micro, mezzo and macro levels. The described system for quality assurance and improvement is still waiting to be implemented in practice, as there is a lack of human and financial resources.

A Slovenian Model of Comprehensive Care for Patients with Difficulties Accessing Healthcare: A Step Towards Health Equity.

Patients that cannot come to their family medicine practice (i.e. who have difficulties with access) do not receive the same preventive screening activities and management of their chronic diseases as those who can. Community nurses who provide healthcare to patients in their homes were trained in additional competencies, including screening for risk factors for selected diseases and the management of patients with selected chronic diseases. The presented model enables equal management of all registered patients, regardless of accessibility. It also fosters exchange of information within the team members and thus improves the quality of the team management of patients.

Safety culture in the primary health care settings based on workers with a leadership role: the psychometric properties of the Slovenian-language version of the safety attitudes questionnaire - short form.

BACKGROUND: Safety culture describes leader and staff interactions, attitudes, routines, awareness, and practices within an organisation. With this study, we aimed to determine the psychometric properties of the Slovenian-language version of the Safety Attitudes Questionnaire (SAQ) - Short Form in primary health care settings. METHODS: This was a cross-sectional study in the largest primary health care in Slovenia. We invited all employees with a leadership role to participate in the study (N = 211). We used the Slovenian-language version of the SAQ - Short Form. RESULTS: There were 154 participants in the final sample (73.0% response rate), of which 136 (88.3%) were women. The mean age of the sample was 46.2 ± 10.0 years. Exploratory factor analysis put forward six factors: 1) Perceptions of Management; 2) Stress recognition; 3) Teamwork Climate; 4) Communication; 5) Safety Climate; 6) Working Conditions and Satisfaction. This model explained 61.7% of the variance of the safety culture in the primary health care setting. The reliability of the whole scale and of the six factors, assessed using Cronbach's alpha, was all above 0.78. CONCLUSION: The results of our study suggests that the Slovenian-language version of the SAQ - Short Form with six factors could be a reliable and valid tool for measuring the safety culture in the primary health care workers with leadership role In Slovenia. The Slovenian version differed from the original SAQ - Short Form and the majority of other translated versions. Also, the data was from one health centre only and therefore we cannot draw strong conclusions on its external validity.

The safety attitudes questionnaire - ambulatory version: psychometric properties of the Slovenian version for the out-of-hours primary care setting.

BACKGROUND: Several tools have been developed to measure safety attitudes of health care providers, out of which the Safety Attitudes Questionnaire (SAQ) is regarded as one of the most appropriate ones. In 2007, it was adapted to outpatient (primary health care) settings and in 2014 it was tested in out-of-hours health care settings in Norway. The purpose of this study was to translate the English version of the SAQ-Ambulatory Version (SAQ-AV) to Slovenian language; to test its reliability; and to explore its factor structure. METHODS: This was a cross-sectional study that took place in Slovenian out-of-hours primary care clinics in March-May 2015 as a part of an international study entitled Patient Safety Culture in European Out-of-hours services. The questionnaire consisted of the Slovenian version of the SAQ-AV. The link to the questionnaire was emailed to health care workers in the out-of-hours clinics. A total of 438 participants were invited. We performed exploratory factor analysis. RESULTS: Out of 438 invited participants, 250 answered the questionnaire (response rate 57.1%). Exploratory factor analysis put forward five factors: 1) Perceptions of management, 2) Job satisfaction, 3) Safety climate, 4) Teamwork climate, and 5) Communication. Cronbach's alpha of the whole SAQ-AV was 0.922. Cronbach's alpha of the five factors ranged from 0.587 to 0.791. Mean total score of the SAQ-AV was 56.6 ± 16.0 points. The factor with the highest average score was Teamwork climate and the factor with the lowest average was Job satisfaction. CONCLUSIONS: Based on the results in our study, we cannot state that the SAQ-AV is a reliable tool for measuring safety culture in the Slovenian out-of-hours care setting. Our study also showed that there might be other safety culture factors in out-of-hours care not recognised before. We therefore recommend larger studies aiming to identify an alternative factor structure.

Are characteristics of team members important for quality management of chronic patients at primary care level?

AIMS AND OBJECTIVES: To determine the possible associations between higher levels of selected quality indicators and the characteristics of providers. BACKGROUND: In 2011, an ongoing project on a new model of family medicine practice was launched in Slovenia; the family physicians' working team (a family physician and a practice nurse) was extended by a nurse practitioner working 0.5 full-time equivalents. This was an example of a personalised team approach to managing chronic patients. METHODS: We included all family medicine practices in the six units of the Community Health Centre Ljubljana which were participating in the project in December 2015 (N = 66). Data were gathered from automatic electronic reports on quality indicators provided monthly by each practice. We also collected demographic data. RESULTS: There were 66 family medicine teams in the sample, with 165 members of their teams (66 family physicians, 33 nurse practitioners and 66 practice nurses). Fifty-six (84.4%) of the family physicians were women, as were 32 (97.0%) of the nurse practitioners, and 86 (95.5%) of the practice nurses. Multivariate analysis showed that a higher level of the quality indicator "Examination of diabetic foot once per year" was independently associated with nurse practitioners having attended additional education on diabetes, duration of participation in the project, age and years worked since graduation of nurse practitioners, working in the Center unit and not working in the Bezigrad unit. CONCLUSIONS: Characteristics of team members are important in fostering quality management of chronic patients. Nurse practitioners working in new model family practices need obligatory, continuous professional education in the management of chronic patients. RELEVANCE TO CLINICAL PRACTICE: The quality of care of chronic patients depends on the specific characteristics of the members of the team, which should be taken into account when planning quality improvements.

Patients' use of and attitudes towards self-medication in rural and remote Slovenian family medicine practices: a cross-sectional multicentre study.

INTRODUCTION: Self-medication is very common in the general population, but its prevalence can differ according to the place of residence. The aim of this study was to determine the prevalence of self-medication in patients attending rural and remote family physicians, and to detect the important factors that are associated with it. METHODS: A cross-sectional multicentre study was performed in 24 rural and remote family medicine practices in Slovenia was performed. The aim was to include 720 patients who visited their family physicians on a particular day. The authors used a validated questionnaire on self-medication, which consisted of questions about demographic characteristics (sex, age, education and working status), questions about health status, questions about self-medication practices, and questions about attitudes towards self-medication. The level of participants' trust in different sources of medical information was measured by a five-point Likert scale. The participants were asked to take into account the year 2013 when completing the questionnaire. RESULTS: Of 720 invited patients, 371 (51.5%) completed the questionnaire. There were 233 (62.8%) women in the sample. The mean age of the participants was 48.1 (±15.1) years. Self-medication was practised by 300 (80.9%) participants. In multivariate analysis, the variables independently associated with self-medication were information on self-medication obtained from pharmacists, and information on self-medication obtained from relatives. Additionally, some other variables had high odds ratios such as information on self-medication obtained from books, information on self-medication obtained from media, and reason for self-medication: burdening physicians. CONCLUSIONS: The practices of self-medication in rural Slovenia as reported by patients can be defined as moderately safe. People tend to seek more information on self-medication but the main sources for this are lay informants. Further studies are needed to explore the safety of such practices.

Regional coordinators: a new teaching opportunity in family medicine training.

BACKGROUND: A new project on education in family medicine training was implemented last year in Slovenia by establishing regional coordinators in the specialist training programme. They are responsible for conducting regular small-group meetings with family medicine trainees. This study wanted to explore the attitudes and opinions of regional coordinators and family medicine trainees concerning this new method. METHODS: This was a qualitative study based on focus groups. The participants were regional coordinators and family medicine specialist trainees. The data were analysed based on the principles of thematic content analysis with inductive technique. RESULTS: The study revealed five themes which were the same for the analysis of transcripts of both regional coordinators and family medicine trainees: 1) Meetings with trainees; 2) Coordination; 3) Characteristics of regional coordinators; 4) Position of regional coordinators, and 5) Evaluation of regional coordinators. CONCLUSION: Participants of the study have many expectations for this new programme. They expect progress in trainees' clinical knowledge through experience-based group learning and with the help of the tutorship role of regional coordinators. The role of regional coordinators represents a new possibility for solving problems in the training programme in their coordinating role. In future, they have the potential to develop into an expert body that supervises the quality of training. A close follow-up is necessary to see if the position of regional coordinators is adequate and if they meet the expectations of the trainees as well as their own goals. Administrative and financial support for the programme is necessary. The project is important also in enabling the adaptation of the training programme's needs and the regional characteristics of medical care.

Enhancing primary care clerkships with virtual patients.

BACKGROUND: Virtual patients, computer-assisted patient scenarios, have been used in different medical disciplines over several years. Researchers have already gained knowledge on how it helps foster clinical thinking, fills knowledge gaps and enables patient management. Nonetheless, despite these advances in knowledge, the use of virtual patients in Family Medicine education remains limited. OBJECTIVES: We point out the current knowledge, benefits and potential ways of using virtual patients in the Family Medicine setting. DISCUSSION: Virtual patients can be used as a preparation tool for clinical clerkships as well as learning about patient treatment not usually encountered in every day practice. Regardless of the means of implementation, students benefit from acquiring skills through multifaceted virtual patients. We firmly believe that, when intelligently applied, virtual patients can enhance and improve future Family Medicine education.

Process quality indicators in family medicine: results of an international comparison.

BACKGROUND: The aim of our study was to describe variability in process quality in family medicine among 31 European countries plus Australia, New Zealand, and Canada. The quality of family medicine was measured in terms of continuity, coordination, community orientation, and comprehensiveness of care. METHODS: The QUALICOPC study (Quality and Costs of Primary Care in Europe) was carried out among family physicians in 31 European countries (the EU 27 except for France, plus Macedonia, Iceland, Norway, Switzerland, and Turkey) and three non-European countries (Australia, Canada, and New Zealand). We used random sampling when national registers of practitioners were available. Regional registers or lists of facilities were used for some countries. A standardized questionnaire was distributed to the physicians, resulting in a sample of 6734 participants. Data collection took place between October 2011 and December 2013. Based on completed questionnaires, a three-dimensional framework was established to measure continuity, coordination, community orientation, and comprehensiveness of care. Multilevel linear regression analysis was performed to evaluate the variation of quality attributable to the family physician level and the country level. RESULTS: None of the 34 countries in this study consistently scored the best or worst in all categories. Continuity of care was perceived by family physicians as the most important dimension of quality. Some components of comprehensiveness of care, including medical technical procedures, preventive care and health care promotion, varied substantially between countries. Coordination of care was identified as the weakest part of quality. We found that physician-level characteristics contributed to the majority of variation. CONCLUSIONS: A comparison of process quality indicators in family medicine revealed similarities and differences within and between countries. The researchers found that the major proportion of variation can be explained by physicians' characteristics.

Role of nurse practitioners in reducing cardiovascular risk factors: a retrospective cohort study.

AIMS AND OBJECTIVES: To determine the impact of nurse practitioners' counselling on reducing cardiovascular risk factors in patients participating in routine preventive check-ups. BACKGROUND: A new model of 'renewed' family practice was introduced in Slovenia as a pilot project in 2011, in which nurse practitioners are included in a team carrying out preventive activities and managing patients with stable chronic diseases. DESIGN: A retrospective cohort study. METHODS: This study was conducted in 16 family medicine practices (eight renewed and eight regular family practices). In each family practice, a systematic sample was selected of registered patients participating in a cardiovascular preventive check-up. Data on sex, age, blood pressure, cholesterol, blood sugar, smoking, level of physical activity and cardiovascular risk were collected. Patients attending renewed family practices received counselling on risk factors from nurse practitioners (test group), and patients attending regular family practices received counselling from family physicians (control group). Data were collected again at least one and no more than five years after the baseline consultation. RESULTS: There were 128 patients in the test group and 129 patients in the control group. At the control visit, the patients counselled by nurse practitioners had significantly lower levels of systolic blood pressure and cholesterol and practiced regular physical activity significantly more often than patients counselled by family physicians. CONCLUSION: Nurse practitioners can be at least as successful as physicians when counselling patients on cardiovascular risk factors during their preventive check-ups. RELEVANCE TO CLINICAL PRACTICE: This study showed that nurse practitioners have an important role in managing patients at the primary care level.

Development and validation of a questionnaire for evaluation of students' attitudes towards family medicine.

The development of the EURACT (European Academy of Teachers in General Practice) Educational Agenda helped many family medicine departments in development of clerkship and the aims and objectives of family medicine teaching. Our aims were to develop and validate a tool for assessment of students' attitudes towards family medicine and to evaluate the impact of the clerkship on students' attitudes regarding the competences of family doctor. In the pilot study, experienced family doctors were asked to describe their attitudes towards family medicine by using the Educational Agenda as a template for brainstorming. The statements were paraphrased and developed into a 164-items questionnaire, which was administered to 176 final-year students in academic year 2007/08. The third phase consisted of development of a final tool using statistical analysis, which resulted in the 60-items questionnaire in six domains which was used for the evaluation of students' attitudes. At the beginning of the clerkship, person-centred care and holistic approach scored lower than the other competences. Students' attitudes regarding the competences at the end of 7 weeks clerkship in family medicine were more positive, with exception of the competence regarding primary care management. The students who named family medicine as his or her future career choice, found holistic approach as more important than the students who did not name it as their future career. With the decision tree, which included students' attitudes to the competences of family medicine, we can successfully predict the future career choice in family medicine in 93.5% of the students. This study reports on the first attempt to develop a valid and reliable tool for measuring attitudes towards family medicine based on EURACT Educational Agenda. The questionnaire could be used for evaluating changes of students' attitudes in undergraduate curricula and for prediction of students' preferences regarding their future professional career in family medicine.