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The perceived meaning of a (w)holistic view among general practitioners and district nurses in Swedish primary care: a qualitative study

BackgroundThe definition of primary care varies between countries. Swedish primary care has developed from a philosophic viewpoint based on quality, accessibility, continuity, co-operation and a holistic view. The meaning of holism in international literature differs between medicine and nursing. The question is, if the difference is due to different educational traditions. Due to the uncertainties in defining holism and a holistic view we wished to study, in depth, how holism is perceived by doctors and nurses in their clinical work. Thus, the aim was to explore the perceived meaning of a holistic view among general practitioners (GPs) and district nurses (DNs).MethodsSeven focus group interviews with a purposive sample of 22 GPs and 20 nurses working in primary care in two Swedish county councils were conducted. The interviews were transcribed verbatim and analysed using qualitative content analysis.ResultsThe analysis resulted in three categories, attitude, knowledge, and circumstances, with two, two and four subcategories respectively. A professional attitude involves recognising the whole person; not only fragments of a person with a disease. Factual knowledge is acquired through special training and long professional experience. Tacit knowledge is about feelings and social competence. Circumstances can either be barriers or facilitators. A holistic view is a strong motivator and as such it is a facilitator. The way primary care is organised can be either a barrier or a facilitator and could influence the use of a holistic approach. Defined geographical districts and care teams facilitate a holistic view with house calls being essential, particularly for nurses. In preventive work and palliative care, a holistic view was stated to be specifically important. Consultations and communication with the patient were seen as important tools.ConclusionHolistic view is multidimensional, well implemented and very much alive among both GPs and DNs. The word holistic should really be spelt wholistic to avoid confusion with complementary and alternative medicine. It was obvious that our participants were able to verbalise the meaning of a wholistic view through narratives about their clinical, every day work. The possibility to implement a wholistic perspective in their work with patients offers a strong motivation for GPs and DNs.

Health Alliance for Prudent Prescribing, Yield and Use of Antimicrobial Drugs in the Treatment of Respiratory Tract Infections (HAPPY AUDIT)

BackgroundExcessive and inappropriate use of antibiotics is considered to be the most important reason for development of bacterial resistance to antibiotics. As antibiotic resistance may spread across borders, high prevalence countries may serve as a source of bacterial resistance for countries with a low prevalence. Therefore, bacterial resistance is an important issue with a potential serious impact on all countries.The majority of respiratory tract infections (RTIs) are treated in general practice. Most infections are caused by virus and antibiotics are therefore unlikely to have any clinical benefit. Several intervention initiatives have been taken to reduce the inappropriate use of antibiotics in primary health care, but the effectiveness of these interventions is only modest. Only few studies have been designed to determine the effectiveness of multifaceted strategies in countries with different practice setting. The aim of this study is to evaluate the impact of a multifaceted intervention targeting general practitioners (GPs) and patients in six countries with different prevalence of antibiotic resistance: Two Nordic countries (Denmark and Sweden), two Baltic Countries (Lithuania and Kaliningrad-Russia) and two Hispano-American countries (Spain and Argentina).Methods/DesignHAPPY AUDIT was initiated in 2008 and the project is still ongoing. The project includes 15 partners from 9 countries. GPs participating in HAPPY AUDIT will be audited by the Audit Project Odense (APO) method. The APO method will be used at a multinational level involving GPs from six countries with different cultural background and different organisation of primary health care. Research on the effect of the intervention will be performed by analysing audit registrations carried out before and after the intervention. The intervention includes training courses on management of RTIs, dissemination of clinical guidelines with recommendations for diagnosis and treatment, posters for the waiting room, brochures to patients and implementation of point of care tests (Strep A and CRP) to be used in the GPssurgeries.To ensure public awareness of the risk of resistant bacteria, media campaigns targeting both professionals and the public will be developed and the results will be published and widely disseminated at a Working Conference hosted by the World Association of Family Doctors (WONCA-Europe) at the end of the project period.DiscussionHAPPY AUDIT is an EU-financed project with the aim of contributing to the battle against antibiotic resistance through quality improvement of GPs diagnosis and treatment of RTIs through development of intervention programmes targeting GPs, parents of young children and healthy adults. It is hypothesized that the use of multifaceted strategies combining active intervention by GPs will be effective in reducing prescribing of unnecessary antibiotics for RTIs and improving the use of appropriate antibiotics in suspected bacterial infections.

Health Alliance for prudent antibiotic prescribing in patients with respiratory tract infections (HAPPY AUDIT) -impact of a non-randomised multifaceted intervention programme

BackgroundExcessive use of antibiotics is worldwide the most important reason for development of antimicrobial resistance. As antibiotic resistance may spread across borders, high prevalence countries may serve as a source of bacterial resistance for countries with a low prevalence. Therefore, bacterial resistance is an important issue with a potential serious impact on all countries. Initiatives have been taken to improve the quality of antibiotic prescribing in primary care, but only few studies have been designed to determine the effectiveness of multifaceted strategies across countries with different practice setting. The aim of this study was to evaluate the impact of a multifaceted intervention targeting general practitioners (GPs) and patients in six countries with different health organization and different prevalence of antibiotic resistance.MethodsGPs from two Nordic countries, two Baltic Countries and two Hispano-American countries registered patients with respiratory tract infections (RTIs) in 2008 and 2009. After first registration they received individual prescriber feedback and they were offered an intervention programme that included training courses, clinical guidelines, posters for waiting rooms, patient brochures and access to point of care tests (Strep A and C-Reactive Protein). Antibiotic prescribing rates were compared before and after the intervention.ResultsA total of 440 GPs registered 47011 consultations; 24436 before the intervention (2008) and 22575 after the intervention (2009). After the intervention, the GPs significantly reduced the percentage of consultations resulting in an antibiotic prescription. In patients with lower RTI the GPs in Lithuania reduced the prescribing rate by 42%, in Russia by 25%, in Spain by 25%, and in Argentina by 9%. In patients with upper RTIs, the corresponding reductions in the antibiotic prescribing rates were in Lithania 20%, in Russia 15%, in Spain 9%, and in Argentina 5%.ConclusionA multifaceted intervention programme targeting GPs and patients and focusing on improving diagnostic procedures in patients with RTIs may lead to a marked reduction in antibiotic prescribing. The pragmatic before-after design used may suffer from some limitations and the reduction in antibiotic prescribing could be influenced by factors not related to the intervention.

Validating the Johns Hopkins ACG Case-Mix System of the elderly in Swedish primary health care

BackgroundIndividualbased measures for comorbidity are of increasing importance for planning and funding health care services. No measurement for individualbased healthcare costs exist in Sweden. The aim of this study was to validate the Johns Hopkins ACG Case-Mix Systems predictive value of polypharmacy (regular use of 4 or more prescription medicines) used as a proxy for health care costs in an elderly population and to study if the prediction could be improved by adding variables from a population based study i.e. level of education, functional status indicators and health perception.MethodsThe Johns Hopkins ACG Case-Mix System was applied to primary health care diagnoses of 1402 participants (60–96 years) in a cross-sectional community based study in Karlskrona, Sweden (the Swedish National study on Ageing and Care) during a period of two years before they took part in the study. The predictive value of the Johns Hopkins ACG Case-Mix System was modeled against the regular use of 4 or more prescription medicines, also using age, sex, level of education, instrumental activity of daily living- and measures of health perception as covariates.ResultsIn an exploratory biplot analysis the Johns Hopkins ACG Case-Mix System, was shown to explain a large part of the variance for regular use of 4 or more prescription medicines. The sensitivity of the prediction was 31.9%, whereas the specificity was 88.5%, when the Johns Hopkins ACG Case-Mix System was adjusted for age. By adding covariates to the model the sensitivity was increased to 46.3%, with a specificity of 90.1%. This increased the number of correctly classified by 5.6% and the area under the curve by 11.1%.ConclusionThe Johns Hopkins ACG Case-Mix System is an important factor in measuring comorbidity, however it does not reflect an individuals capability to function despite a disease burden, which has importance for prediction of comorbidity. In this study we have shown that information on such factors, which can be obtained from short questionnaires increases the probability to correctly predict an individuals use of resources, such as medications.

Wound management for 287 patients with chronic leg ulcers demands 12 full-time nurses Leg ulcer epidemiology and care in a well-defined population in southern Sweden

Objective - To study the prevalence, aetiology and treatment of chronic leg and foot ulcers, and to estimate the nurses time in wound management. Design - A structured questionnaire with 19 questions about chronic ulcers and wound management was sent to all district and community nurses in the county during 1 week in March 1998. A similar questionnaire has been administered regularly since 1986. Setting - Primary and community care in the county of Blekinge, Sweden, with a population of 151 610. Patients - 287 patients with chronic leg and foot ulcers were identified during the week studied. Main outcome measures - Prevalence of leg and foot ulcers, ulcer aetiology, treatment of ulcers and wound management time. Results - The estimated prevalence of chronic leg and foot ulcers was 0.19%. Venous ulcers were the most common (38%), of which 87% were treated with some form of compression therapy. Seven percent of the nurses workload was devoted to ulcer care. During the period 1986 to 1998, ulcers with missing or unknown aetiology decreased from 31% to 6% and ulcers with a duration of more than 2 years from 44% to 27%, while treatment time per ulcer decreased from 2.1 to 1.7 hours/week. Conclusion ? Monitoring standards for ulcer aetiology through repeated questionnaires seems to ensure more accurate diagnoses. Thorough and detailed information about treatment time documents the workload for wound management.

What is the future of primary care research?: Probably fairly bright, if we may believe the historical development

Objective. To study one aspect of the development of primary care research from 1975 to 2003.Design. Quantitative bibliometric study.Setting. Pub Med database.Subjects. Four Nordic countries (Denmark, Finland, Norway, and Sweden), seven countries from the rest of Europe (Belgium, France, Germany, Italy, the Netherlands, Spain, and the UK), and seven countries from the rest of the world (Australia, Canada, India, Japan, New Zealand, South Africa, and the USA).Main outcome measures. Number of primary healthcare publications per million inhabitants. Percentage of publications in primary healthcare of all publications in human medicine.Results. In 2003, New Zealand, the UK, and Australia were in the lead, with barely 20 primary care publications per million inhabitants, followed by Norway, Sweden, the Netherlands, and Denmark, where the corresponding figure was around 10. A vigorous increase in publications from 1975 to 2003 was clearly seen in most of the countries. However, during the same period the proportion of publications from primary care in relation to all publications in human medicine was only moderately increased, or virtually unchanged.Conclusion. It is believed that primary care research has a future, and it is hoped it may even be bright. However, searching Pub Med gave but one aspect of the historical development, and in particular the comparisons between countries may be questionable.

A Nordic Collaboration on Medical Audit: The APO method for quality development and continuous medical education (CME) in primary health care

Key messages: A Nordic collaboration is the basis of large-scale audits and makes comparison between countries possible.The Nordic collaboration further develops the APO method for quality development and continuous medical education in primary health care.The method is based on a prospective self-registration on a simple registration chart acceptable to busy professionals.The method is suitable for quality development with regard to frequently occurring, central topics.Rational use of the method requires that the quality circle is completed consistently from idea to evaluation.

Influence of self-registration on audit participants and their non-participating colleagues A retrospective study of medical records concerning prescription patterns

Objective To compare participants and non-participants early in the process of an audit on treatment of respiratory tract infections (RTIs) and to analyse any effect of the actual self-registration on the prescription of antibiotics in both groups. Design All 80 general practitioners (GPs) at 14 health centres were invited to audit their use of antibiotics and 45 agreed to participate. There were both participants and non-participants at all centres. Data were collected retrospectively from the electronic patient records of all visits for RTI during five periods including the self-registration period. Comparisons were made over time within and between the groups. Setting Primary health care in Blekinge county, Southern Sweden. Subjects 80 GPs: 45 participants and 35 non-participants. Main outcome measure Proportion of patients with RTI who received antibiotics. Results At the start, the difference in prescription frequency between participants and non-participants was six percentage points (RR=0.92; 95% CI=0.87–0.97), and at the end seven percentage points (0.88; 0.81–0.95). The proportion of RTIs treated with antibiotics fell for both groups, (0.86; 0.80–0.92 and 0.90; 0.83–0.97, respectively). Conclusions GPs who chose to take part in the audit had a different prescription pattern from the non-participants right from the start. Both groups reduced their prescription of antibiotics during the study period. Either the registration had no effect on the participants or it had an effect on both the participants and the non-participants.

Predictors for antibiotic prescribing in patients with exacerbations of COPD in general practice

Background: The aim of this study was to describe the antibiotic prescribing rate in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD), to analyse predictors for antibiotic prescribing and to explore the influence of the use C-reactive protein (CRP) rapid test. Methods: A cross-sectional study was carried out in January and February 2008 in primary care. General practitioners (GPs) from six countries (Denmark, Sweden, Lithuania, Russia, Spain and Argentina) registered all patients with AECOPD during a 3-week period. A multilevel logistic regression model was estimated using two hierarchical levels, (i) patients and (ii) physicians, and was used to analyse the association between antibiotic prescribing and potential predictors for antibiotic use: patients’ age and gender, duration and symptoms and signs of exacerbations (fever, cough, dyspnoea, sputum volume and purulence) and the results of the CRP test. Results: A total of 617 GPs registered 1233 patients with AECOPD. A total of 970 patients (79%) were prescribed antibiotics, varying from 49% (Denmark) to 93% (Russia). The presence of purulent sputum was the strongest predictor for antibiotic treatment (odds ratio [OR] 8.7; 95% confidence interval [CI] 5.9–12.8). CRP determination was carried out mainly in Denmark and Sweden and its use was the strongest protective factor for antibiotic therapy (OR 0.3; 95% CI 0.2-0.6). GPs that used CRP testing weighted purulent sputum lower than GPs who did not use CRP testing. CRP values had a strong influence on the antibiotic prescribing rate. Conclusions: Antibiotic treatment for AECOPD is very high. This study shows that GPs performing CRP rapid tests prescribe fewer antibiotics than those who do not.

Differences in referral rates to specialised health care from four primary health care models in Klaipeda, Lithuania

BackgroundLithuanian primary health care (PHC) is undergoing changes from the systems prevalent under the Soviet Union, which ensured free access to specialised health care. Currently four different PHC models work in parallel, which offers the opportunity to study their respective effect on referral rates. Our aim was to investigate whether there were differences in referrals rates from different Lithuanian PHC models in Klaipeda after adjustment for co-morbidity.MethodsThe population listed with 18 PHC practices serving inhabitants in Klaipeda city and region (250 070 inhabitants). Four PHC models: rural state-owned family medicine practices, urban privately owned family medicine practices, state-owned polyclinics and privately owned polyclinics. Information on listed patients and referrals during 2005 from each PHC practice in Klaipeda was obtained from the Lithuanian State Sickness Fund database. The database records included information on age, gender, PHC model, referrals and ICD 10 diagnoses. The Johns Hopkins ACG Case-Mix system was used to study co-morbidity. Referral rates from different PHC models were studied using Poisson regression models.ResultsPatients listed with rural state-owned family medicine practices had a significantly lower referral rate to specialised health care than those in the other three PHC models. An increasing co-morbidity level correlated with a higher physician- to self-referral ratio.ConclusionFamily medicine practices located in rural-, but not in urban areas had significantly lower referral rates to specialised health care. It could not be established whether this was due to organisation, training of physicians or financing, but suggests there is room for improving primary health care in urban areas. Patients place of residence and co morbidity level were the most important factors for referral rate. We also found that gatekeeping had an effect on the referral pattern with respect to co-morbidity level, so that those with a physician referral were more likely to have had higher co-morbidity.