Jean Karl Soler

The research agenda for general practice/family medicine and primary health care in Europe. Part 3. Results: Person centred care, comprehensive and holistic approach

Abstract The recently published ‘Research Agenda for General Practice/Family Medicine and Primary Health Care in Europe’ summarizes the evidence relating to the core competencies and characteristics of the Wonca Europe definition of GP/FM, and its implications for general practitioners/family doctors, researchers and policy makers. The European Journal of General Practice publishes a series of articles based on this document. In a first article, background, objectives, and methodology were discussed. In a second article, the results for the two core competencies ‘primary care management’ and ‘community orientation’ were presented. This article reflects on the three core competencies, which deal with person related aspects of GP/FM, i.e. ‘person centred care’, ‘comprehensive approach’ and ‘holistic approach’. Though there is an important body of opinion papers and (non-systematic) reviews, all person related aspects remain poorly defined and researched. Validated instruments to measure these competencies are lacking. Concerning patient-centredness, most research examined patient and doctor preferences and experiences. Studies on comprehensiveness mostly focus on prevention/care of specific diseases. For all domains, there has been limited research conducted on its implications or outcomes.

The Research Agenda for General Practice/Family Medicine and Primary Health Care in Europe. Part 1. Background and methodology 1

Abstract At the WONCA Europe conference 2009 the recently published ‘Research Agenda for General Practice/Family Medicine and Primary Health Care in Europe’ was presented. The Research Agenda is a background paper and reference manual for GPs/ family doctors, researchers and policy makers, providing advocacy of general practice/family medicine GP/FM in Europe. The Research Agenda summarizes the evidence relating to the core competencies and characteristics of the WONCA Europe definition of GP/FM, and its meaning for researchers and policy makers. Evidence gaps and research needs are pointed out to provide a basis for planning research for which there is a need and for action that may influence health and research policy, i.e. applying/lobbying for research funds. WONCA Europe and its associated networks and special interest groups could consider the agendas research priorities when planning future conferences, courses, or projects, and for funding purposes. The European Journal of General Practice will publish a series of articles based on this document. In this first article, background, objectives, methodology and relevant literature are discussed. In subsequent articles, the results will be presented.

Series: The research agenda for general practice/family medicine and primary health care in Europe. Part 4. Results: Specific problem solving skills

Abstract The ‘Research Agenda for General Practice/Family Medicine and Primary Health Care in Europe’ summarizes the evidence relating to the core competencies and characteristics of the Wonca Europe definition of GP/FM, and its implications for general practitioners/family doctors, researchers and policy makers. The European Journal of General Practice publishes a series of articles based on this document. The previous articles presented background, objectives, and methodology, as well results on ‘primary care management’ and ‘community orientation’ and the person-related core competencies of GP/FM. This article reflects on the general practitioners ‘specific problem solving skills’. These include decision making on diagnosis and therapy of specific diseases, accounting for the properties of primary care, but also research questions related to quality management and resource use, shared decision making, or professional education and development. Clinical research covers most specific diseases, but often lacks pragmatism and primary care relevance. Quality management is a stronghold of GP/FM research. Educational interventions can be effective when well designed for a specific setting and situation. However, their message that ‘usual care’ by general practitioners is insufficient may be problematic. GP and their patients need more research into diagnostic reasoning with a step-wise approach to increase predictive values in a setting characterized by uncertainty and low prevalence of specific diseases. Pragmatic comparative effectiveness studies of new and established drugs or non-pharmaceutical therapy are needed. Multi-morbidity and complexity should be addressed. Studies on therapy, communication strategies and educational interventions should consider impact on health and sustainability of effects.

Series: The research agenda for general practice/family medicine and primary health care in Europe. Part 5: Needs and implications for future research and policy

The European General Practice Research Network (EGPRN) has provided the discussions on priorities in research in general practice/family medicine (GP/ FM) and primary health care (PHC) with an important background document. In this issue the conclusions are presented, framing a broad perspective for setting the future research agenda (1). It will be strategically important to defi ne some spearheads that may guide priority setting for the next decade. The following principles could be used to underpin the debate: relevance, equity, quality, cost effectiveness, sustainability, person-centeredness, and innovation.AbstractThe recently published ‘Research Agenda for General Practice/Family Medicine and Primary Health Care in Europe’ summarizes the evidence relating to the core competencies and characteristics of the Wonca Europe definition of GP/FM, and highlights related needs and implications for future research and policy. The European Journal of General Practice publishes a series of articles based on this document. In a first article, background, objectives, and methodology were discussed. In three subsequent, articles the results for the six core competencies of the European Definition of GP/FM were presented. This article formulates the common aims for further research and appropriate research methodologies, based on the missing evidence and research gaps identified form the comprehensive literature review. In addition, implications of this research agenda for general practitioners/family doctors, researchers, research organizations, patients and policy makers are presented. The concept of six core competenci...

An international comparative family medicine study of the Transition Project data from the Netherlands, Malta, Japan and Serbia. An analysis of diagnostic odds ratios aggregated across age bands, years of observation and individual practices

INTRODUCTION This is a study of the process of diagnosis in family medicine (FM) in four practice populations from the Netherlands, Malta, Serbia and Japan. Diagnostic odds ratios (ORs) for common reasons for encounter (RfEs) and episode titles are used to study the process of diagnosis in international FM and to test the assumption that data can be aggregated across different age bands, practices and years of observation. METHODOLOGY Participating family doctors (FDs) recorded details of all their patient contacts in an episode of care (EoC) structure using the International Classification of Primary Care (ICPC). RfEs presented by the patient and the diagnostic labels (EoC titles) recorded for each encounter were classified with ICPC. The relationships between RfEs and episode titles were expressed as ORs using Bayesian probability analysis to calculate the posterior (post-test) odds of an episode title given an RfE, at the start of a new EoC. RESULTS The distributions of diagnostic ORs from the four population databases are tabled across age groups, years of observation and practices. CONCLUSIONS There is a lot of congruence in diagnostic process and concepts between populations, across age groups, years of observation and FD practices, despite differences in the strength of such diagnostic associations. There is particularly little variability of diagnostic ORs across years of observation and between individual FD practices. Given our findings, it makes sense to aggregate diagnostic data from different FD practices and years of observation. Our findings support the existence of common core diagnostic concepts in international FM.

The development of research capacity in Europe through research workshops—the EGPRN perspective

The academic development of the domain of General Practice and family medicine (FM) has made notable progress recently, but one should never rest on one’s laurels. Continuing progress requires a strong research base for the discipline, which is still weak both in terms of evidence, with relatively few publications from primary care, and in the limited number of research institutes around the world. Ironically, even though the evidence for primary care in health care systems is rather strong and international political support has been repeatedly promised, the spirit of Alma Ata seems not to have been realized and governments seem to be more supportive of investment in secondary and tertiary care. The key to development as an independent specialist discipline is the development of an independent research base to define the characteristics of the domain, to support clinical work and to inform educational and professional development. Primary care researchers have to go beyond the agenda of public health and secondary care and carry out research into the content and delivery of primary care and into diagnosis in primary care. What does research in general practice/FM entail? The researcher may be a clinician with a special interest, a student who is preparing a dissertation for a University degree or a researcher from a field outside medicine. A research question is developed, and with some advice, an appropriate methodology is selected (such as a questionnaire to fellow clinicians, a study of patient records or an intervention to improve practice). The novice researcher will benefit enormously from expert advice at this stage since errors in research question development or methodology for data collection may make the project untenable at a later stage. Successful completion of the project may result in obtaining a degree, improving practice at a local or regional setting in a specific domain or national or international publication of a paper and the start of a new academic career in parallel or instead of a purely clinical one. Successful publication will make access to research grants and/or career posts, and further publication, more likely.

Developing a Mediterranean family medicine group

On 9 September 2000, a meeting on General Practice/Family Medicine (GP/FM) in the Mediterranean was held at the 6th Mediterranean Congress in Malta. The creation of a Mediterranean GP/FM group was discussed among delegates from seven Mediterranean countries. Historical, cultural and epidemiological concepts supporting this initiative are presented. The main aims of this group and the key issues of the Malta consensus are clarified.

Is Burnout in Family Physicians in Croatia Related to Interpersonal Quality of Care

The impact of physician burnout on the quality of patient care is unclear. This cross-sectional study aimed to investigate the prevalence of burnout in family physicians in Croatia and its association with physician and practice characteristics, and patient enablement as a consultation outcome measure. Hundred and twenty-five out of 350 family physicians responded to our invitation to participate in the study. They were asked to collect data from 50 consecutive consultations with their adult patients who had to provide information on patient enablement (Patient Enablement Instrument). Physicians themselves provided their demographic and professional data, including workload, job satisfaction, consultation length, and burnout [Maslach Burnout Inventory - Human Services Survey (MBI-HSS )]. MBI-HSS scores were analysed in three dimensions: emotional exhaustion (EE), depersonalisation (DP), and personal accomplishment (PA). Of the responding physicians, 42.4 % scored high for EE burnout, 16.0 % for DP, and 15.2 % for PA. Multiple regression analysis showed that low job satisfaction and more patients per day predicted high EE scores. Low job satisfaction, working more years at a current workplace, and younger age predicted high DP scores. Lack of engagement in education and academic work, shorter consultations, and working more years at current workplace predicted low PA scores, respectively (P<0.05 for each). Burnout is common among family physicians in Croatia yet burnout in our physicians was not associated with patient enablement, suggesting that it did not affect the quality of interpersonal care. Job satisfaction, participation in educational or academic activities and sufficient consultation time seem to reduce the likelihood of burnout. Sažetak Povezanost sindroma izgaranja liječnika i kvalitete skrbi nije potpuno jasna. Cilj rada bio je istražiti učestalost sindroma izgaranja u liječnika obiteljske medicine (LOM) u Hrvatskoj te povezanost sindroma izgaranja i obilježja liječnika i njegove prakse te osposobljenosti bolesnika kao mjere ishoda konzultacije. Provedeno je presječno istraživanje na nacionalnom stratificiranom slučajnom uzorku od 350 LOM koji su prikupili podatke od 50 odraslih bolesnika tijekom 50 susljednih konzultacija. Za bolesnike su prikupljeni podaci o osposobljenosti bolesnika (Upitnik za procjenu osposobljenosti bolesnika, PEI), duljini konzultacije, a za liječnike podaci o demografskim i profesionalnim značajkama, opterećenju poslom, zadovoljstvu poslom, prisutnosti sindroma izgaranja na poslu (Maslach Burnout Inventory - MBI-HSS). Vrijednosti MBI-HSS analizirane su u tri dimenzije: emocionalna iscrpljenost (EI), depersonalizacija (DP) i osobno postignuće (OP). Među 125 liječnika, EI visokog stupnja zabilježena je kod 42,4 %, DP visokog stupnja kod 16,0 % te OP visokog stupnja kod 15,2 % liječnika. U regresijskoj analizi visoke vrijednosti EI su predviđali manje zadovoljstvo poslom i veći broj bolesnika dnevno. Visoke vrijednosti DP su predviđali manje zadovoljstvo poslom, više godina na sadašnjem radnom mjestu i mlađa dob. Niske vrijednosti OP su predviđale izostanak sudjelovanja u nastavnim ili akademskim aktivnostima, kraće konzultacije te više godina na sadašnjem radnom mjestu (P<0.05 za svaki). Sindrom izgaranja prisutan je među LOM u Hrvatskoj. Nismo utvrdili povezanost sindroma izgaranja liječnika i osposobljenosti bolesnika, odnosno prisutnost sindroma izgaranja nije bila povezana s kvalitetom komunikacijske skrbi. Zadovoljstvo poslom, sudjelovanje u nastavnim ili akademskim aktivnostima te dostatno vrijeme konzultacije mogli bi imati zaštitni učinak u nastanku sindroma izgaranja u liječnika.

Series: The research agenda for general practice/family medicine and primary health care in Europe. Part 6: Reaction on commentaries – how to continue with the Research Agenda?

Abstract The Research Agenda should be used as a key reference point to which new research should relate its usefulness and added value. Primary care evolves towards more interdisciplinary care, and research should focus more on the core competency of person-centred team care. There is an urgent need to develop clear definitions and appropriate research instruments for this domain. It will be a particular challenge to study comprehensive approaches in primary-care patients with multi-morbidity. The Research Agenda and the commentaries on it show future directions for primary care research. There are challenges related to a changing society, the shared responsibility and guidance of research by professionals and citizens (patients), and the need to fully integrate research as part of primary healthcare provision. There will be a need for a prioritization of spearheads to guide primary care research for the next decade: translational research, research on equity and health differences, on chronic disease and health systems research. This can not be realized without the development and maintenance of a solid research infrastructure: easily maintained and accessed observational databases, helpful information technology, strategies and techniques for patient involvement, advanced research training possibilities, and the development and validation of appropriate research instruments and outcome measures to capture the different challenges. Worldwide, primary care not only is a priority for health care policy, but it needs to become a research priority as well.

Research using electronic patient records in general practice. The EGPRN meeting in Bertinoro, Italy, May 2009

Abstract The European General Practice Research Network organized an international workshop on research using electronic patient records in Bertinoro, Italy, in May 2009. The authors were keynote speakers at the workshop, tasked with summarizing the theme research presentations on each of the two days of the meeting. The conference discussed the utility of capturing data in a way that can be appropriately analysed. In this application, the use of ICPC was repeatedly mentioned. Such research requires disciplined data entry and retrieval, and many times consistency in coding is a challenge, which may be met by definitions for coded classes. Quality of data is a concern in such research, and there were suggestions to involve the patients in improving the quality of their record. Clinicians are qualified to code data into electronic patient records accurately, capturing the fine nuances of the consultation. Income incentives, such as the Quality Outcomes Framework, run the risk of data distortion to improve financial gain. The role of all family doctors in research was emphasized, and the full potential of collecting data from family practice is practically achievable only through large databases collecting clinical records from every practice. EGPRN has dealt with this emerging theme in primary care research over the years. Interested family doctors are invited to attend future conferences to develop collaborative research projects using electronic patient records.