Merethe Kirstine Kousgaard Andersen

Evaluation of general practitioners' assessment of overweight among children attending the five-year preventive child health examination: a cross-sectional survey.

Abstract Objective. To evaluate general practitioners’ (GPs’) assessment of potential overweight among children attending the five-year preventive child health examination (PCHE) by comparing their assessment of the childrens weight-for-stature with overweight defined by body mass index (BMI) according to paediatric standard definitions. Design. A cross-sectional survey. Data were obtained from a questionnaire survey of childrens health in general and their growth in particular. Setting. The five-year preventive child health examination (PCHE) in general practice in the Central Denmark Region. Subjects. Children attending the five-year PCHE in general practice, regardless of their weight status. Main outcome measures. Paediatric standard definitions for childhood overweight based on BMI were used as the gold standard for categorizing weight-for-stature. Identification of overweight was analysed with regard to sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the GPs’ assessment of weight-for-stature. Results. A total of 165 GPs conducted 1138 PCHEs. GPs assessed that 171 children had a weight-for-stature above normal. Use of the Danish Standards (DS), i.e. the Danish national growth charts for BMI, as the gold standard yielded a sensitivity of 70.1% (95% CI 62.0–77.3) and a specificity of 92.4% (95% CI 90.6–93.9). The sensitivity was influenced by the GPs’ use of BMI and the presence of previous notes regarding abnormal weight development. Conclusion. At the five-year PCHE almost one-third of overweight children were assessed to be normal weight by GPs. Use of BMI and presence of notes on abnormal weight in medical records were positively associated with a higher identification. Hence, utilization of medical record data and BMI charts may refine GPs’ assessment of childhood overweight.

How is defensive medicine understood and experienced in a primary care setting? A qualitative focus group study among Danish general practitioners

Objectives Recent years have witnessed a progressive increase in defensive medicine (DM) in several Western welfare countries. In Danish primary and secondary care, documentation on the extent of DM is lacking. Before investigating the extent of DM, we wanted to explore how the phenomenon is understood and experienced in the context of general practice in Denmark. The objective of the study was to describe the phenomenon of DM as understood and experienced by Danish general practitioners (GPs). Design A qualitative methodology was employed and data were generated through six focus group interviews with three to eight GPs per group (n=28) recruited from the Region of Southern Denmark. Data were analysed using a thematic content analysis inspired by a hermeneutic-phenomenological focus on understanding and meaning. Results DM is understood as unnecessary and meaningless medical actions, carried out mainly because of external demands that run counter to the GP’s professionalism. Several sources of pressure to act defensively were identified by the GPs: the system’s pressure to meet external regulations, demands from consumerist patients and a culture among GPs and peers of infallibility and zero-risk tolerance. Conclusions GPs understand DM as unnecessary and meaningless actions driven by external demands instead of a focus on the patient’s problem. GPs consider defensive actions to be carried out as a result of succumbing to various sources of pressure deriving from the system, the patients, the GPs themselves and peers.

Child overweight in general practice – parents’ beliefs and expectations – a questionnaire survey study

BackgroundCare for overweight children in general practice involves collaboration with parents. Acknowledging the parents’ frames of references is a prerequisite for successful management. We therefore aimed to analyse parental beliefs about the presumed causes and consequences of overweight in children and expectations towards the GP. Moreover, we aimed at comparing the beliefs and expectations of parents of non-overweight children (NOWC) and parents of overweight children (OWC).MethodsA cross-sectional survey. Data were obtained from a questionnaire exploring parents’ beliefs and expectations regarding overweight in children. The questionnaires were completed by parents following their child’s participation in the five-year preventive child health examination (PCHE).Parental agreement upon statements concerning beliefs and expectations regarding overweight in children was measured on a Likert scale. Differences in levels of agreement between parents of non-overweight children and parents of overweight children were analysed using Chi-squared test and Fisher’s exact test.ResultsParents of 879 children completed and returned questionnaires. Around three fourths of the parents agreed that overweight was a health problem. A majority of parents (93%) agreed that the GP should call attention to overweight in children and offer counselling on diet and exercise. Almost half of the parents expected a follow-up programme. Parents of overweight children seemed to agree less upon some of the proposed causes of overweight, e.g. inappropriate diet and lack of exercise. These parents also had stronger beliefs about overweight disappearing by itself as the child grows up.ConclusionsAccording to parental beliefs and expectations, general practice should have an important role to play in the management of child overweight. Moreover, our findings suggest that GPs should be aware of the particular beliefs that parents of overweight children may have regarding causes of overweight in their child.

Can external interventions crowd in intrinsic motivation? A cluster randomised field experiment on mandatory accreditation of general practice in Denmark

Motivation crowding studies have demonstrated that external interventions can harm effort and performance through crowding out of intrinsic motivation, when interventions are perceived as lack of trust. However, motivation crowding theory also presents a much less investigated crowding in effect, which occurs when external interventions increase intrinsic motivation. This study empirically tests the motivational effect of a specific external intervention and its associations with the perception of the intervention. We draw on a cluster randomised stepwise introduction of a mandatory accreditation system in general practice in Denmark combined with baseline and follow-up questionnaires of 1146 GPs. Based on a series of mixed effects multilevel models, we find no evidence of motivation crowding out among surveyed GPs, although most GPs perceived accreditation as a tool for external control prior to its implementation. Rather, our results indicate that being accredited crowds in intrinsic motivation. This is especially the case when GPs perceive accreditation as an instrument for quality improvement. External interventions can therefore, at least in some cases, foster intrinsic motivation of health care professionals.

Defensive medicine in primary health care

During the past year, a case of a young Danish doctor in vocational training as general practitioner accused in court of gross negligence has been all over the Danish media. A patient died maybe because of over dosage of insulin. The doctor’s ordering of blood glucose measurement was given verbally but not written in the patient record and the normal procedures for a patient with diabetes failed after the doctor had left her night shift. The young doctor was first acquitted of all charges in primary court, then convicted in national court, and finally cleared in Supreme Court by a three judges versus two ruling. During the process, thousands of Danish doctors, including many in primary health care, joined the hashtag campaign #DetKuHaVaeretMig (#ItCouldHaveBeenMe) in support of the doctor accused and as a way of protesting against perceived misconduct of the Danish Patient Safety Authority (STPS) as well as the hospital management. It is worrying that the case ended in the judicial system, despite the fact that the doctors actions were not significantly different from ordinary practice. Stories like the above increase the fear of malpractice claims and police accusations among doctors. Doctoring seems to be hampered by a harmful zero-mistake culture that is likely to have enormous consequences for patients and doctors as well as society. Defensive medicine (DM) refers to actions that healthcare providers take in order to protect themselves from malpractice claims rather than actions benefitting the patient. DM has been demonstrated in healthcare systems all over the world and is documented to have increased during the past few years. For example, DM has been estimated to account for 10% of all spent healthcare resources in Italy [1]. It affects peoples’ lives from even before birth, in the way that obstetricians’ choice of making a C-section is motivated by defensive behaviour [2]. In a recent Danish study among GPs DM was experienced on a daily basis as actions taken because of pressures deriving from four different sources: “the system,” the patients, the GPs themselves and their peers [3]. In particular, the system-imposed pressure to document every medical action in detail was experienced as leading to meaningless and even potentially harmful doctoring. The hashtag campaign #DetKuHaVaeretMig is about clearer rules for how detailed medical actions need to be recorded. Detailed patient records may protect doctors from being blamed in case of a patient complaint and hence from becoming second victims. Older GPs make less detailed patient records. Maybe therefore they are more likely to be disciplined in case of a complaint compared to younger [4]. This practice and stories like the young doctor’s enforces a tendency towards automatized, fully detailed, all covering, and knowingly redundant patient records. However, long patient records and computer-generated journal phrases may do well in a juridical setting at the risk of making the record a less useful in the clinical setting, increasing the risk of overlooking important information, slowing down GPs’ work and reducing the time spent with the patients. It favours strategic and cynical doctor-patient interaction leading to low job satisfaction and preterm retirement [5]. It is time to confront and reduce the pressures for meaningless doctoring rather than continue adding longer phrases to the computer systems.

Frailty characteristics and preventive home visits: an audit on elderly patients in Danish general practice

Aim. Preventive home visits (PHVs) to frail elderly patients, provided by the GP, have been widely promoted in many health care systems, including the Danish system. This study investigates to what extent PHVs are provided to patients with characteristics of frailty. Methods. During a four-week period, GPs and their staff in three different parts of Denmark filled in a questionnaire for each patient aged 75 years or older who attended the clinic or received a home visit. The association between 20 different frailty characteristics and the receipt of a PHV was assessed through logistic regression. Results. A total of 73 GPs and 41 staff members sampled information about 3133 patients, of whom 332 patients (10.7%) had received a PHV within one year prior to their audit date. A PHV was closely associated with the patient’s number of frailty characteristics. The adjusted odds ratios show that the receipt of a PHV was associated with a low walking distance 2.34 (1.65–3.31), dementia 3.35 (2.26–4.96), depression 2.24 (1.38–3.63) and a need for home care 3.40 (2.45–4.73), and increased with the GP’s tendency to provide PHVs. Conclusion. Most PHV-receiving elderly patients have several characteristics of frailty, the most significant being impaired mobility, dementia, depression and a need for home care. PHVs are also more often provided to patients listed with a GP who has an overall high tendency to conduct these visits.