Nina Badertscher

Gaps in continuity of care at the interface between primary care and specialized care: general practitioners' experiences and expectations

Introduction Discontinuity of care at the interface between inpatient and outpatient management can lead to increased morbidity and mortality. Appropriate communication and flow of information is indispensable to ensure continuity of care. Consequently, the aim of this study was to assess general practitioners’ (GPs) experiences of cooperation with a university hospital, as well as their needs and obvious barriers regarding an optimized information flow. Methods A qualitative study was performed. In March 2011, 300 GPs from the Zurich Canton were invited to participate in two focus group meetings. Based on a review of the literature, an interview guide was created addressing two main issues. In the first part, experiences and barriers regarding cooperation with the university were explored. In the second part, needs and suggestions to improve cooperation were addressed. Results Fifteen GPs participated in two focus groups. GPs complained that they have often not been adequately informed about ongoing treatments or appointments for their patients. GPs feel responsible for the continuity of care and wish to be more involved, especially in long-term treatment decisions or at the end of life. By not involving them, they stated, important information concerning patients’ medical history and social setting was not taken into account. Improvements are also required at discharge: GPs often do not receive important information about treatments in the hospital and further requirements within a reasonable time. Conclusion Exchange of information between the hospital and the GP at admission and discharge is essential. However, at present, involvement during hospitalization of the patient is lacking. This includes the exchange of information after an unexpected clinical procedure and input from GPs when difficult clinical decisions are made, such as at the beginning or termination of long-term therapies.

Attitudes, barriers and facilitators for health promotion in the elderly in primary care A qualitative focus group study

QUESTIONS UNDER STUDY Effective health promotion is of great importance from clinical as well as from public health perspectives and therefore should be encouraged. Especially regarding health promotion in the elderly, general practitioners (GPs) have a key role. Nevertheless, evidence suggests a lack of health promotion by GPs, especially in this age group. The aim of our study was to assess self-perceived attitudes, barriers and facilitators of GPs to provide health promotion in the elderly. METHODS We performed a qualitative focus group study with 37 general practitioners. The focus group interviews were recorded digitally, transcribed literally and analysed with ATLAS.ti, a software program for qualitative text analysis. RESULTS Among the participating GPs, definitions of health promotion varied widely and the opinions regarding its effectiveness were very heterogeneous. The two most important self-perceived barriers for GPs to provide health promotion in the elderly were lack of time and insufficient reimbursement for preventive and health promotion advice. As intervention to increase health promotion in the elderly, GPs suggested, for example, integration of health promotion into under and postgraduate training. Changes at the practice level such as involving the practice nurse in health promotion and counselling were discussed very controversially. CONCLUSION Health promotion, especially in the elderly, is crucial but in the opinion of the GPs we involved in our study, there is a gap between public health requirements and the reimbursement system. Integration of health promotion in medical education may be needed to increase knowledge as well as attitudes of GPs regarding this issue.

General practitioners’ experiences, attitudes, and opinions regarding the pneumococcal vaccination for adults: a qualitative study

Introduction Diseases caused by Streptococcus pneumoniae generate substantial morbidity and mortality. Despite official recommendations to vaccinate everyone over the age of 64, the estimated vaccination rate for this target population is around 2%. In Switzerland, pneumococcal vaccinations are for the most part provided by general practitioners (GPs); in addition, a small number of patients get vaccinated during a hospital stay. We wanted to investigate GPs’ attitudes and opinions about the pneumococcal vaccination in primary care and why it is so rarely provided. Methods For this qualitative study, we conducted semistructured interviews with 20 GPs. Transcriptions of all interviews were analyzed following the technique of qualitative content analysis, supported by the ATLAS.ti© software. Results Most GPs reported that they know pneumococcal vaccination is recommended for several risk groups and elderly patients. As to reasons for the low vaccination rate, GPs mentioned the pneumococcal vaccination had little priority in daily practice, especially in comparison with the importance of other vaccinations, namely influenza. This low level of priority was supported by the fact that the GPs rarely ever experienced a case of a severe pneumococcal disease in their daily work. Furthermore, perceived insufficient evidence resulting from existing epidemiologic data and clinical trials enhanced the little attention given to the pneumococcal vaccination. Conclusion We found the generally low level of priority given within a consultation, the missing awareness of this subject in daily practice, and the perception of epidemiologic and scientific data as insufficient, as the reasons for the low rate in pneumococcal vaccinations. Efforts to increase the epidemiologic data on the pneumococcal vaccination should be taken. To increase the vaccination rate, it would be necessary to raise the awareness and priority of the pneumococcal vaccination; a feasible way could be the combination of the seasonal flu vaccination campaign with a campaign for pneumococcal vaccination.

Career after successful medical board examination in general practice – a cross-sectional survey

QUESTION UNDER STUDY Switzerland is facing a shortage of general practitioners (GPs). Knowledge of the factors influencing career choice is crucial for increasing the attractiveness of general practice. The aim of our study was to report the working conditions of recently certified GPs and the effect of vocational training in general practice on GP skills and knowledge, and economic skills. Furthermore, we recorded when GPs chose general practice as a career, as well as potential barriers to and facilitators of their decision. METHODS STUDY DESIGN Cross-sectional survey with an online-based questionnaire. STUDY GROUP 1,133 physicians certified in general practice between the years 2000 and 2010. RESULTS The response rate was 40.6% (456); 426 (44.1% females) were included in further analysis. A total of 341 (80.0%) were currently working in general practice. Female GPs were significantly more often employed (rather than working independently), working part-time and in group practices. Fifty-two (12.2%) of the participants did not work in general practice although they had intended to earlier. The majority (54.3%) of the participants working as GPs decided to become a GP during their residency. Overall, 60.6% of all participants completed vocational training in a general practice, which significantly improved self-perceived general practice skills compared with their colleagues without such training. CONCLUSIONS Residency is a more important time-period than medical school for career decisions to become a GP. Attractive residency programmes must be developed to engage physicians in this vulnerable phase. The workplace settings of female GPs were significantly different from those of male GPs. Vocational training in general practice had a positive effect on self-perceived GP skills.

Screening and prevention in Swiss primary care: a systematic review.

Background and objectives Prevention is a challenging area of primary care. In Switzerland, little is known about attitudes to and performance of screening and prevention services in general practice. To implement prevention services in primary care it is important to know about not only potential facilitators but also barriers. Primary care encompasses the activities of general practitioners, including those with particular interest and/or specializations (eg, pediatrics, gynecology). The aim of this study was to review all studies with a focus on prevention services which have been conducted in Switzerland and to reveal barriers and facilitators for physicians to participate in any preventive measures. Methods The Cochrane Library, PubMed, EMBASE and BIOSIS were searched from January 1990 through December 2010. Studies focussing on preventive activities in primary care settings were selected and reviewed. The methodological quality of the identified studies was classified according to the guidelines in the Consolidated Standards of Reporting Trials (CONSORT) statement. Results We identified 49 studies including 45 descriptive studies and four randomised controlled trials (RCTs). Twelve studies addressed the prevention of epidemics, eleven out of them vaccinations. Further studies focused on lifestyle changes, physical activity counselling, smoking cessation, cardiovascular prevention and cancer screening. Perceived lack of knowledge/training and lack of time were the most commonly stated barriers. Motivation, feasibility and efficiency were the most frequently reported supporting factors for preventive activities. The methodological quality was weak, only one out of four RCTs met the applied quality criteria. Conclusion Most studies focussing on screening and prevention activities in primary care addressed vaccination, lifestyle modification or cardiovascular disease prevention. Identified barriers and facilitators indicate a need for primary-care-adapted education and training which are easy to handle, time-saving and reflect the specific needs of general practitioners. If new prevention programs are to be implemented in general practices, RCTs of high methodological quality are needed to assess their impact.

Feasibility and diagnostic accuracy of teledermatology in Swiss primary care: process analysis of a randomized controlled trial.

RATIONALE, AIM AND OBJECTIVE To test feasibility and diagnostic accuracy of dermatologists feedback based on digital images of skin lesions collected in Swiss primary care. METHODS This was a process analysis of a randomized controlled trial, conducted in 2011/2012. 30 of 78 general practitioners (GPs) were randomized to an intervention, which included dermatologists feedback on digital images of skin lesions. Feedback was categorized into four categories: (1) no further investigation; (2) clinical observation; (3) biopsy; and (4) other. Histologic findings were allocated to the same categories. Feasibility was measured in the perspective of GPs concerning technical handling and of dermatologists as proportion of images usable for feedback. Diagnostic accuracy was measured as proportion of malignant histology of the first three feedback groups. No long-term data was collected. RESULTS 981 images of skin lesions were collected, two were not eligible due to low quality of images. The majority of GPs (77.8%) reported no problem with the procedure. 207 images were in feedback category 1, 353 in 2, 360 in 3 and 59 in 4. A total of 236 histologic tests were collected. Three cases in category 1 indicated malignancy (1 melanoma). 201 of category 3 received a biopsy, where in 91 (45.3%) malignancy was confirmed. CONCLUSION Teledermatology with digital images taken in primary care was feasible from a GP and from a specialist perspective. However, diagnostic appropriateness regarding avoidance of specialist care and possible missed skin cancer raises concerns. These results therefore question a promotion of teledermatology in clinical routine.

minSKIN Does a multifaceted intervention improve the competence in the diagnosis of skin cancer by general practitioners? Study protocol for a randomised controlled trial

AbstractBackgroundIn Switzerland, skin cancer is one of the most common neoplasms. Melanoma is the most aggressive one and can be lethal if not detected and removed on time. Nonmelanoma skin cancer is more frequent as melanoma; it is seldom lethal but can disfigure patients in advanced stages. General practitioners (GPs) are often faced with suspicious skin lesions of their patients.Methods/DesignDesign: Randomised controlled trial (RCT). Population: 60 GPs, randomised into intervention group and control group. Intervention: GPs get a Lumio loupe, a digital camera and continuous feedback based on pictures of skin lesions they send to the Dermatologist. Primary outcome: Competence in the diagnosis of skin cancer by GPs, measured as the percentage of correctly classified pictures of skin lesions. Measurements: At baseline, and prior to any intervention (T0), GPs will be asked to rate 36 pictures of skin lesions according to their likelihood of malignancy on a visual analogue scale (VAS). After a full day training course with both groups (T1) and after one year of continuous feedback (T2) with the intervention group, we will repeat the picture scoring session with both groups, using new pictures.DiscussionWe want to determine whether a multifaceted intervention (including technical equipment and a continuous feedback on skin lesions) leads to an improved competence in the diagnosis of skin cancer by GPs. This study addresses the hypothesis that an additional feedback loop, based on pictures performed in daily practice by GPs is superior to a simple educational intervention regarding diagnostic competence. We expect an improvement of the competence in skin cancer diagnosis by GPs in both groups after the full day training course. Beside this immediate effect, we also expect a long term effect in the intervention group because of the continuous problem based feedback.Trial registrationISRCTN: ISRCTN29854485

The role of skin self-examination at the Swiss skin cancer day

BackgroundThe rising incidence of melanoma - Switzerland has the highest incidence in Europe - is a major public health challenge. Swiss dermatologist introduced the “Swiss Skin Cancer Day” (SSCD) in 2006, which provides skin cancer screening at no costs. The aim of the study was to describe the participating subjects and their motivation and investigate factors influencing the probability of a clinical diagnosis of skin malignancy.Methods150 dermatologists were involved in the SSCD in May 2012. Dermatologists were not remunerated. Participants had the opportunity to show a single skin lesion to a dermatologist at no cost. A questionnaire for each participating subject collected data about subjects’ age, sex, risk factors and reason for encounter; furthermore the dermatologist noted down clinical diagnosis and further management. We used descriptive statistics to report characteristics of participants and skin lesions. We built two multiple logistic regression models, one regarding the clinical diagnosis of skin malignancy and one regarding the further management.Results5266 subjects (55.6% female) were assessed; in 308 (5.8%) participants a clinical diagnosis of skin malignancy was found. In 1732 participants (32.9%) a clinical follow up or an excision was recommended. In the multiple logistic regression model age, sex, skin phototype and the reason for participation at the SSCD were found as significant risk factors regarding the clinical diagnosis of skin malignancy. Participants with skin cancer risk factors were more likely to get a clinical follow up recommended even if the clinical diagnosis was benign.ConclusionA self-perceived suspicious lesion was the strongest predictor for a clinical diagnosis of skin malignancy at the SSCD. This suggests that skin self-examination might also work in general population. Future research should focus on better access to a specialist in case a suspicious skin lesion was discovered. Safety and quality of the SSCD should be further investigated, especially concerning the discrepancy between the low number of malignant lesions and the high quantity of participants where further clinical examinations or interventions were recommended.