Tuomas H. Koskela

User perspectives on an electronic decision-support tool performing comprehensive medication reviews - a focus group study with physicians and nurses

BackgroundAlthough a number of studies have evaluated the effectiveness of computerized decision-support systems (CDSS), there is lack of data on user perspectives, barriers, and facilitators to the implementation of CDSSs in real-life surroundings. The aim of this study was to assess individually perceived barriers, facilitators and ideas influencing the CDSS implementation and usability.MethodsIn this qualitative study, five focus groups were carried out with physicians and nurses separately at the Tampere City Health Center, Finland. The participants were end-users of the EBMeDS computerized decision support system. An explorative data content analysis was applied.ResultsThe most important barrier to benefitting from CDSS was the lack of structured and coded diagnosis documentation and outdated medication information in the electronic health records. This led to false alerts and distrust towards the system. Among the major facilitators found were e.g. the beneficial reminders that helped practitioners take into account matters otherwise ignored; automatic glomerular filtration rate (GFR) calculations; medication safety checks; and the summaries in the single medication review at a glance.ConclusionsPhysicians’ and nurses’ are keen to use the CDSS and it may enhance their inter-professional collaboration. Documenting patient information in a structured, uniform and easy manner is the essential starting point for electronic decision support. When implementing CDSS, managers need to focus on common practices in documenting structured data in their organizations in order to prevent undermining trust in the system.

Multiple physical healthcare needs among outpatients with schizophrenia: findings from a health examination study

Abstract Background: Despite the abundant literature on physical comorbidity, the full range of the concurrent somatic healthcare needs among individuals with schizophrenia has rarely been studied. Aims: This observational study aimed to assess the distressing somatic symptoms and needs for physical health interventions in outpatients with schizophrenia, and factors predicting those needs. Methods: A structured, comprehensive health examination was carried out, including a visit to a nurse and a general practitioner on 275 outpatients with schizophrenia. The required interventions were classified by type of disease. Logistic regression was used to assess the influence of sociodemographic factors, lifestyle, functional limitations, factors related to psychiatric disorder, and healthcare use on the need for interventions. Results: In total, 44.9% of the patients (mean age 44.9 years) reported somatic symptoms affecting daily life; 87.6% needed specific interventions for a disease or condition, most commonly for cardiovascular, dermatological, dental, ophthalmological, and gastrointestinal conditions, and for altered glucose homeostasis. Smoking and obesity predicted significantly a need of any intervention, but the predictors varied in each disease category. Strikingly, use of general practitioner services during the previous year did not reduce the need for interventions. Conclusions: Health examinations for outpatients with schizophrenia revealed numerous physical healthcare needs. The health examinations for patients with schizophrenia should contain a medical history taking and a physical examination, in addition to basic measurements and laboratory tests. Prevention and treatment of obesity and smoking should be given priority in order to diminish somatic comorbidities in schizophrenia.

The relationship between childhood adversities and fibromyalgia in the general population

BACKGROUND Fibromyalgia is a syndrome characterized by widespread pain and a variety of somatic symptoms. The international prevalence of fibromyalgia is 2-5%, but its current prevalence in Finland is unclear. Various adversities are linked to the onset of fibromyalgia. However, there is need for more data regarding the association between childhood physical abuse and fibromyalgia. Further, the association of childhood emotional stressors and fibromyalgia is disputed. The aim of the current study is to produce more information about that relationship using data from the Health and Social Support (HeSSup) Study. METHODS HeSSup is a postal study consisting of a random sample of the Finnish population. The study setting is cross-sectional. Participants in the study were asked if they have been diagnosed with fibromyalgia. Those responding affirmatively were classified as fibromyalgia patients. Six childhood adversities were enquired, and the relationship between fibromyalgia and these events were analysed by cross tabulation and logistic regression. RESULTS There were associations between examined adversities and fibromyalgia before and after adjustments for demographic features and depression (being afraid of a family member: odds ratio after adjustment 1.60, 95% CI 1.28-2.01; long-lasting financial difficulties 1.45, 1.18-1.77; serious conflicts in the family 1.40, 1.14-1.72; parental divorce 1.34, 1.05-1.72; serious or chronic illnesses in the family 1.27, 1.05-1.55; alcohol problems in the family 1.25, 1.02-1.53). CONCLUSION All six enquired adversities were associated with fibromyalgia after adjustments. These findings emphasize the importance of preventing adverse childhood experiences.

Encouraging primary care research: evaluation of a one-year, doctoral clinical epidemiology research course

Abstract Objective: Research and PhDs are relatively rare in family medicine and primary care. To promote research, regular one-year research courses for primary care professionals with a focus on clinical epidemiology were started. This study explores the academic outcomes of the first four cohorts of research courses and surveys the participants’ perspectives on the research course. Design: An electronic survey was sent to the research course participants. All peer-reviewed scientific papers published by these students were retrieved by literature searches in PubMed. Setting: Primary care in Finland. Subjects: A total of 46 research course participants who had finished the research courses between 2007 and 2012. Results: Of the 46 participants 29 were physicians, eight nurses, three dentists, four physiotherapists, and two nutritionists. By the end of 2014, 28 of the 46 participants (61%) had published 79 papers indexed in PubMed and seven students (15%) had completed a PhD. The participants stated that the course taught them critical thinking, and provided basic research knowledge, inspiration, and fruitful networks for research. Conclusion: A one-year, multi-professional, clinical epidemiology based research course appeared to be successful in encouraging primary care research as measured by research publications and networking. Activating teaching methods, encouraging focus on own research planning, and support from peers and tutors helped the participants to embark on research projects that resulted in PhDs for 15% of the participants. Key Points Clinical research and PhDs are rare in primary care in Finland, which has consequences for the development of the discipline and for the availability of clinical lecturers at the universities. A clinical epidemiology oriented, one-year research course increased the activity in primary care research. Focus on own research planning and learning the challenges of research with peers appeared to enhance the success of a doctoral research course. A doctoral research course encouraged networking, and the course collaboration sometimes led to paper co-authoring. In the Nordic countries, the primary care health professionals are used to working in multi-professional teams. A multi-professional strategy also seems fruitful in doctoral research education.

40 years of biannual family medicine research meetings – The European General Practice Research Network (EGPRN)

Abstract Objective. To document family medicine research in the 25 EGPRN member countries in 2010. Design. Semi-structured survey with open-ended questions. Setting. Academic family medicine in 23 European countries, Israel, and Turkey. Subjects. 25 EGPRN national representatives. Main outcome measures. Demographics of the general population and family medicine. Assessments, opinions, and suggestions. Results. EGPRN has represented family medicine for almost half a billion people and > 300 000 general practitioners (GPs). Turkey had the largest number of family medicine departments and highest density of GPs, 2.1/1000 people, Belgium had 1.7, Austria 1.6, and France 1.5. Lowest GP density was reported from Israel 0.17, Greece 0.18, and Slovenia 0.4 GPs per 1000 people. Family medicine research networks were reported by 22 of 25 and undergraduate family medicine research education in 20 of the 25 member countries, and in 10 countries students were required to do research projects. Postgraduate family medicine research was reported by 18 of the member countries. Open-ended responses showed that EGPRN meetings promoted stimulating and interesting research questions such as comparative studies of chronic pain management, sleep disorders, elderly care, healthy lifestyle promotion, mental health, clinical competence, and appropriateness of specialist referrals. Many respondents reported a lack of interest in family medicine research related to poor incentives and low family medicine status in general and among medical students in particular. It was suggested that EGPRN exert political lobbying for family medicine research. Conclusion. Since 1974, EGPRN organizes biannual conferences that unite and promote primary care practice, clinical research and academic family medicine in 25 member countries.

Burden of cardiovascular disease across 29 countries and GPs’ decision to treat hypertension in oldest-old

Abstract Objectives: We previously found large variations in general practitioner (GP) hypertension treatment probability in oldest-old (>80 years) between countries. We wanted to explore whether differences in country-specific cardiovascular disease (CVD) burden and life expectancy could explain the differences. Design: This is a survey study using case-vignettes of oldest-old patients with different comorbidities and blood pressure levels. An ecological multilevel model analysis was performed. Setting: GP respondents from European General Practice Research Network (EGPRN) countries, Brazil and New Zeeland. Subjects: This study included 2543 GPs from 29 countries. Main outcome measures: GP treatment probability to start or not start antihypertensive treatment based on responses to case-vignettes; either low (<50% started treatment) or high (≥50% started treatment). CVD burden is defined as ratio of disability-adjusted life years (DALYs) lost due to ischemic heart disease and/or stroke and total DALYs lost per country; life expectancy at age 60 and prevalence of oldest-old per country. Results: Of 1947 GPs (76%) responding to all vignettes, 787 (40%) scored high treatment probability and 1160 (60%) scored low. GPs in high CVD burden countries had higher odds of treatment probability (OR 3.70; 95% confidence interval (CI) 3.00–4.57); in countries with low life expectancy at 60, CVD was associated with high treatment probability (OR 2.18, 95% CI 1.12–4.25); but not in countries with high life expectancy (OR 1.06, 95% CI 0.56–1.98). Conclusions: GPs’ choice to treat/not treat hypertension in oldest-old was explained by differences in country-specific health characteristics. GPs in countries with high CVD burden and low life expectancy at age 60 were most likely to treat hypertension in oldest-old. Key Points  • General practitioners (GPs) are in a clinical dilemma when deciding whether (or not) to treat hypertension in the oldest-old (>80 years of age).  • In this study including 1947 GPs from 29 countries, we found that a high country-specific cardiovascular disease (CVD) burden (i.e. myocardial infarction and/or stroke) was associated with a higher GP treatment probability in patients aged >80 years.  • However, the association was modified by country-specific life expectancy at age 60. While there was a positive association for GPs in countries with a low life expectancy at age 60, there was no association in countries with a high life expectancy at age 60.  • These findings help explaining some of the large variation seen in the decision as to whether or not to treat hypertension in the oldest-old.

Which positive factors determine the GP satisfaction in clinical practice? A systematic literature review

BackgroundLooking at what makes General Practitioners (GPs) happy in their profession, may be important in increasing the GP workforce in the future. The European General Practice Research Network (EGPRN) created a research team (eight national groups) in order to clarify the factors involved in GP job satisfaction throughout Europe. The first step of this study was a literature review to explore how the satisfaction of GPs had been studied before. The research question was “Which factors are related to GP satisfaction in Clinical Practice?”MethodsSystematic literature review according to the PRISMA statement. The databases searched were Pubmed, Embase and Cochrane. All articles were identified, screened and included by two separate research teams, according to inclusion or exclusion criteria. Then, a qualitative appraisal was undertaken. Next, a thematic analysis process was undertaken to capture any issue relevant to the research question.ResultsThe number of records screened was 458. One hundred four were eligible. Finally, 17 articles were included. The data revealed 13 subthemes, which were grouped into three major themes for GP satisfaction. First there were general profession-related themes, applicable to many professions. A second group of issues related specifically to a GP setting. Finally, a third group was related to professional life and personal issues.ConclusionsA number of factors leading to GP job satisfaction, exist in literature They should be used by policy makers within Europe to increase the GP workforce. The research team needs to undertake qualitative studies to confirm or enhance those results.

Identifying important health system factors that influence primary care practitioners’ referrals for cancer suspicion: a European cross-sectional survey

Objectives Cancer survival and stage of disease at diagnosis and treatment vary widely across Europe. These differences may be partly due to variations in access to investigations and specialists. However, evidence to explain how different national health systems influence primary care practitioners’ (PCPs’) referral decisions is lacking. This study analyses health system factors potentially influencing PCPs’ referral decision-making when consulting with patients who may have cancer, and how these vary between European countries. Design Based on a content-validity consensus, a list of 45 items relating to a PCP’s decisions to refer patients with potential cancer symptoms for further investigation was reduced to 20 items. An online questionnaire with the 20 items was answered by PCPs on a five-point Likert scale, indicating how much each item affected their own decision-making in patients that could have cancer. An exploratory factor analysis identified the factors underlying PCPs’ referral decision-making. Setting A primary care study; 25 participating centres in 20 European countries. Participants 1830 PCPs completed the survey. The median response rate for participating centres was 20.7%. Outcome measures The factors derived from items related to PCPs’ referral decision-making. Mean factor scores were produced for each country, allowing comparisons. Results Factor analysis identified five underlying factors: PCPs’ ability to refer; degree of direct patient access to secondary care; PCPs’ perceptions of being under pressure; expectations of PCPs’ role; and extent to which PCPs believe that quality comes before cost in their health systems. These accounted for 47.4% of the observed variance between individual responses. Conclusions Five healthcare system factors influencing PCPs’ referral decision-making in 20 European countries were identified. The factors varied considerably between European countries. Knowledge of these factors could assist development of health service policies to produce better cancer outcomes, and inform future research to compare national cancer diagnostic pathways and outcomes.

Patient enablement after a single appointment with a GP: Analysis of Finnish QUALICOPC data

Background: Patient enablement is described as patient’s ability to understand and cope with illness after a consultation. The purpose of this study was to analyze factors associated with enablement in Finnish primary health care. An additional aim was to evaluate whether a single question could be used to measure enablement. Methods: A questionnaire survey was addressed to Finnish general practitioners (GPs) within the Quality and Costs of Primary Care in Europe (QUALICOPC) study framework. A trained fieldworker contacted nine patients for every participating GP. Two to 9 patients per GP (median 9 patients) completed the questionnaire. Patient enablement was measured by a single question based on the Patient Enablement Instrument questionnaire. Multivariate and multilevel analyses were performed to find variables that have an independent association with patient enablement. Results: A total of 1196 patients completed the QUALICOPC questionnaire. A total of 898 patients (75.1%) agreed that they felt better able to cope with their health problem or illness after an appointment with a GP, reflecting patient enablement. In the theme group analyses, 11 factors were found to have a statistically significant (P < .05) association with enablement. In the final multivariable model, positive perceptions of doctor-patient communication and patient satisfaction were positively associated with enablement. Conclusions: The results, using a single question to measure enablement, are comparable to previous findings on factors associated with enablement. Further research is needed and these results should be regarded as preliminary.

Primary-care-based episodes of care and their costs in a three-month follow-up in Finland.

Abstract Objective To explore patient characteristics, resource use, and costs related to different episodes of care (EOC) in Finnish health care. Design Data were collected during a three-month prospective, non-randomized follow-up study (Effective Health Centre) using questionnaires and an electronic health record. Setting Three primary health care practices in Pirkanmaa, Finland. Subjects Altogether 622 patients were recruited during a one-week period. Inclusion criteria: the patient had a doctor’s or nurse’s appointment on the recruiting day and agreed to participate. Exclusion criteria: patients visiting a specialized health guidance clinic for pregnant women, children, and mothers. Main outcome measures Patient characteristics, resource use, and costs based on the ICPC-2 EOC classification. Results On average, the patients had 1.22 EOCs during the three months. Patient characteristics and resource use differed between the EOC chapters. Chapter L, “Musculoskeletal”, had the most episodes (17%). The most common (8%) single EOC was “upper respiratory infection”. The mean cost of an episode (COE) was €389.56 (standard error 61.11) and the median COE was €165.00 (interquartile range €118.46–288.56) during the three-month follow-up. The most expensive chapter was K, “Circulatory”, with a mean COE of €909.85. The most expensive single COE was in chapter K, €32 545.56. The most expensive 1% of the COEs summed up covered 36% of the total COEs. Conclusion Patient characteristics, resource use, and costs differed between the ICPC-2 chapters, which could be taken into account in service planning and pricing. Future studies should incorporate more specific diagnoses, larger data sets, and longer follow-up times. Key points The most common episodes were under the ICPC-2 “Musculoskeletal” chapter, but the highest mean and single-episode costs were related to the “Circulatory” chapter. The mean (median) cost of episodes that started in primary care was €390 (€165) during the three-month follow-up. Patient characteristics, resource use, and costs differed significantly between the ICPC-2 chapters. The most expensive 1% of the episodes covered 36% of the total costs of all the episodes.