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Well-Child Care (WCC) is the provision of preventive health care services for children and their families. Prior research has highlighted that several barriers exist for the provision of WCC services. To study \"real life\" visits of parents and children with health professionals in order to enhance the theoretical understanding of factors affecting WCC. Participant observations of a cross-sectional sample of 71 visits at three general practices were analysed using a mixed-methods approach. The median age of the children was 18 months (IQR, 6-36 months), and the duration of visits was 13 mins (IQR, 9-18 mins). The reasons for the visits were immunisation in 13 (18.5%), general check-up in 10 (13.8%), viral illness in 33 (49.2%) and miscellaneous reasons in 15 (18.5%). Two clusters with low and high WCC emerged; WCC was associated with higher GP patient-centeredness scores, younger age of the child, fewer previous visits, immunisation and general check-up visits, and the solo general practitioner setting. Mothers born overseas received less WCC advice, while longer duration of visit increased WCC. GPs often made observations on physical growth and development and negotiated mothers concerns to provide reassurance to them. The working style of the GP which encouraged informal conversations with the parents enhanced WCC. There was a lack of systematic use of developmental screening measures. GPs and practice nurses are providing parent/child centered WCC in many visits, particularly when parents present for immunisation and general check-ups. Providing funding and practice nurse support to GPs, and aligning WCC activities with all immunisation visits, rather than just a one-off screening approach, appears to be the best way forward. A cluster randomised trial for doing structured WCC activities with immunisation visits would provide further evidence for cost-effectiveness studies to inform policy change.

Objective The PaCUDAHL randomized clinical trial evaluated an HPV self-sampling device provided by the family doctor to female patients not participating in the usual opportunistic cervical screening program from 2016 to 2019. Reliable data on the Hawthorne (observer) effect (HE) in clinical trials were lacking. This nested study aimed to verify whether there was a significant difference between participating and non-participating general practitioners (GPs) in the trial, and to measure whether there was an HE in the female patients of participating GPs. Results We carried out an analytical retrospective cohort study involving 332 GPs and their 70,983 female patients, aged 25–65, registered with the Health Insurance Fund of Flanders, using claims database for the three-year periods 2012–2015 and 2016–2019. Statistical analyses were performed using a linear generalized hierarchical mixed model with geographic level as a random effect. The patients of the 24 participating GPs did not have a cervical cancer screening rate different from that of the non-participating GPs, either before recruitment ( p   = 0.24 ) or during the PaCUDAHL trial period ( p   = 0.15 ). There were significant increases in cervical cancer screening rates over four years regardless of the group considered ( p   < 0.0001 ). In conclusion there was no observer effect but a significant cohort effect.

Uptake of screening through the Australian National Bowel Cancer Screening Program remains low. General practice guidelines support the general practitioners’ role to offer CRC screening. This study tests the effect that an intervention including point‐of‐care FOBT provision, printed screening advice and GP endorsement has on self‐reported FOBT uptake. A multisite, 1:1 parallel‐arm, cluster‐randomised controlled trial. Participants aged 50–74, at average risk of CRC and overdue for screening were recruited from four general practices in New South Wales, Australia, from September 2016 to May 2017. Self‐report of FOBT up to eight weeks post baseline. A total of 336 participants consented to complete a baseline survey (64% consent rate), of which 123 were recruited into the trial (28 usual care days and 26 intervention days). Follow‐up data was collected for 114 participants (65 usual care and 49 intervention). Those receiving the intervention had ten times greater odds of completing screening compared to usual care (39% vs. 6%; OR 10.24; 95%CI 2.9‐36.6, p=0.0006). A multicomponent intervention delivered in general practice significantly increased self‐reported FOBT uptake in those at average risk of CRC. General practice interventions could serve as an important adjunct to the Australian National Bowel Cancer Screening Program to boost plateauing screening rates.

Background Cervical cancer screening is effective in reducing mortality due to uterine cervical cancer (UCC). However, inequalities in participation in UCC screening exist, especially according to age and social status. Considering the current situation in France regarding the ongoing organized UCC screening campaign, we aimed to assess general practitioners’ (GPs) and gynaecologists’ preferences for actions designed to reduce screening inequalities. Methods French physicians’ preferences to UCC screening modalities was assessed using a discrete choice experiment. A national cross-sectional questionnaire was sent between September and October 2014 to 500 randomly selected physicians, and numerically to all targeted physicians working in the French region Midi-Pyrénées. Practitioners were offered 11 binary choices of organized screening scenarios in order to reduce inequalities in UCC screening participation. Each scenario was based on five attributes corresponding to five ways to enhance participation in UCC screening while reducing screening inequalities. Results Among the 123 respondents included, practitioners voted for additional interventions targeting non-screened women overall ( p  <  0.05), including centralized invitations sent from a central authority and involving the mentioned attending physician, or providing attending physicians with the lists of unscreened women among their patients. However, they rejected the specific targeting of women over 50 years old ( p  <  0.01) or living in deprived areas ( p  <  0.05). Only GPs were in favour of allowing nurses to perform Pap smears, but both GPs and gynaecologists rejected self-collected oncogenic papillomavirus testing. Conclusions French practitioners tended to value the traditional principle of universalism. As well as rejecting self-collected oncogenic papillomavirus testing, their reluctance to support the principle of proportionate universalism relying on additional interventions addressing differences in socioeconomic status needs further evaluation. As these two concepts have already been recommended as secondary development leads for the French national organized screening campaign currently being implemented, the adherence of practitioners and the adaptation of these concepts are necessary conditions for reducing inequalities in health care.

Background Patients with advanced chronic non-malignant conditions often experience significant symptom burden. Therefore, overcoming barriers to interprofessional collaboration between general practitioners (GPs) and specialist palliative home care (SPHC) teams is essential to facilitate the timely integration of palliative care elements. The KOPAL trial aimed to examine the impact of case conferences between GPs and SPHC teams on symptom burden and pain in patients with advanced chronic heart failure, chronic obstructive pulmonary disease, and dementia. Methods The cluster-randomised controlled trial compared a structured palliative care nurse visit followed by an interprofessional case conference to usual care. Data were collected from GPs at baseline and 48 weeks, while standardised patient interviews were conducted at baseline, 6, 12, 24, and 48 weeks. Results We analysed 172 patients from 49 German GP practices. Both groups showed marginal improvement in symptom burden; however, no statistically significant between-group difference was found ( =-0.561, 95% CI: -3.201–2.079, p  = .68). Patients with dementia experienced a significant pain reduction ( =2.187, 95% CI: 0.563–3.812, p  = .009). Conversely, the intervention did not have a significant effect on pain severity ( =-0.711, 95% CI: -1.430 − 0.008, p =.053) or pain interference ( =-0.036, 95% CI:-0.797 − 0.725, p =.926) in other patient groups. Conclusions The intervention showed promise in the timely introduction of palliative care elements to address pain management in patients with dementia. Further studies are needed to identify and effectively address symptom burden and pain in other patient groups. Trial registration German Clinical Trials Register: https://www.drks.de/DRKS00017795 (Registration date: 9th January 2020).

To compare the impact of unconditional and conditional financial incentives on response rates among Australian general practitioners invited by mail to participate in an online survey about cancer care and to investigate possible differential response bias between incentive groups. Australian general practitioners were randomly allocated to unconditional incentive (book voucher mailed with letter of invitation), conditional incentive (book voucher mailed on completion of the online survey), or control (no incentive). Nonresponders were asked to complete a small subset of questions from the online survey. Among 3,334 eligible general practitioners, significantly higher response rates were achieved in the unconditional group (167 of 1,101, 15%) compared with the conditional group (118 of 1,111, 11%) (P = 0.0014), and both were significantly higher than the control group (74 of 1,122, 7%; both P < 0.001). Although more positive opinions about cancer care were expressed by online responders compared with nonresponders, there was no evidence that the magnitude of difference varied by the incentive group. The incremental cost for each additional 1% increase above the control group response rate was substantially higher for the unconditional incentive group compared with the conditional incentive group. Both unconditional and conditional financial incentives significantly increased response with no evidence of differential response bias. Although unconditional incentives had the largest effect, the conditional approach was more cost-effective.

The increasing prevalence of dermatological diseases will pose a growing challenge to the health care system and, in particular, to general practitioners (GPs) as the first point of contact for these patients. In many countries, primary care physicians are supported by teledermatology services. The aim of this study was to detect learning effects and gains among GPs through teledermatology consultations (TCs) in daily practice. As part of a mixed methods study embedded in a cluster-randomized controlled trial (TeleDerm), a full survey and semiguided face-to-face interviews were conducted among GPs of participating intervention practices using the telemedicine approach. A TC assessment tool (TC-AT) was developed to evaluate the quality of clinical data and images of TCs conducted during the run-in and intervention phases, with a score ranging from 0 (lowest quality) to 10 (highest quality). Mixed methods analysis triangulated qualitative content analysis, survey data with a growth curve model calculated from TC-AT data, comparing subjective experiences of GPs with objective process data. A total of 487 TCs of 33 practices were analyzed. Questionnaires from n=46 GPs (practice-level response rate: 69.9%) were included in the quantitative analysis. Two-thirds of the GPs (n=31; 67.4%) in the written survey rated the TCs as helpful for differential diagnosis and treatment management. Improved self-reported confidence in diagnosing skin diseases due to the timely clinical feedback from dermatologists was reported by more than half of the responding GPs (n=25; 54.3%). In the interviews (n=13), teleconsultations were mainly seen as a learning opportunity by the GPs. Regarding the quality of TCs, a mean TC-AT score of 7.4 (SD 1.7, range 0-10) was observed. In the growth curve model, a simple linear time trend provided the best fit to the TC-AT score trajectory across the observed study period. A significant time * TC-AT start score interaction was found (F452=30.66, P<.001). While regardless of the initial TC-AT score, repeated TCs lead to process quality improvements over time, post hoc probing of the TC-AT start score as a moderator of the learning effect over time revealed the highest improvements among GP practices with a lower initial TC-AT score (-1 SD: standardized slope=0.59, P<.001; mean: standardized slope=0.38, P<.001; +1 SD: standardized slope=0.18, P<.001). TCs have been shown to be an effective method of education for GPs in terms of \"learning on the job\" in daily practice. The telemedicine approach seems to be an easily implementable and effective tool to support continuing medical education in the field of dermatology. Strategies could be developed to train GPs and medical students in the use of TC to adequately prepare them for the increasing technological demands of their future profession in primary care.

Aims: Using qualitative interviews, this study explored the experiences of GPs, vocational advisers and patients towards a new vocational advice (VA) service in primary care. Methods: This study was nested within the Study of Work and Pain (SWAP) cluster randomised controlled trial. The SWAP trial located a VA service within three general practices in Staffordshire. Interviews took place with 10 GPs 12 months after the introduction of the VA service, four vocational advisers whilst the VA service was running and 20 patients on discharge from the VA service. The data were analysed using the constant comparative method, which is a variation of grounded theory. Results: The key factors determining the acceptability and perceived effectiveness of the VA service from the perspective of the three groups of stakeholders were (1) the timing of referrals to the VA, (2) the perceived lack of patient demand for the service and (3) role uncertainty experienced by VAs. Conclusions: Early vocational intervention may not be appropriate for all musculoskeletal patients with work difficulties. Indeed, many patients felt they did not require the support of a VA, either because they had self-limiting work difficulties and/or already had support mechanisms in place to return to work. Future VA interventions may be better implemented in a targeted way so that appropriate patients are identified with characteristics which can best be addressed by the VA service.

Homeless people have complex problems. GP enhanced care (Pathway) has shown benefits. We performed a randomised, ­parallel arm trial at two large inner city hospitals. Inpatient homeless adults were randomly allocated to either standard care (all management by the hospital-based clinical team) or enhanced care with input from a homeless care team. The hospital data system provided healthcare usage information, and we used questionnaires to assess quality of life. 206 patients were allocated to enhanced care and 204 to usual care. Length of stay (up to 90 days after admission) did not differ between groups (standard care 14.0 days, enhanced care 13.3 days). Average reattendance at the emergency department within a year was 5.8 visits in the standard care group and 4.8 visits with enhanced care, but this decrease was not significant. ­Quality of life scores after discharge (in 108 patients) improved with enhanced care (EQ-5D-5L score increased by 0.12 [95% CI 0.032 to 0.22] compared wtih 0.03 [–0.1 to 0.15; p=0.076] with standard care). The proportion of people sleeping on the streets after discharge was 14.6% in the standard care arm and 3.8% in the enhanced care arm (p=0.034). The quality-of-life cost per quality-adjusted life-year was £26,000. The Pathway approach doesn’t alter length of stay but improves quality of life and reduces street ­homelessness.

Background General Practitioners (GPs) are the main providers of primary palliative care (PPC). At the same time they are the main initiators of specialised palliative homecare (SPHC). In Germany, little is known about factors which influence GPs in their involvement of SPHC. Aim of our study is to identify factors that drive GPs to give value to and involve SPHC. Methods A cross-sectional survey was performed. In 2018, questionnaires were mailed to 6000 randomly selected GPs from eight German federal states, focusing on the extent of GPs’ palliative care activities and their involvement of SPHC. Results With a response rate of 19.4% and exclusion of GPs working in SPHC-teams, n  = 1026 questionnaires were appropriate for analysis. GPs valued SPHC support as the most “important/very important” for both “technical/invasive treatment measures” (95%) and availability outside practice opening hours (92%). The most relevant factor influencing perceived SPHC-importance was GPs’ self-reported extent of engagement in palliative care (β = − 0.283; CI 95% = − 0.384;−0.182), followed by the perceived quality of utilised SPHC (β = 0.119; CI 95% = 0.048;0.190), involvement in treatment of palliative patients after SPHC initiation (β = 0.088; CI 95% = 0.042;0.134), and conviction that palliative care should be a central part of GPs’ work (β = − 0.062; CI 95% = − 0.116;−0.008). Perceived SPHC-importance is also associated with SPHC-referrals (β =0.138; p  < 0.001). The lower the engagement of GPs in palliative care, the more they involve SPHC and vice versa. Conclusions GPs with low reported activity in palliative care are more likely to initialise SPHC for palliative care activities they do not deliver themselves for various reasons, which might mean that the involvement of SPHC is substitutive instead of complementary to primary palliative care. This finding and its interpretation should be given more attention in the future policy framework for (specialised) palliative homecare. Trial registration German Clinical Trials Register DRKS00014726 , 14.05.2018.