What Are the Factors Influencing Implementation of Advanced Access in Family Medicine Units? A Cross-Case Comparison of Four Early Adopters in Quebec

Introduction. Advanced access is an organizational model that has shown promise in improving timely access to primary care. In Quebec, it has recently been introduced in several family medicine units (FMUs) with a teaching mission. The objectives of this paper are to analyze the principles of advanced access implemented in FMUs and to identify which factors influenced their implementation. Methods. A multiple case study of four purposefully selected FMUs was conducted. Data included document analysis and 40 semistructured interviews with health professionals and staff. Cross-case comparison and thematic analysis were performed. Results. Three out of four FMUs implemented the key principles of advanced access at various levels. One scheduling pattern was observed: 90% of open appointment slots over three- to four-week periods and 10% of prebooked appointments. Structural and organizational factors facilitated the implementation: training of staff to support change, collective leadership, and openness to change. Conversely, family physicians practicing in multiple clinical settings, lack of team resources, turnover of clerical staff, rotation of medical residents, and management capacity were reported as major barriers to implementing the model. Conclusion. Our results call for multilevel implementation strategies to improve the design of the advanced access model in academic teaching settings.

Women’s Joint Decision on Contraceptive Use in Gedeo Zone, Southern Ethiopia: A Community Based Comparative Cross-Sectional Study

A community based comparative cross-sectional study design was employed to assess the mutual consent of women about family planning use in urban and rural villages of Gedeo zone. Two-thirds (67.4%) of women made joint decision on contraceptive use, varying between urban (70.9%) and rural (63.4%) settings. This difference was statistically significant where women in urban setup had a 41% (AOR, 1.41; 95% CI (1.15, 2.01) added chance of making joint decision than the rural counterpart. In both settings, attitude towards contraceptive method was an independent predictor of joint contraceptive decision (AOR = 2.85) in urban and (AOR = 2.81) rural women. Contrarily, different factors were found to be associated with joint contraceptive decision in either setup. In urban, having better knowledge about contraceptive methods (AOR = 2.9) and having lower age difference (AOR = 2.2) were found to be strong predictors of joint decision on contraceptive use, while having too many children (AOR = 2.2) and paternal support (AOR = 7.1) in rural setups. Lower level of joint decision making on contraceptive use was reported in both setups. Factors associated with joint decision varied between the two setups, except for attitude towards contraceptive methods. Future family planning program should address sociocultural, knowledge and attitude factors.

Type of Multimorbidity and Patient-Doctor Communication and Trust among Elderly Medicare Beneficiaries

Background. Effective communication and high trust with doctor are important to reduce the burden of multimorbidity in the rapidly aging population of the US. However, the association of multimorbidity with patient-doctor communication and trust is unknown. Objective. We examined the relationship between multimorbidity and patient-doctor communication and trust among the elderly. Method. We used the Medicare Current Beneficiary Survey (2012) to analyze the association between multimorbidity and patient-doctor communication and trust with multivariable logistic regressions that controlled for patient’s sociodemographic characteristics, health status, and satisfaction with care. Results. Most elderly beneficiaries reported effective communication (87.5–97.5%) and high trust (95.4–99.1%) with their doctors. The elderly with chronic physical and mental conditions were less likely than those with only physical conditions to report effective communication with their doctor (Adjusted Odds Ratio [95% Confidence Interval] = 0.80 [0.68, 0.96]). Multimorbidity did not have a significant association with patient-doctor trust. Conclusions. Elderly beneficiaries had high trust in their doctors, which was not affected by the presence of multimorbidity. Elderly individuals who had a mental condition in addition to physical conditions were more likely to report ineffective communication. Programs to improve patient-doctor communication with patients having cooccurring chronic physical and mental health conditions may be needed.

A Few Observations on Health Service for Immigrants at a Primary Health Care Centre

Objective. Icelandic society is rapidly changing, from being an ethnically homogeneous population towards a multicultural immigrant society. In the hope of optimizing the service for immigrants at the health care centre, we decided to evaluate health care utilization by immigrants. Methods. As a case control study we invited all immigrants that attended the health care centre during a two-week period to participate. Paired controls of Icelanders were invited for comparison. Results. There were 57 immigrants, 48 females and 9 males, from 27 countries. Significantly more of the immigrant women were married, P<0.001. Interpreters were needed in 21% of the consultations. The immigrants often attended the clinic and had the same diagnoses as did the nonimmigrants. The immigrants evaluated the quality of the service in Iceland as 4.3 and the service in their homeland as 1.68, P<0.001. Conclusion. Immigrants attending a health care centre in Iceland came from all over the world, had the same diagnoses, and attended the clinic as often per annum as the nonimmigrants. Only one-fifth of them needed translators. The health and health care utilization of immigrants were similar to those of nonimmigrants.

A Focus Group on Dental Pain Complaints with General Medical Practitioners: Developing a Treatment Algorithm

Objective. The differential diagnosis of pain in the mouth can be challenging for general medical practitioners (GMPs) as many different dental problems can present with similar signs and symptoms. This study aimed to create a treatment algorithm for GMPs to effectively and appropriately refer the patients and prescribe antibiotics. Design. The study design is comprised of qualitative focus group discussions. Setting and Subjects. Groups of GMPs within the Gold Coast and Brisbane urban and city regions. Outcome Measures. Content thematically analysed and treatment algorithm developed. Results. There were 5 focus groups with 8-9 participants per group. Addressing whether antibiotics should be given to patients with dental pain was considered very important to GMPs to prevent overtreatment and creating antibiotic resistance. Many practitioners were unsure of what the different forms of dental pains represent. 90% of the practitioners involved agreed that the treatment algorithm was useful to daily practice. Conclusion. Common dental complaints and infections are seldom surgical emergencies but can result in prolonged appointments for those GMPs who do not regularly deal with these issues. The treatment algorithm for referral processes and prescriptions was deemed easily downloadable and simple to interpret and detailed but succinct enough for clinical use by GMPs.

Ten-Year Trends in the Morbidity of Diabetes Mellitus and Antidiabetic Drug Utilization in Croatia: A Study Based on Routinely Collected Data

Objectives. To investigate trends of diabetes mellitus (DM) morbidity and antidiabetic drug utilization in Croatian primary health care (PHC) from 2005 to 2014. Method. Routinely collected morbidity data from all PHC units, presented in Croatian health-statistics yearbooks, were retrieved. Data on drug utilization were retrieved from the Annual Reports of the Croatian Agency for Medicinal Products and Medical Devices (ATC/DDD, antidiabetic, A10). Results. Total morbidity increased by 33.3% and DM increased by 65.6%, mostly in patients over age 65 (from 50% to 57%). Estimated DM prevalence in adults increased from 3.9% to 6.4%. Increased morbidity was followed by an even higher increase in drug utilization (120%). Metformin was first, with a constant increase (from 18% to 39%), followed by glimepiride, while glibenclamide use decreased. Total utilization of insulin increased even more, mostly for aspart (600%) and newly introduced glargine and detemir, while human insulin usage sharply decreased. Spending also increased, mostly for aspart (from 21% to 61% of total). Conclusions. Increased DM is followed by a higher increase in antidiabetic drug utilization; this trend will continue in the future. In Croatian PHC, metformin has primacy along with insulin analogues.

Exploring Self-Efficacy in Australian General Practitioners Managing Patient Obesity: A Qualitative Survey Study

Background. Obesity is a leading cause of morbidity and mortality in the Australian community, and general practitioners (GPs) are commonly approached by patients for assistance in losing weight. Previous studies have shown that GPs have low self-efficacy and low outcome expectation when it comes to managing overweight and obese patients, which affects their willingness to initiate and continue with weight counselling. This qualitative survey study aimed to explore the factors influencing confidence and behaviour in obesity management in GPs. Method. Twelve GPs recruited to deliver a pilot of an obesity management program participated in semistructured interviews, and interpretive analysis underpinned by social cognitive theory was performed on the transcripts. Results. Analysis identified five main themes: (1) perceived knowledge and skills, (2) structure to management approach, (3) the GP-patient relationship, (4) acknowledged barriers to weight loss and lifestyle change, and (5) prior experience and outcome expectation. Conclusions. GPs are likely to welcome tools which provide a more structured approach to obesity management. Shifting away from weight and BMI as sole yardsticks for success or failure and emphasising positive lifestyle changes for their own sake may improve GP self-efficacy and allow for a more authentic GP-patient interaction.

“Negotiorum Gestio” in Family Medicine, Informed Consent Obtainment, and Disciplinary Responsibility

Introduction. Negotiorum gestio (NG) denotes an action where a person well intendedly acts on behalf of another without obtaining the latter’s prior consent. In broad terms, NG-like actions have played a considerable role in health care provision. In some settings, health care delivery with only little or presumed patients’ consent has been the rule rather than the exception. However, bioethical principles regarding patient autonomy and obtainment of the patient’s informed consent (IC) before intervention are now increasingly materialized in the law of many countries. Aim. To study legal consequences of NG in family medicine and IC handling options. Methods. Case law examination. Results. A disciplinary board case is described concerning a family doctor conducting unlawful NG by not coming up to legal IC requirements. Discussion and Conclusion. The practical and legal implications of IC and possible role of novel Shared Decision-Making approaches in coming up to regulation and bioethical demands are discussed. It is concluded that a doctor may run an unnecessary legal risk when conducting NG in decision-competent patients and furthermore it is suggested that novel Shared Decision-Making approaches could help in obtaining a rightful and practicable IC.

General Practitioners’ Participation in a Large, Multicountry Combined General Practitioner-Patient Survey: Recruitment Procedures and Participation Rate

Background. The participation of general practitioners (GPs) is essential in research on the performance of primary care. This paper describes the implementation of a large, multicountry study in primary care that combines a survey among GPs and a linked survey among patients that visited their practice (the QUALICOPC study). The aim is to describe the recruitment procedure and explore differences between countries in the participation rate of the GPs. Methods. Descriptive analyses were used to document recruitment procedures and to assess hypotheses potentially explaining variation in participation rates between countries. Results. The survey was implemented in 31 European countries. GPs were mainly selected through random sampling. The actual implementation of the study differed between countries. The median participation rate was 30%. Both material (such as the payment system of GPs in a country) and immaterial influences (such as estimated survey pressure) are related to differences between countries. Conclusion. This study shows that the participation of GPs may indeed be influenced by the context of the country. The implementation of complex data collection is difficult to realize in a completely uniform way. Procedures have to be tuned to the context of the country.

Trajectories of Change in Obesity among Tehranian Families: Multilevel Latent Growth Curve Modeling

Objectives. To evaluate the trajectories of change in obesity within and between Tehranian families, who participated in the Tehran Lipid and Glucose Study (TLGS). Methods. This study is a family-based longitudinal design, in four waves. A total of 14761 individuals, within 3980 families, were selected. Three anthropometric measurements, body mass index (BMI), waist circumference (WC), and a body shape index (ABSI), were recorded. Multilevel latent growth curve modeling (MLGCM) approach was used for evaluating the change trajectories in obesity within and between the families. Results. The mean age of the subjects in the present study was 33.28±19.01 (range 3–89 years) and 50.1% were male. Obesity was significantly increased (P<0.001). Individuals with more fat become obese slower, whereas families with more fat become obese faster (P<0.001). The initial value and growth rate of WC and ABSI were greater in men than in women, while this result is contrary to BMI (P<0.001). Conclusions. Our findings demonstrated that there is an alarming increase in the obesity trend in Tehranian families. The important role of the family in the prevention of obesity is highlighted, underlining the need for public health programs, as family centered educations to lifestyle modification, which can address this emerging crisis.