Different abdominal symptoms may signal cancer, but their role is unclear.
To examine associations between abdominal symptoms and subsequent cancer diagnosed in the abdominal region.
Prospective cohort study comprising 493 GPs from surgeries in Norway, Denmark, Sweden, Scotland, Belgium, and the Netherlands.
Over a 10-day period, the GPs recorded consecutive consultations and noted: patients who presented with abdominal symptoms pre-specified on the registration form; additional data on non-specific symptoms; and features of the consultation. Eight months later, data on all cancer diagnoses among all study patients in the participating general practices were requested from the GPs.
Consultations with 61 802 patients were recorded and abdominal symptoms were documented in 6264 (10.1%) patients. Malignancy, both abdominal and non-abdominal, was subsequently diagnosed in 511 patients (0.8%). Among patients with a new cancer in the abdomen (n = 251), 175 (69.7%) were diagnosed within 180 days after consultation. In a multivariate model, the highest sex- and age-adjusted hazard ratio (HR) was for the single symptom of rectal bleeding (HR 19.1, 95% confidence interval = 8.7 to 41.7). Positive predictive values of >3% were found for macroscopic haematuria, rectal bleeding, and involuntary weight loss, with variations according to age and sex. The three symptoms relating to irregular bleeding had particularly high specificity in terms of colorectal, uterine, and bladder cancer.
A patient with undiagnosed cancer may present with symptoms or no symptoms. Irregular bleeding must always be explained. Abdominal pain occurs with all types of abdominal cancer and several symptoms may signal colorectal cancer. The findings are important as they influence how GPs think and act, and how they can contribute to an earlier diagnosis of cancer.
The aims were to develop auditing according to the APO (Audit Project Odense) method for measuring soft data, exemplified by a holistic view, and to test the instrument.
A descriptive study of the development of an APO chart and a test registration.
Primary health care, Blekinge County, Sweden.
Ten general practitioners (GPs) were invited to transform categories of the concept of a holistic view obtained in an earlier study, into 30 variables on an APO registration chart. The participants chose to study different kinds of knowledge as aspects of holistic care.
An APO registration chart and test of the instrument.
After three meetings the group had drawn up an APO registration chart supplemented with Likert scales. A pilot audit was performed. Eight doctors registered 255 consultations. In assessment of the patients' problems, factual medical knowledge was important in 83% of the cases, familiarity in 53%, and a capacity for judgement in 36%. In decision-making factual medical knowledge was used in 88% and capacity for judgement in 58%. A holistic view was necessary for the outcome in 43% and valuable in 25%. The GPs used the Likert scales in a majority of the cases.
In this first step in developing an instrument, the results indicate that the APO method could be an alternative for studying what happens in the consultation, and the occurrence of an abstract phenomenon such as the use of different kinds of knowledge as part of a holistic view.
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BACKGROUND: Excessive and inappropriate use of antibiotics is considered to be the most important reason for development of bacterial resistance to antibiotics. As antibiotic resistance may spread across borders, high prevalence countries may serve as a source of bacterial resistance for countries with a low prevalence. Therefore, bacterial resistance is an important issue with a potential serious impact on all countries. The majority of respiratory tract infections (RTIs) are treated in general practice. Most infections are caused by virus and antibiotics are therefore unlikely to have any clinical benefit. Several intervention initiatives have been taken to reduce the inappropriate use of antibiotics in primary health care, but the effectiveness of these interventions is only modest. Only few studies have been designed to determine the effectiveness of multifaceted strategies in countries with different practice setting. The aim of this study is to evaluate the impact of a multifaceted intervention targeting general practitioners (GPs) and patients in six countries with different prevalence of antibiotic resistance: Two Nordic countries (Denmark and Sweden), two Baltic Countries (Lithuania and Kaliningrad-Russia) and two Hispano-American countries (Spain and Argentina). METHODS/DESIGN: HAPPY AUDIT was initiated in 2008 and the project is still ongoing. The project includes 15 partners from 9 countries. GPs participating in HAPPY AUDIT will be audited by the Audit Project Odense (APO) method. The APO method will be used at a multinational level involving GPs from six countries with different cultural background and different organisation of primary health care. Research on the effect of the intervention will be performed by analysing audit registrations carried out before and after the intervention. The intervention includes training courses on management of RTIs, dissemination of clinical guidelines with recommendations for diagnosis and treatment, posters for the waiting room, brochures to patients and implementation of point of care tests (Strep A and CRP) to be used in the GPs'surgeries. To ensure public awareness of the risk of resistant bacteria, media campaigns targeting both professionals and the public will be developed and the results will be published and widely disseminated at a Working Conference hosted by the World Association of Family Doctors (WONCA-Europe) at the end of the project period. DISCUSSION: HAPPY AUDIT is an EU-financed project with the aim of contributing to the battle against antibiotic resistance through quality improvement of GPs' diagnosis and treatment of RTIs through development of intervention programmes targeting GPs, parents of young children and healthy adults. It is hypothesized that the use of multifaceted strategies combining active intervention by GPs will be effective in reducing prescribing of unnecessary antibiotics for RTIs and improving the use of appropriate antibiotics in suspected bacterial infections.
To explore factors and circumstances contributing to prudent antibiotic prescribing for respiratory tract infections in primary care.
Two focus groups representing rural and urban areas. A semi-structured interview guide with open-ended questions and an editing analysis style was used. They were examined to identify meaning units that were sorted into categories in an iterative process throughout the analysis.
Primary health care in two counties in southern Sweden.
Two groups including seven and six general practitioners (GPs) respectively, men and women of different ages with different professional experiences.
Exploration of categories, determination of themes, construction of models.
The decision to prescribe antibiotics takes place in the encounter between GP and patient, initially characterized by harmony or fight and the subsequent process by collaboration or negotiation, resulting in agreement, compromise, or disagreement. Several factors influence the meeting and contribute to enhancing the conditions for rational prescribing. These conditions are connected to the GP, the relationship, and the setting; organization as well as professional culture. The findings indicate synergies between the factors, and that one factor can sometimes compensate for lack of another. Continuity and mutual trust can make a brief consultation successful, but lack of continuity can eliminate the effects of knowledge and professional skills.
The findings emphasize the importance of the encounter between the GP and the patient for prudent antibiotic prescribing. Furthermore, the importance of an appropriate organization of primary care, which promotes continuity and encourages professional autonomy, is demonstrated.
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To compare participants and non-participants early in the process of an audit on treatment of respiratory tract infections (RTIs) and to analyse any effect of the actual self-registration on the prescription of antibiotics in both groups.
All 80 general practitioners (GPs) at 14 health centres were invited to audit their use of antibiotics and 45 agreed to participate. There were both participants and non-participants at all centres. Data were collected retrospectively from the electronic patient records of all visits for RTI during five periods including the self-registration period. Comparisons were made over time within and between the groups.
Primary health care in Blekinge county, Southern Sweden.
80 GPs: 45 participants and 35 non-participants.
Proportion of patients with RTI who received antibiotics.
At the start, the difference in prescription frequency between participants and non-participants was six percentage points (RR = 0.92; 95% CI = 0.87-0.97), and at the end seven percentage points (0.88; 0.81-0.95). The proportion of RTIs treated with antibiotics fell for both groups, (0.86; 0.80-0.92 and 0.90; 0.83-0.97, respectively).
GPs who chose to take part in the audit had a different prescription pattern from the non-participants right from the start. Both groups reduced their prescription of antibiotics during the study period. Either the registration had no effect on the participants or it had an effect on both the participants and the non-participants.
Prescribing of antibiotics for common infections varies widely, and there is no medical explanation. Systematic reviews have highlighted factors that may influence antibiotic prescribing and that this is a complex process. It is unclear how factors interact and how the primary care organization affects diagnostic procedures and antibiotic prescribing. Therefore, we sought to explore and understand interactions between factors influencing antibiotic prescribing for respiratory tract infections in primary care.
Our mixed methods design was guided by the Triangulation Design Model according to Creswell. Quantitative and qualitative data were collected in parallel. Quantitative data were collected by prescription statistics, questionnaires to patients, and general practitioners' audit registrations. Qualitative data were collected through observations and semi-structured interviews.
From the analysis of the data from the different sources an overall theme emerged: A common practice in the primary health care centre is crucial for low antibiotic prescribing in line with guidelines. Several factors contribute to a common practice, such as promoting management and leadership, internalized guidelines including inter-professional discussions, the general practitioner's diagnostic process, nurse triage, and patient expectation. These factors were closely related and influenced each other. The results showed that knowledge must be internalized and guidelines need to be normative for the group as well as for every individual.
Low prescribing is associated with adapted and transformed guidelines within all staff, not only general practitioners. Nurses' triage and self-care advice played an important role. Encouragement from the management level stimulated inter-professional discussions about antibiotic prescribing. Informal opinion moulders talking about antibiotic prescribing was supported by the managers. Finally, continuous professional development activities were encouraged for up-to-date knowledge.
Swedish nursing homes (NH) have limited capacity. As a result elderly people living in NH represent the part of the elderly population in most need of care. In Sweden a General Practitioner (GP) is usually responsible for the medical care of all subjects living in a NH. The residents in NH seldom have adequate pharmacological treatment according to diagnosis and often have polypharmacy and/or inappropriate medical treatment regarding concerns of declining renal function. What prevents optimal care for the elderly is multifaceted, but there is limited research on how GPs experience their work with the elderly in NH in Sweden. This study aims to illuminate the GPs' work with the elderly in NH to provide input on how the care can be improved, as well as to identify potential obstacles for good quality of care.
This qualitative study is based on individual semi-structured interviews with 12 GPs and a follow-up focus group discussion with six of the interviewed GPs. The interviews were analysed with systematic text condensation, with the process leading to identify categories and themes. Thereafter, the themes were discussed among six of the participating GPs in a focus group interview.
Two main themes were identified: concern for the patient and sustainable working conditions. The principal focus for the GPs was to contribute to the best possible quality of life for the patients. The GPs described discordance between the demand from staff for medications and the patients' actual need of care. GPs found their work with NH enjoyable. Even though the patients at the NH often suffered from multiple illnesses, which could lead to difficult decisions being made, the doctors felt confident in their role by having a holistic view of the patient in tandem with reliable support from the nurse at the NH.
Working with NH patients was considered important and meaningful, with the GPs striving for the patient's well-being with special consideration to the continuum of ageing. A continuous and well-functioning relationship between the GP and the nurse was crucial for the patients' well-being.
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Cites: Lancet. 2001 Aug 11;358(9280):483-811513933
To explore how a group of Swedish general practitioners (GPs) manage patients with a sore throat in relation to current guidelines as expressed in interviews.
Qualitative content analysis was used to analyse semi-structured interviews.
Swedish primary care.
A strategic sample of 25 GPs.
Perceived management of sore throat patients.
It was found that nine of the interviewed GPs were adherent to current guidelines for sore throat and 16 were non-adherent. The two groups differed in terms of guideline knowledge, which was shared within the team for adherent GPs while idiosyncratic knowledge dominated for the non-adherent GPs. Adherent GPs had no or low concerns for bacterial infections and differential diagnosis whilst non-adherent GPs believed that in patients with a sore throat any bacterial infection should be identified and treated with antibiotics. Patient history and examination was mainly targeted by adherent GPs whilst for non-adherent GPs it was often redundant. Non-adherent GPs reported problems getting patients to abstain from antibiotics, whilst no such problems were reported in adherent GPs.
This interview study of sore throat management in a strategically sampled group of Swedish GPs showed that while two-thirds were non-adherent and had a liberal attitude to antibiotics one-third were guideline adherent with a restricted view on antibiotics. Non-adherent GPs revealed significant knowledge gaps. Adherent GPs had discussed guidelines within the primary care team while non-adherent GPs had not. Guideline implementation thus seemed to be promoted by knowledge shared in team discussions.
Excessive antibiotics use increases the risk of resistance. Previous studies have shown that the Centor score combined with Rapid Antigen Detection Test (RADT) for Group A Streptococci can reduce unnecessary antibiotic prescribing in patients with sore throat. According to the former Swedish guidelines RADT was recommended with 2-4 Centor criteria present and antibiotics were recommended if the test was positive. C- reactive protein (CRP) was not recommended for sore throats. Inappropriate use of RADT and CRP has been reported in several studies.
From a larger project 16 general practitioners (GPs) who stated management of sore throats not according to the guidelines were identified. Half-hour long semi-structured interviews were conducted. The topics were the management of sore throats and the use of near-patient tests. Qualitative content analysis was used.
The use of the near-patient test interplayed with the clinical assessment and the perception that all infections caused by bacteria should be treated with antibiotics. The GPs expressed a belief that the clinical picture was sufficient for diagnosis in typical cases. RADT was not believed to be relevant since it detects only one bacterium, while CRP was considered as a reliable numerical measure of bacterial infection.
Inappropriate use of near-patient test can partly be understood as remnants of outdated knowledge. When new guidelines are introduced the differences between them and the former need to be discussed more explicitly.
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The definition of primary care varies between countries. Swedish primary care has developed from a philosophic viewpoint based on quality, accessibility, continuity, co-operation and a holistic view. The meaning of holism in international literature differs between medicine and nursing. The question is, if the difference is due to different educational traditions. Due to the uncertainties in defining holism and a holistic view we wished to study, in depth, how holism is perceived by doctors and nurses in their clinical work. Thus, the aim was to explore the perceived meaning of a holistic view among general practitioners (GPs) and district nurses (DNs).
Seven focus group interviews with a purposive sample of 22 GPs and 20 nurses working in primary care in two Swedish county councils were conducted. The interviews were transcribed verbatim and analysed using qualitative content analysis.
The analysis resulted in three categories, attitude, knowledge, and circumstances, with two, two and four subcategories respectively. A professional attitude involves recognising the whole person; not only fragments of a person with a disease. Factual knowledge is acquired through special training and long professional experience. Tacit knowledge is about feelings and social competence. Circumstances can either be barriers or facilitators. A holistic view is a strong motivator and as such it is a facilitator. The way primary care is organised can be either a barrier or a facilitator and could influence the use of a holistic approach. Defined geographical districts and care teams facilitate a holistic view with house calls being essential, particularly for nurses. In preventive work and palliative care, a holistic view was stated to be specifically important. Consultations and communication with the patient were seen as important tools.
'Holistic view' is multidimensional, well implemented and very much alive among both GPs and DNs. The word holistic should really be spelled 'wholistic' to avoid confusion with complementary and alternative medicine. It was obvious that our participants were able to verbalize the meaning of a 'wholistic' view through narratives about their clinical, every day work. The possibility to implement a 'wholistic' perspective in their work with patients offers a strong motivation for GPs and DNs.
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