Patients' subjective concepts about primary healthcare utilisation: the study protocol of a quality comparative study between Norway and Germany

Background In Germany, utilisation of ambulatory healthcare services is high compared with other countries: While a study based on the process data of German statutory health insurances showed an average of 17.1 physician-patient-contacts per year, the comparable figure for Norway is about five. The usual models of healthcare utilisation, such as Rosenstock's Health Belief Model and Andersen's Behavioural Model, cannot explain these differences adequately. Organisational factors of the healthcare system, such as gatekeeping, do not explain the magnitude of the differences. Our hypothesis is that patients’ subjective concepts about primary healthcare utilisation play a major role in explaining different healthcare utilisation behaviour in different countries. Hence, the aim of this study is to explore these subjective concepts comparatively, between Germany and Norway. Methods/design With that aim in mind, we chose a comparative qualitative study design. In Norway and Germany, we are going to interview 20 patients each with qualitative episodic interviews. In addition, we are going to conduct participant observation in four German and four Norwegian primary care practices. The data will be analysed by thematic coding. Using selected categories, we are going to conduct comparative case and group analyses. Ethics and dissemination The study adheres to the Declaration of Helsinki. All interviewees will sign informed consent forms and all patients will be observed during consultation. Strict rules for data security will apply. Developed theory and policy implications are going to be disseminated by a workshop, presentations for experts and laypersons and publications.publishedVersio

Typologies in GPs’ referral practice

Background: GPs’ individual decisions to refer and the various ways of working when they refer are important determinants of secondary care use. The objective of this study was to explore and describe potential characteristics of GPs’ referral practice by investigating their opinions about referring and their self-reported experiences of what they do when they refer. Methods: Observational cross-sectional study using data from 128 Norwegian GPs who filled in a questionnaire with statements on how they regarded the referral process, and who were invited to collect data when they actually referred to hospital during one month. Only elective referrals were recorded. The 57 participants (44,5 %) recorded data from 691 referrals. The variables were included in a principal component analysis. A multiple linear regression analysis was conducted to identify typologies with GP’s age, gender, specialty in family medicine and location as independent variables. Results: Eight principal components describe the different ways GPs think and work when they refer. Two typologies summarize these components: confidence characterizing specialists in family medicine, mainly female, who reported a more patient-centred practice making priority decisions when they refer, who confer easily with hospital consultants and who complete the referrals during the consultation; uncertainty characterizing young, mainly male non-specialists in family medicine, experiencing patients’ pressure to be referred, heavy workload, having reluctance to cooperate with the patient and reporting sparse contact with hospital colleagues. Conclusions: Training specialists in family medicine in patient-centred method, easy conference with hospital consultant and cooperation with patients while making the referral may foster both self-reflections on own competences and increased levels of confidence.publishedVersio

Predicting the use of antibiotics after initial symptomatic treatment of an uncomplicated urinary tract infection:analyses performed after a randomised controlled trial

Objective To predict antibiotic use after initial treatment with ibuprofen using data from a randomised controlled trial comparing ibuprofen to pivmecillinam in the treatment of women with symptoms of an uncomplicated urinary tract infection (UTI). Setting 16 sites in a primary care setting in Norway, Sweden and Denmark. Participants Data from 181 non-pregnant women aged 18–60 presenting with symptoms of uncomplicated UTI, initially treated with ibuprofen. Methods Using the least absolute shrinkage and selection operator logistic regression model, we conducted analyses to see if baseline information could help us predict which women could be treated with ibuprofen without risking treatment failure and which women should be recommended antibiotics. Results Of the 143 women included in the final analysis, 77 (53.8%) recovered without antibiotics and 66 (46.2 %) were subsequently prescribed antibiotics. In the unadjusted binary logistic regression, the number of days with symptoms before inclusion (<3 days) and feeling moderately unwell or worse (≥4 on a scale of 0–6) were significant predictors for subsequent antibiotic use. In the adjusted model, no predictors were significantly associated with subsequent antibiotic use. The area under the curve of the final model was 0.66 (95% CI: 0.57 to 0.74). Conclusion We did not find any baseline information that significantly predicted the use of antibiotic treatment. Identifying women who need antibiotic treatment to manage their uncomplicated UTI is still challenging. Larger data sets are needed to develop models that are more accurat

Brannsikring av båthotell/vinterlagring

Rapporten omhandler brannsikring av båthotell/vinterlagring. Det gås nøye gjennom alle relevante norske lover, forskrifter og veiledninger, for å sikre bygg, anlegg og virksomheter mot brann. Det er gjort et forsøk på å innhente alt av relevant informasjon, for å finne løsninger på de farene som eksisterer ved virksomheten. Mye av arbeidet baseres på befaringer av seks bestående båthotell/vinterlager, og de observerte tiltak, samt de faremomenter som bruk og drift av slike anlegg representerer. Det finnes også en gjennomgang av amerikansk standard for brannsikring av marinaer, båthotell, pirer og nærliggende virksomheter. [NFPA 303

The consultants' role in the referring process with general practitioners: partners or adjudicators? a qualitative study

Background: Within the health system, communication between the different levels of care is essential for the patients’ clinical pathways and medical treatment. This includes the referral process: how and why patients are sent from the primary care level to specialist health services. We wanted to identify and describe hospital consultants’ reflections on and attitudes to the referral process and cooperation with general practitioners (GPs). Methods: A qualitative study of semi-structured interviews with 13 hospital consultants representing eight different specialties, analyzed using systematic text condensation. Interviews conducted from February 2011 to October 2012. Results: The consultants reported a considerable workload assessing referrals from GPs and prioritizing patients for specialist services. National guidelines were used as well as individual standards and guidelines. Good referrals could make the prioritization process easier. The specialists expressed a deep concern about securing a fair priority of patients and a willingness to give reasonable advice back to the referring GP when rejecting a referral. Better communication, such as a telephone call to confer with a hospital specialist before referral, was wanted. Conclusions: Better communication and cooperation between hospital consultants and GPs could make the referral process more balanced, and the participants more like partners

Passive range of motion in patients with adhesive shoulder capsulitis, an intertester reliability study over eight weeks

Background Measuring range of motion (ROM) in the shoulder joint is important for the diagnosis and monitoring of change over time. To what degree passive ROM can be trusted as a reliable outcome measure was examined as part of an on-going randomized controlled trial for patients with shoulder capsulitis. The aim of this study was to examine intertester reliability of passive ROM in the shoulder joint over a period of eight weeks in patients with adhesive capsulitis stage II. Methods Fifty patients with a clinical diagnosis of adhesive shoulder capsulitis were examined by two independent testers. A predefined protocol was used for measuring passive range of motion with an inclinometer, a plurimeter, in both affected and non-affected shoulders three times; at the start of the study and after 4 and 8 weeks. Results Very good to excellent intertester agreements were found for most parameters for the affected arm at all three test points. The intraclass correlation coefficient (ICC 2.1) values ranged from 0.76 to 0.98, i.e. from very reliable to excellent. The measurement error was in general small for the affected arm (5°–7°). ICCs were slightly lower for the non-affected arm at 8 weeks, but with acceptable measurement errors. Conclusions Intertester reliability between two testers was very good at three visits over a time period of eight weeks using a plurimeter to measure passive range of motion in patients with adhesive shoulder capsulitis. This method can reliably determine passive range of motion in this patient population and be a reliable outcome measure

General practitioners’ reflections on referring: An asymmetric or non-dialogical process?

Objective. Identify and describe general practitioners’ (GPs’) reflections on and attitudes to the referral process and cooperation with hospital specialists. Design. Qualitative study using semi-structured focus-group interviews with GPs analysed using Giorgi's method as modified by Malterud. Setting. Interviews conducted over four months from November 2010 to February 2011. Subjects. 17 female and 14 male GPs aged 29 to 61 years from 21 different practices, who had practised for 3–35 years. Main outcome measures. Description of GPs’ views on the referral process. Results. GPs wished for improved dialogue with the hospital specialists. The referral process was often considered as asymmetric and sometimes humiliating. GPs saw the benefit of using templates in the referral process, but were sceptical concerning the use of mandatory fixed formats. Conclusions. The referral process is essential for good patient care between general practice and specialist services. GPs consider referring as asymmetric and sometimes humiliating. The dichotomy between the wish for mutual dialogue and the convenience of using templates should be kept in mind when assuring quality of the referral process

Patients' subjective concepts about primary healthcare utilisation: the study protocol of a quality comparative study between Norway and Germany

Background In Germany, utilisation of ambulatory healthcare services is high compared with other countries: While a study based on the process data of German statutory health insurances showed an average of 17.1 physician-patient-contacts per year, the comparable figure for Norway is about five. The usual models of healthcare utilisation, such as Rosenstock's Health Belief Model and Andersen's Behavioural Model, cannot explain these differences adequately. Organisational factors of the healthcare system, such as gatekeeping, do not explain the magnitude of the differences. Our hypothesis is that patients’ subjective concepts about primary healthcare utilisation play a major role in explaining different healthcare utilisation behaviour in different countries. Hence, the aim of this study is to explore these subjective concepts comparatively, between Germany and Norway. Methods/design With that aim in mind, we chose a comparative qualitative study design. In Norway and Germany, we are going to interview 20 patients each with qualitative episodic interviews. In addition, we are going to conduct participant observation in four German and four Norwegian primary care practices. The data will be analysed by thematic coding. Using selected categories, we are going to conduct comparative case and group analyses. Ethics and dissemination The study adheres to the Declaration of Helsinki. All interviewees will sign informed consent forms and all patients will be observed during consultation. Strict rules for data security will apply. Developed theory and policy implications are going to be disseminated by a workshop, presentations for experts and laypersons and publications