"What lies beneath it all?" - an interview study of GPs' attitudes to the use of guidelines

Background: General practitioners (GPs) adopt clinical practice guidelines to varying degrees. Several factors have been found to influence application of guidelines in practice and the GP is apparently the key actor. Studies are needed to increase our understanding of how GPs' attitudes influence their use of guidelines. In this study we explored GPs' attitudes to guidelines. Methods: In 2007 we conducted six semi-structured group interviews with a purposive sample of 27 Norwegian GPs. The participants were encouraged to discuss guidelines they were familiar with, the evidence base of guidelines, professional autonomy and doctor-patient relations. We used thematic content analysis to extract central themes and arguments. Results: When deciding whether tfollow guideline recommendations, GPs consider whether guidelines are trustworthy, whether they suit patients and whether the recommended action is feasible. There were two important findings. First, the GP's were concerned that guidelines may be more heavily influenced by economic considerations than clinical ones. Second, in contrast to earlier findings, changes in recommendations and disagreement between experts were mostly viewed positively. Conclusion: This study underscores the need for transparency in the process of development and implementation of guidelines. To enhance the use of guidelines, primary care physicians should be involved in the process of developing guidelines and the process should be transparent and explicit regarding the evidence base and economic considerations.publishedVersio

Recommended content of referral letters from general practitioners to specialised mental health care: a qualitative multi-perspective study

Background: In most Western countries, the referral letter forms the basis for establishing the priority of patients for specialised health care and for the coordination of care between the services. To be able to define the quality of referral letters, the potential impact of the quality on the organisation of care, and to improve the quality of the letters, we need a multidimensional definition of the ideal content. The study’s aim was to explore what information is seen as most important and should be included in referral letters from primary care to specialised mental health care to facilitate prioritisation and planning of treatment and follow-up of the patients. Methods: Based on purposive sampling, four mixed discussion groups, which included general practitioners, mental health nurses from primary health care, psychiatrists and psychologists from specialised mental health care, managers and patient representatives, were formed; they were asked to identify the information they considered important in a mental health referral letter. In line with the Delphi technique, the importance of the themes was later individually rated by the participants. The study was conducted within The Western Norway Regional Health Authority.Results: The four groups identified 174 information themes. After excluding themes that were assessed as duplicates, replaceable or less important, 40 themes were suggested, organised in seven units. A set of check-off points of essential information is recommended as an introduction in the referral letter. Conclusion: Compared with general guidelines and guidelines for somatic care, the results of this study suggest that the referral letter to specialised mental health care should have a larger emphasis on the overall treatment plan, on the specific role of specialised health care in the continuum of care, and on patient involvement. Further research should evaluate the validity of these findings for other patient groups in need of integrated care and investigate how the quality of referral letters affects patient-related and organisational outcomes

General practitioners' experiences with sickness certification: a comparison of survey data from Sweden and Norway

<p>Abstract</p> <p>Background</p> <p>In most countries with sickness insurance systems, general practitioners (GPs) play a key role in the sickness-absence process. Previous studies have indicated that GPs experience several tasks and situations related to sickness certification consultations as problematic. The fact that the organization of primary health care and social insurance systems differ between countries may influence both GPs' experiences and certification. The aim of the present study was to gain more knowledge of GPs' experiences of sickness certification, by comparing data from Sweden and Norway, regarding frequencies and aspects of sickness certification found to be problematic.</p> <p>Methods</p> <p>Statistical analyses of cross-sectional survey data of sickness certification by GPs in Sweden and Norway. In Sweden, all GPs were included, with 3949 (60.6%) responding. In Norway, a representative sample of GPs was included, with 221 (66.5%) responding.</p> <p>Results</p> <p>Most GPs reported having consultations involving sickness certification at least once a week; 95% of the GPs in Sweden and 99% of the GPs in Norway. A majority found such tasks problematic; 60% of the GPs in Sweden and 53% in Norway. In a logistic regression, having a higher frequency of sickness certification consultations was associated with a higher risk of experiencing them as problematic, in both countries. A higher rate of GPs in Sweden than in Norway reported meeting patients wanting a sickness certification without a medical reason. GPs in Sweden found it more problematic to discuss the advantages and disadvantages of sick leave with patients and to issue a prolongation of a sick-leave period initiated by another physician. GPs in Norway more often worried that patients would go to another physician if they did not issue a certificate, and a higher proportion of Norwegian GPs found it problematic to handle situations where they and their patient disagreed on the need for sick leave.</p> <p>Conclusions</p> <p>The study confirms that many GPs experience sickness absence consultations as problematic. However, there were differences between the two countries in GPs' experiences, which may be linked to differences in social security regulations and the organization of GP services. Possible causes and consequences of national differences should be addressed in future studies.</p

Using qualitative research to develop an elaboration of the TIDieR checklist for interventions to enhance vaccination communication: short report

BACKGROUND: The COVID-19 pandemic has led to an increased interest in communication with the public regarding vaccination. Our recent Cochrane qualitative evidence synthesis points to several factors that could influence the implementation and success of healthcare worker communication with older adults about vaccination. However, it is often difficult to assess whether factors identified as potentially important in qualitative studies have been considered in randomized trials because of poor trial reporting. We therefore decided to use our qualitative evidence synthesis findings to encourage better reporting of vaccination communication interventions in trials by developing an elaboration of the TIDieR (Template for Intervention Description and Replication) checklist for intervention reporting. METHODS: We examined the findings from our Cochrane qualitative evidence synthesis on healthcare workers’ perceptions of and experiences with communicating about vaccination with adults over the age of 50 years. We identified factors that could influence the implementation and uptake, and thereby the effectiveness, of vaccination communication interventions. We then drafted a list of the information elements we would need from trial reports to assess whether these factors had been considered in the development of the interventions evaluated in these trials. Finally, we compared our list of information elements to the TIDieR checklist items. We were able to align all of our information elements with the TIDieR items. However, for several of the TIDieR items, we developed a more detailed description to ensure that relevant information would be captured sufficiently in trial reports. RESULTS: We developed elaborations for the following TIDieR items: “Why” (item 2), “What—materials” (item 3), “Who provided” (item 5), “How” (item 6), “Where” (item 7) and “Tailoring” (item 9). CONCLUSIONS: Both qualitative research and trials of intervention effectiveness are critical to furthering our understanding of what works, where, for whom and through which mechanisms. However, a key ingredient for developing this understanding is adequate reporting of intervention design, content and implementation in randomized trials. We hope that this elaboration of the TIDier checklist will improve reporting of interventions in trials focused on vaccine communication with older adults, and thereby enhance the usability of this research for developing future communication strategies

Guidelines; from foe to friend? Comparative interviews with GPs in Norway and Denmark

<p>Abstract</p> <p>Background</p> <p>GPs follow clinical guidelines to varying degrees across practices, regions and countries, but a review study of GPs' attitudes to guidelines found no systematic variation in attitudes between studies from different countries. However, earlier qualitative studies on this topic are not necessarily comparable. Hence, there is a lack of empirical comparative studies of GP's attitudes to following clinical guidelines. In this study we reproduce a Norwegian focus group study of GPs' general attitudes to national clinical guidelines in Denmark and conduct a comparative analysis of the findings.</p> <p>Methods</p> <p>A strategic sample of GP's in Norway (27 GPs) and Denmark (18 GPs) was interviewed about their attitudes to guidelines, and the interviews coded and compared for common themes and differences.</p> <p>Results</p> <p>Similarities dominated the comparative material, but the analysis also revealed notable differences in attitudes between Norwegian and the Danish GPs. The most important difference was related to GP's attitudes to clinical guidelines that incorporated economic evaluations. While the Norwegian GPs were sceptical to guidelines that incorporated economic evaluation, the Danish GPs regarded these guidelines as important and legitimate. We suggest that the differences could be explained by the history of guideline development in Norway and Denmark respectively. Whereas government guidelines for rationing services were only newly introduced in Norway, they have been used in Denmark for many years.</p> <p>Conclusion</p> <p>Comparative qualitative studies of GPs attitudes to clinical guidelines may reveal cross-national differences relating to the varying histories of guideline development. Further studies are needed to explore this hypothesis.</p

Lay perceptions of evidence-based information – a qualitative evaluation of a website for back pain sufferers

BACKGROUND: In an evidence-informed patient choice the patient has access to research-based information about the effectiveness of health care options and is encouraged to use this information in treatment decisions. This concept has seen growing popularity in recent years. However, we still know relatively little about users' attitudes to the use of research-based information, possibly because people have been unexposed to this type of information. After developing the BackInfo website where the results of Cochrane systematic reviews on the effects of low back pain were adapted and presented to lay users we evaluated how users responded to this information. METHODS: Focus group meetings were held with 18 chronic back pain sufferers, after they had been sent a link to the website before the meetings. RESULTS: The focus groups suggest that the most important challenges to the use of BackInfo's research-based information are not primarily tied to the comprehension or presentation of the information, but are mainly associated with participants' attitudes towards the credibility of research and researchers, and the applicability of research results to themselves as individuals. Possible explanations for participants' lack of trust in research and their apparent difficulties in applying this research to their own situations include aspects that may be typical for the general public including the media's presentation of research, and a lack of familiarity with and feelings of distance to research evidence. Other aspects may be typical for patient groups with chronic and unclear medical conditions, such as a lack of trust in the health care establishment in general. CONCLUSION: In order to enhance the credibility and applicability of research evidence, providers of research-based information could explore a number of possibilities including the use of including personal stories to illustrate the research outcomes

Psychiatry out-of-hours: a focus group study of GPs' experiences in Norwegian casualty clinics

Background: For Norwegian general practitioners (GPs), acute treatment of mental illness and substance abuse are among the most commonly experienced emergency situations in out-of-hours primary healthcare. The largest share of acute referrals to emergency psychiatric wards occurs out-of-hours, and out-of-hours services are responsible for a disproportionately high share of compulsory referrals. Concerns exist regarding the quality of mental healthcare provided in the out-of-hours setting. The aim of this study was to explore which challenges GPs experience when providing emergency care out-of-hours to patients presenting problems related to mental illness or substance abuse. Methods: We conducted a qualitative study based on two individual interviews and six focus groups with purposively sampled GPs (totally 45 participants). The interviews were analysed successively in an editing style, using a thematic approach based on methodological descriptions by Charmaz and Malterud. Results: Safety and uncertainty were the dominating themes in the discussions. The threat to personal safety due to unpredictable patient behaviour was a central concern, and present security precautions in the out-of-hours services were questioned. The GPs expressed high levels of uncertainty in their work with patients presenting problems related to mental illness or substance abuse. The complexity of the problems presented, shortage of time, limited access to reliable information and limited range of interventions available during out-of-hours contributed to this uncertainty. Perceived access to second opinion seemed to have a major impact on subjectively experienced work stress. Conclusions: The GPs experienced out-of-hours psychiatry as a field with high levels of uncertainty and limited support to help them meet the experienced challenges. This might influence the quality of care provided. If the current organisation of emergency mental healthcare is to be kept, we need to provide GPs with a better support framework out-of-hours

What about N? A methodological study of sample-size reporting in focus group studies

<p>Abstract</p> <p>Background</p> <p>Focus group studies are increasingly published in health related journals, but we know little about how researchers use this method, particularly how they determine the number of focus groups to conduct. The methodological literature commonly advises researchers to follow principles of data saturation, although practical advise on how to do this is lacking. Our objectives were firstly, to describe the current status of sample size in focus group studies reported in health journals. Secondly, to assess whether and how researchers explain the number of focus groups they carry out.</p> <p>Methods</p> <p>We searched PubMed for studies that had used focus groups and that had been published in open access journals during 2008, and extracted data on the number of focus groups and on any explanation authors gave for this number. We also did a qualitative assessment of the papers with regard to how number of groups was explained and discussed.</p> <p>Results</p> <p>We identified 220 papers published in 117 journals. In these papers insufficient reporting of sample sizes was common. The number of focus groups conducted varied greatly (mean 8.4, median 5, range 1 to 96). Thirty seven (17%) studies attempted to explain the number of groups. Six studies referred to rules of thumb in the literature, three stated that they were unable to organize more groups for practical reasons, while 28 studies stated that they had reached a point of saturation. Among those stating that they had reached a point of saturation, several appeared not to have followed principles from grounded theory where data collection and analysis is an iterative process until saturation is reached. Studies with high numbers of focus groups did not offer explanations for number of groups. Too much data as a study weakness was not an issue discussed in any of the reviewed papers.</p> <p>Conclusions</p> <p>Based on these findings we suggest that journals adopt more stringent requirements for focus group method reporting. The often poor and inconsistent reporting seen in these studies may also reflect the lack of clear, evidence-based guidance about deciding on sample size. More empirical research is needed to develop focus group methodology.</p

Using Qualitative Evidence in Decision Making for Health and Social Interventions: An Approach to Assess Confidence in Findings from Qualitative Evidence Syntheses (GRADE-CERQual)

Published onlineJournal ArticleResearch Support, Non-U.S. Gov'tThis is the final version of the article. Available from Public Library of Science via the DOI in this record.Simon Lewin and colleagues present a methodology for increasing transparency and confidence in qualitative research synthesis.This work was supported by funding from the Department of Reproductive Health and Research, WHO (www.who.int/reproductivehealth/about_us/en/) and Norad (Norwegian Agency for Development Cooperation: www.norad.no) to the Norwegian Knowledge Centre for the Health Services. Additional funding for several of the pilot reviews was provided by the Alliance for Health Policy and Systems Research (www.who.int/alliance-hpsr/en/). We also received funding for elements of this work through the Cochrane supported "Methodological Investigation of Cochrane reviews of Complex Interventions" (MICCI) project (www.cochrane.org). SL is supported by funding from the South African Medical Research Council (www.mrc.ac.za). The funders had no role in study design, data collection and analysis, preparation of the manuscript or the decision to publish

The changing role of gatekeepers: Rationing and shared decision-making in primary care

The Norwegian health care system is increasingly dependent on the general practitioner’s(GP’s) gatekeeper function for cost containment and for fair and effective resource allocation.GPs enjoy extensive professional freedom and there is considerable room for discretionarychoices. At the same time, during recent decades, the patient’s power and rights have beenstrengthened. This situation calls for a better understanding of GPs’ allocative decisionmaking and the patient’s role in it. Hitherto the literature on resource allocation tends tooverlook the patient’s role in GP decision-making while the literature about GP–patientinteraction tends to omit questions of resource allocation.This thesis takes an interdisciplinary approach to GPs’ rationing decisions and the ideals ofpatient involvement. It is based on two separate studies. The first study explores how GPsexperience the gatekeeper role under the influence of patients and other factors such asmedical responsibility, economic incentives, competition and the desire to preserveprofessional autonomy. The second study analyses how attitudes towards patient involvementinfluence patient satisfaction and referral rates.Study 1 (Paper I and II) is based on focus group interviews with a strategic sample of 81 GPsfrom the municipalities of Bergen and Oslo combined with a short questionnaire surveyamong the same participants. The interviews took place in 2002. Interviews were coded byhand and analysed qualitatively through framework analysis. The survey data were analyseddescriptively. Study 2 is a questionnaire study among GPs and their patients carried outduring 2004 in Bergen. The data are based on questionnaires handed out by 56 GPs and theresponses from 1268 of their patients. Descriptive statistics, linear and logistic regressionswere the main forms of analysis. The key finding of the first study was that Norwegian GPs’commitment to the gatekeeper role seems to be declining, and that they generally makerationing decisions only when they are able to come to an agreement with patients and avoidconflict. The findings also suggest that many Norwegian GPs do not fully understand the needfor rationing while others regard rationing as conflicting with other concerns.In study 2 (Paper III and IV) the results indicate that Norwegian patients have a strongpreference for patient involvement while GPs are relatively less positive to involving patientsin medical decision-making. GPs with positive attitudes to patient involvement referred less and were more likely to have satisfied patients. Agreement of attitudes towards patientinvolvement between patients and GP had a strong and significant negative effect on referralrate but no significant effect on patient satisfaction.The suggested interpretation of the results is that the participating GPs have turned theirattention towards patients’ preferences and away from unpleasant rationing decisions. GPsand patients’ attitudes towards patient involvement affect resource allocation, but thisassociation is poorly understood. Hence there is a need for further interdisciplinary studies toexplore how GP–patient interaction affects resource allocation. Open debate about the roleand limitations of patient involvement and how increased patient power affects resourceallocation should be encouraged