General practitioners' and patients experiences and expectations: A cross-sectional study from Norwegian and Nordic general practice

Comprehensive primary care services are associated with better healthcare quality. The aims of this thesis were to compare medical services provided by GPs in the Nordic countries, to study associations between organisational factors and Norwegian patients´ experiences in GP consultations, and to explore possible differences between GPs´ and patients´ expectations regarding the GPs´ services in Norway. The thesis is based on questionnaire data from 875 GPs from Norway, Denmark, Sweden, Finland and Iceland as well as questionnaire data from 1529 Norwegian patients. GPs in the Nordic countries provided a wide spectrum of medical services. The Finnish GPs more frequently than their Nordic colleagues had access to advanced technological equipment like ultrasound and gastroscopes. Ninety per cent of Norwegian and 86% of Danish GPs inserted intra-uterine devices, and were significantly more likely to do this procedure than GPs in the other Nordic countries (Sweden 20%, Finland 70%, Iceland 13%). Icelandic GPs were less likely than Norwegian GPs to be involved in follow-up of patients with a selection of medical conditions, including rheumatoid arthritis, myocardial infarction, and Parkinson´s disease. Patients visiting GPs with a short (≤900) or long patient lists (> 1300) were less likely than patients visiting GPs with medium sized patient list (900 – 1300) to report positive experiences with the communication with the GP. Norwegian GPs overestimated to what degree their patients would see them for a variety of common medical problems, e.g. deteriorating vision, anxiety, and sexual problems. Differences in the medical services offered by Nordic GPs may be related to variations in remuneration systems and differences in task distribution. From the patients´ point of view, a medium sized patient list is preferable to allow for a more positive communicative experience. A further discussion on which tasks that should form part of general practice is warranted

Legevakt i Norden før og nå

Velfungerende legevakttjenester er nødvendige for å kunne tilby gode helsetjenester til et lands befolkning til alle døgnets tider. Ulike helsetjenestesystemer organiserer legevakt på forskjellige måter. Denne artikkelen tar for seg likheter og ulikheter i de nordiske landene, primært i et nåtidsperspektiv, men også med en historisk bakgrunn. I Danmark har man for eksempel sett at tjenester av god kvalitet som er lett tilgjengelige, er populære blant befolkningen.Da blir velfungerende, lett tilgjengelige legevakttjenester mye brukt. Generelt er det viktig å sikre god tilgjengelighet og kvalitet i allmennlegetjenesten på dagtid for å lette presset mot legevakttjenestene. Norske erfaringer viser at økt reisetid reduserer legevaktbruk selv for mer alvorlige tilstander. Vi må derfor fortsette å utvikle strukturen rundt legevakten slik at vi tilbyr solide tjenester både i urbane og rurale områder

Patients' and GPs' expectations regarding healthcare-seeking behaviour: a Norwegian comparative study

Background: GPs are Norwegian patients' first contact point with the healthcare system for most medical problems. However, little is known regarding GPs' expectations towards their patients' healthcare-seeking behaviour, or whether doctors and patients have coinciding expectations of what GPs can do for their patients. Aim: To investigate patients' and GPs’ expectations regarding patients’ healthcare-seeking behaviour in primary care, and to make comparisons between the two. Design & setting: Norwegian data from the Quality and Costs of Primary Care in Europe (QUALICOPC) questionnaire study, with information from GPs and their patients. Method: Binary logistic regression was used to investigate associations between expectations, sex and age of GPs and patients, list size, and geographical location of practice. Results are presented as odds ratios (ORs) with 95% confidence intervals (CIs). Expectation differences between GPs and patients were analysed using generalised estimating equations (GEEs). Due to multiple testing, Bonferroni correction was used to define significance level at P≤0.002. Results: In total, 198 GPs (39.1% female) and 1529 patients (61.9% female) responded. No associations with sex or age were found for the GPs' expectations regarding patients' healthcare-seeking behaviour. Among patients, fewer males than females expected that most people would see their GP for sprained ankle (OR 0.7, 95% CI = 0.5 to 0.9), finger cut (OR 0.6, 95% CI = 0.4 to 0.7), smoking cessation (OR 0.6, 95% CI = 0.5 to 0.8), or anxiety (OR 0.4, 95% CI = 0.3 to 0.6). Older patients (aged >65 years) found it more important than younger patients to see a doctor in the presence of medical symptoms. GPs had higher expectations than their patients that people in general would see them for deteriorated vision (OR 4.2, 95% CI = 2.5 to 6.9), sexual problems (OR 1.8, 95% CI =1.3 to 2.6), and anxiety (OR 3.0, 95% CI =1.5 to 6.0). Conclusion: For several common health problems, males are less likely than females to believe that people will see their GP. GPs may overestimate to what degree their patients will see them for a number of common medical problems

Good communication was valued as more important than accessibility according to 707 Nordic primary care patients: a report from the QUALICOPC study

Objective To explore Nordic patients’ ranking of the importance of different aspects of general practice. Design Patients ranked the importance of 47 statements reflecting five quality domains: communication, involvement, accessibility, continuity, and comprehensiveness. Setting Nordic general practice. Subjects Patients ≥18 years in general practitioners waiting rooms. Main outcome measures Items rated as important or very important by ≥ 90% in all countries were identified. Associations with patient characteristics were analysed by logistic regression. Results 209 Danish, 175 Norwegian, 129 Finnish, 112 Swedish and 82 Icelandic patients responded. Ten statements were ranked as important or very important by ≥90% in each country. Six pertained to communication, three to patient involvement and one to the comprehensiveness of care. No items regarding accessibility or continuity exceeded the 90% limit. The item most frequently rated as very important was ‘I understand what the GP explains’’. Female patients were more likely to value personal treatment (OR = 2.9; 95%CI 1.5–5.5) and receiving instructions if things went wrong (1.7; 1.2–2.2). Older patients >65 years put less emphasis than those <35 on whether the GP takes them seriously (0.4; 0.3–0.5) and on the importance of instructions (0.5; 0.4–0.7). Patients with chronic diseases were less concerned (0.6; 0.4–0.8) with receiving instructions, but valued strongly that a GP knows when to refer (2.2; 1.5–3.3). Conclusion Patients in all countries assigned high value to good communication. Availability was deemed important but came secondary to good communication. Implications Organisational framework for general practice must allow for acceptable communication quality as well as availability.Key points In order to identify relevant service areas for quality improvement in primary care, we aimed to increase knowledge of patient ranked importance of different dimensions of care. Nordic primary care patients valued good communication and involvement in decisions higher than accessibility to care. A singular focus on the access of care when developing services may not be in accordance with patient preferences

Promoters and inhibitors for quality improvement work in general practice: a qualitative analysis of 2715 free-text replies

Background Continuous quality improvement (QI) is necessary to develop and maintain high quality general practice services. General Practitioners (GPs’) motivation is an important factor in the success of QI initiatives. We aimed to identify factors that impair or promote GPs’ motivation for and participation in QI projects. Material and methods We analysed 2715 free-text survey replies from 2208 GPs participating in the QI intervention ‘Correct Antibiotic Use in the Municipalities’. GPs received reports detailing their individual antibiotic prescriptions for a defined period, including a comparison with a corresponding previous period. The content was discussed in peer group meetings. Each GP individually answered work-sheets on three separate time-points, including free-text questions regarding their experiences with the intervention. Data were analysed using inductive thematic analysis. Results We identified three overarching themes in the GPs’ thoughts on inhibitors and promoters of QI work: (1) the desire to be a better doctor, (2) structural and organisational factors as both promoters and inhibitors and (3) properties related to different QI measures. The provision of individual prescription data was generally very well received. The participants stressed the importance of a safe peer group, like the Continuous Medical Education group, for discussions, and also underlined the motivating effect of working together with their practice as a whole. Lack of time was essential in GPs’ motivation for QI work. QI tools should be easily available and directly relevant in clinical work. Conclusion The desire to be good doctor is a strong motivator for improvement, but the framework for general practice must allow for QI initiatives. QI tools must be easily obtainable and relevant for practice. Better tools for obtaining clinical data for individual GPs are needed.publishedVersio

Changes in work tasks and organization of general practice in Norway during the COVID-19 pandemic: results from a comparative international study

Abstract Background The COVID-19 pandemic led to huge and rapid changes in general practice in Norway as in the rest of Europe. This paper aims to explore to what extent the COVID-19 pandemic changed the work tasks and organization of Norwegian general practice. Material and method We analysed data from the Norwegian part of the international, cross-sectional PRICOV-19 study, collecting data from general practice via an online self-reported questionnaire. We included 130 Norwegian general practices, representing an estimated 520 Norwegian general practitioners (GPs). All Norwegian GPs were invited to participate. In the analyses, we focused on items related to the use of alternatives to face-to-face consultations, changes in the workload, tasks and delegated responsibilities of both the GPs and other personnel in the GP offices, adaptations in routines related to hygiene measures, triage of patients, and how the official rules and recommendations affected the practices. Results There was a large and significant increase in the use of all forms of alternative consultation forms (digital text-based, video- and telephone consultations). The use of several different infection prevention measures were significantly increased, and the provision of hand sanitizer to patients increased from 29.6% pre-pandemic to 95.1% since the pandemic. More than half of the GPs (59.5%) reported that their responsibilities in the practice had increased, and 41% were happy with the task shift. 27% felt that they received adequate support from the government; however, 20% reported that guidelines from the government posed a threat to the well-being of the practice staff. We found no associations with the rurality of the practice location or size of the municipalities. Conclusion Norwegian GPs adapted well to the need for increased use of alternatives to face-to-face consultations, and reported a high acceptance of their increased responsibilities. However, only one in four received adequate support from the government, which is an important learning point for similar situations in the future. </jats:sec

Changes in work tasks and organization of general practice in Norway during the COVID-19 pandemic: results from the Pricov-19 study

Background: The COVID-19 pandemic led to huge and rapid changes in general practice in Norway as in the rest of Europe. Knowledge regarding these changes can inform measures in similar future situations. Research questions: We aimed to obtain more knowledge on the changes in use of alternative consultation forms, workload, tasks and delegated responsibilities of both the GPs and other personnel in the GP offices, adaptations in routines related to hygiene measures, triage of patients, and how the official rules and recommendations affected the practices. Method: We analysed data from the Norwegian part of the PRICOV-19 study, collecting data from general practice via an online self-reported questionnaire. We included 130 Norwegian general practices, representing an estimated 520 Norwegian general practitioners (GPs). All Norwegian GPs were invited to participate. Results: During the pandemic, Norwegian GPs significantly increased their use of alternative consultation forms and the implementation of infection prevention measures in their clinics. There was a large and significant increase in the use of all forms of alternative consultation forms (Digital text-based, video- and telephone consultations). The use of several different infection prevention measures were significantly increased, and the provision of hand sanitizer to patients increased from 29.6% pre-pandemic to 95.1% since the pandemic. More than half of the GPs (59.5%) reported that their responsibilities in the practice had increased, and 41% were happy with the task shift. 27% felt that they received adequate support from the government; however, 20% reported that guidelines from the government posed a threat to the well-being of the practice staff. We found no associations with the rurality of the practice location or size of the municipalities. Conclusions: Norwegian GPs adapted well to the need for increased use of alternative consultation forms, and reported a high acceptance of their increased responsibilities. However, only one in four experienced adequate support from the government. Points for discussion: How do the Norwegian findings differ from the changes related to the COVID-19 pandemic in other European countries? To what degree are national results and conclusions transferable to other countries with very different health services systems? How can health authorities help GP practices through future pandemics

Visions of Paulo

Background Patient enablement is a concept developed to measure quality in primary health care. The comparative analysis of patient enablement in an international context is lacking. Objective To explain variation in patient enablement between patients, general practitioners (GPs) and countries. To find independent variables associated with enablement. Design We constructed multi‐level logistic regression models encompassing variables from patient, GP and country levels. The proportions of explained variances at each level and odds ratios for independent variables were calculated. Setting and Participants A total of 7210 GPs and 58 930 patients in 31 countries were recruited through the Quality and Costs of Primary Care in Europe (QUALICOPC) study framework. In addition, data from the Primary Health Care Activity Monitor for Europe (PHAMEU) study and Hofstede's national cultural dimensions were combined with QUALICOPC data. Results In the final model, 50.6% of the country variance and 18.4% of the practice variance could be explained. Cultural dimensions explained a major part of the variation between countries. Several patient‐level and only a few practice‐level variables showed statistically significant associations with patient enablement. Structural elements of the relevant health‐care system showed no associations. From the 20 study hypotheses, eight were supported and four were partly supported. Discussion and Conclusions There are large differences in patient enablement between GPs and countries. Patient characteristics and patients’ perceptions of consultation seem to have the strongest associations with patient enablement. When comparing patient‐reported measures as an indicator of health‐care system performance, researchers should be aware of the influence of cultural elements

Patient experiences and the association with organizational factors in general practice: results from the Norwegian part of the international, multi-centre, cross-sectional QUALICOPC study

Background: General practitioners (GPs) constitute a vital part of a strong primary health care system. We need further knowledge concerning factors that may affect the patients’ experiences in their meetings with the GPs. We investigated to what degree organizational factors and GP characteristics are associated with patients’ communicative experiences in a consultation. Methods: We used data from the Norwegian part of the international, multi-center study Quality and Costs of Primary Care in Europe (QUALICOPC). We included 198 Norwegian GPs and 1529 patients. The patients completed a survey concerning experiences in a consultation with a GP on the inclusion day. The GPs completed a survey regarding organizational aspects of their own practice. Main outcome measures were seven statements concerning how the patients experienced the communication with the GP during the consultation. A generalized estimating equation logistic regression model was used to identify variations in patient experiences associated with characteristics of the GPs and their practices. Results: The patients reported overall positive experiences with their GP consultations. Patients who consulted a GP with a short patient list were less likely than patients who consulted a GP with a medium sized list to regard the GP as polite (Odds Ratio (OR) 0.2; 95 % CI 0.1–0.7), to report that the GP asked questions about their health problems (OR 0.6; 0.4–1.0) or that the GP used sufficient time (OR 0.5; CI 0.3–0.9). Patients who consulted a GP with a long patient list compared to patients who consulted a GP with a medium sized list were less likely to feel that they could cope better after the GP visit (OR 0.5; 0.3–0.9) and more likely to feel that the GP hardly looked at them while talking (OR 1.8; 1.0–3.0). No associations with patient experiences were found with the average duration of the consultations, whether the GP worked in a fee-for-service model or whether the GP was the patient’s regular doctor. Conclusions: Norwegian patients report predominantly positive experiences when consulting a GP. Positive communication experiences are most likely to be reported when the GP has a medium sized patient list

Differences in medical services in Nordic general practice: a comparative survey from the QUALICOPC study

Objective: We aim to describe medical services provided by Nordic general practitioners (GPs), and to explore possible differences between the countries. Design and setting: We did a comparative analysis of selected data from the Nordic part of the study Quality and Costs of Primary Care in Europe (QUALICOPC). Subjects: A total of 875 Nordic GPs (198 Norwegian, 80 Icelandic, 97 Swedish, 212 Danish and 288 Finnish) answered identical questionnaires regarding their practices. Main outcome measures: The GPs indicated which equipment they used in practice, which procedures that were carried out, and to what extent they were involved in treatment/follow-up of a selection of diagnoses. Results: The Danish GPs performed minor surgical procedures significantly less frequent than GPs in all other countries, although they inserted IUDs significantly more often than GPs in Iceland, Sweden and Finland. Finnish GPs performed a majority of the medical procedures more frequently than GPs in the other countries. The GPs in Iceland reported involvement in a more narrow selection of conditions than the GPs in the other countries. The Finnish GPs had more advanced technical equipment than GPs in all other Nordic countries. Conclusions: GPs in all Nordic countries are well equipped and offer a wide range of medical services, yet with a substantial variation between countries. There was no clear pattern of GPs in one country doing consistently more procedures, having consistently more equipment and treating a larger diversity of medical conditions than GPs in the other countries. However, structural factors seemed to affect the services offered