Multiple perspectives on symptom interpretation in primary care research

BACKGROUND: Assessment and management of symptoms is a main task in primary care. Symptoms may be defined as 'any subjective evidence of a health problem as perceived by the patient’. In other words, symptoms do not appear as such; symptoms are rather the result of an interpretation process. We aim to discuss different perspectives on symptom interpretation as presented in the disciplines of biomedicine, psychology and anthropology and the possible implications for our understanding of research on symptoms in relation to prevalence and diagnosis in the general population and in primary care. DISCUSSION: Symptom experiences are embedded in a complex interplay between biological, psychological and cultural factors. From a biomedical perspective, symptoms are seen as possible indicators of disease and are characterized by parameters related to seriousness (e.g. appearance, severity, impact and temporal aspects). However, such symptom characteristics are rarely unambiguous, but merely indicate disease probability. In addition, the GP’s interpretation of presenting symptoms will also be influenced by other factors. From a psychological perspective, factors affecting interpretation are in focus (e.g. internal frame of reference, attention to sensations, illness perception and susceptibility to suggestion). These individual factors cannot stand alone either, but are influenced by the surroundings. Anthropological research suggests that personal experiences and culture form a continuous feedback relationship which influence when and how sensations are understood as symptoms of disease and acted upon. SUMMARY: The different approaches to symptom interpretation imply that we need to be cautious and conscious when interpreting survey findings that are based on symptom prevalence in the general population or in primary care. These findings will reflect a variety of interpretations of sensations, which are not equivalent to expressions of underlying disease. Furthermore, if diagnosis of disease is based exclusively on the presence of specific symptom characteristics, we may risk reinforcing a dualistic approach, including medicalisation of normal phenomena and devaluation of medically unexplained symptoms. Future research in primary care could gain from exploring symptoms as a generic phenomenon and raised awareness of symptom complexity

Early intervention for childhood overweight:A randomized trial in general practice

Objective. To evaluate the effect of two intervention modalities concerning overweight and obesity among children in general practice. Design. Prospective randomized controlled trial. Setting. A total of 60 general practices in the former County of Funen, Denmark. Subjects. Overweight children, identified by International Obesity Task Force criteria, aged 5–9 years. Intervention. Model 1 with health consultations in general practice during a two-year period or Model 2, an educational programme for the children and their families in addition to the health consultations. Main outcome measures. Change in body mass index (BMI) z-score in order to compare the results, independent of gender- and age-related changes over time. Results. A total of 80 children were recruited with 35 and 45 children allocated to Model 1 and Model 2, respectively. No significant differences were found in the change in BMI z-score (SDS) between the two groups. A decrease in the mean BMI z-score from baseline to study end of −0.20 (95%CI −0.38 to −0.01) in Model 1 and −0.26 (95%CI −0.44 to −0.09) in Model 2, respectively, was detected. The majority of the participants (2/3) continued in the study for more than one year in both models, with a mean of 12 consultations in general practice. Conclusion. In this particular setting the two intervention strategies against overweight and obesity did not differ significantly with regard to change in BMI z-scores

Prescribing antibiotics:the use of diagnostic tests in general practice. A register-based study

OBJECTIVE: To assess (i) the pattern of antibiotic prescribing in Danish general practice, (ii) the use of diagnostic tests [point-of-care (POC) and tests analysed at the hospital laboratory (laboratory tests)], and (iii) the frequency of diagnostic testing in relation to antibiotic prescriptions. DESIGN: Retrospective cross-sectional register-based study. SETTING: General practice in a geographical area of Denmark covering 455,956 inhabitants. SUBJECTS: We studied redeemed antibiotic prescriptions and performed diagnostic tests in general practice from 2013 to 2017 among inhabitants in nine selected municipalities. MAIN OUTCOME MEASURES: Frequency of antibiotic courses. Frequency and type of diagnostic testing performed in relation to types of antibiotics. RESULTS: A total of 783,252 antibiotic courses were redeemed from general practice with an overall decrease of 19% during 2013–2017. Diagnostic testing increased by 6% during this period. POC tests comprised the majority of performed diagnostic tests (83%) with C-reactive protein (CRP) as the most frequently used test. A 27% increase in the use of laboratory tests was observed. Tests were performed in relation to 43% of all antibiotic courses; most in relation to prescriptions for sulphonamide and trimethoprim (57%) and rarely when prescribing tetracyclines (10%). Conflicting with national guidelines, Danish GPs prescribed fluoroquinolones without performing any kind of diagnostic testing in 48% of the cases. CONCLUSIONS: This study provides an overview of the use of diagnostic tests in relation to antibiotics and creates basis for further research into the variability between types of antibiotics. The study indicates that there is room for improvement to use diagnostic tests as an aid to promote prudent antibiotic use. KEY POINTS: Diagnostic tests (point-of-care or tests analysed at the hospital laboratory), can increase diagnostic certainty and lead to a reduction in antibiotic use in general practice. A decrease in antibiotic courses in general practice in Denmark was observed during 2013–2017, while the use of diagnostic tests increased. A diagnostic test was performed in relation to 43% of antibiotic courses. Only 52% of prescribed fluoroquinolones was related to a diagnostic test, conflicting with national guidelines

Factors associated with C-reactive protein testing when prescribing antibiotics in general practice:a register-based study

BACKGROUND: The use of C-reactive protein (CRP) tests has been shown to safely reduce antibiotic prescribing for acute respiratory tract infections (RTIs). The aim of this study was to explore patient and clinical factors associated with the use of CRP testing when prescribing antibiotics recommended for RTIs. METHODS: A nation-wide retrospective cross-sectional register-based study based on first redeemed antibiotic prescriptions issued to adults in Danish general practice between July 2015 and June 2017. Only antibiotics recommended for treatment of RTIs were included in the analysis (penicillin-V, amoxicillin, co-amoxicillin or roxithromycin/clarithromycin). Logistic regression models were used to estimate odds ratios for patient-related and clinical factors on performing a CRP test in relation to antibiotic prescribing. RESULTS: A total of 984,149 patients redeemed at least one antibiotic prescription during the two-year period. About half of these prescriptions (49.6%) had an RTI stated as the indication, and a CRP test was performed in relation to 45.2% of these scripts. Lower odds of having a CRP test performed in relation to an antibiotic prescription was found for patients aged 75 years and above (OR 0.82, 95CI 0.79–0.86), with a Charlson Comorbidity Index of more than one (OR 0.93, 95CI 0.91–0.95), unemployed or on disability pension (OR 0.84, 95CI 0.83–0.85) and immigrants (OR 0.91, 95CI 0.88–0.95) or descendants of immigrants (OR 0.90, 95CI 0.84–0.96). Living with a partner (OR 1.08, 95CI 1.07–1.10), being followed in practice for a chronic condition (OR 1.22, 95CI 1.18–1.26) and having CRP tests performed in the previous year (OR 1.78, 95CI 1.73–1.84) were associated with higher odds of CRP testing in relation to antibiotic prescribing. CONCLUSIONS: Differences were observed in the use of CRP tests among subgroups of patients indicating that both sociodemographic factors and comorbidity influence the decision to use a CRP test in relation to antibiotic prescriptions in general practice. Potentially, this means that the use of CRP tests could be optimised to increase diagnostic certainty and further promote rational prescribing of antibiotics. The rationale behind the observed differences could be further explored in future qualitative studies. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s12875-021-01614-6

Multimorbidity and mortality:A 15-year longitudinal registry-based nationwide Danish population study

Supplementary_material_5_JoC for Multimorbidity and mortality: A 15-year longitudinal registry-based nationwide Danish population study by TG Willadsen, V Siersma, DR Nicolaisdóttir, R Køster-Rasmussen, DE Jarbøl, S Reventlow, SW Mercer, and N de Fine Olivarius in Journal of Comorbidity</p

The role of diseases, risk factors and symptoms in the definition of multimorbidity:a systematic review

<p>Objective is to explore how multimorbidity is defined in the scientific literature, with a focus on the roles of diseases, risk factors, and symptoms in the definitions. Design: Systematic review. Methods: MEDLINE (PubMed), Embase, and The Cochrane Library were searched for relevant publications up until October 2013. One author extracted the information. Ambiguities were resolved, and consensus reached with one co-author. Outcome measures were: cut-off point for the number of conditions included in the definitions of multimorbidity; setting; data sources; number, kind, duration, and severity of diagnoses, risk factors, and symptoms. We reviewed 163 articles. In 61 articles (37%), the cut-off point for multimorbidity was two or more conditions (diseases, risk factors, or symptoms). The most frequently used setting was the general population (68 articles, 42%), and primary care (41 articles, 25%). Sources of data were primarily self-reports (56 articles, 42%). Out of the 163 articles selected, 115 had individually constructed multimorbidity definitions, and in these articles diseases occurred in all definitions, with diabetes as the most frequent. Risk factors occurred in 98 (85%) and symptoms in 71 (62%) of the definitions. The severity of conditions was used in 26 (23%) of the definitions, but in different ways. The definition of multimorbidity is heterogeneous and risk factors are more often included than symptoms. The severity of conditions is seldom included. Since the number of people living with multimorbidity is increasing there is a need to develop a concept of multimorbidity that is more useful in daily clinical work. Key Points</p><p>The increasing number of multimorbidity patients challenges the healthcare system. The concept of multimorbidity needs further discussion in order to be implemented in daily clinical practice.</p><p>Many definitions of multimorbidity exist and most often a cut-off point of two or more is applied to a range of 4–147 different conditions.</p><p>Diseases are included in all definitions of multimorbidity.</p><p>Risk factors are often included in existing definitions, whereas symptoms and the severity of the conditions are less frequently included.</p><p></p> <p>The increasing number of multimorbidity patients challenges the healthcare system. The concept of multimorbidity needs further discussion in order to be implemented in daily clinical practice.</p> <p>Many definitions of multimorbidity exist and most often a cut-off point of two or more is applied to a range of 4–147 different conditions.</p> <p>Diseases are included in all definitions of multimorbidity.</p> <p>Risk factors are often included in existing definitions, whereas symptoms and the severity of the conditions are less frequently included.</p

Identification of Important Factors Affecting Use of Digital Individualised Coaching and Treatment of Type 2 Diabetes in General Practice: A Qualitative Feasibility Study

Most type 2 diabetes patients are treated in general practice and there is a need of developing and implementing efficient lifestyle interventions. eHealth interventions have shown to be effective in promoting a healthy lifestyle. The purpose of this study was to test the feasibility, including the identification of factors of importance, when offering digital lifestyle coaching to type 2 diabetes patients in general practice. We conducted a qualitative feasibility study with focus group interviews in four general practices. We identified two overall themes and four subthemes: (1) the distribution of roles and lifestyle interventions in general practice (subthemes: external and internal distribution of roles) and (2) the pros and cons for digital lifestyle interventions in general practice (subthemes: access to real life data and change in daily routines). We conclude that for digital lifestyle coaching to be feasible in a general practice setting, it was of great importance that the general practitioners and practice nurses knew the role and content of the intervention. In general, there was a positive attitude in the general practice setting towards referring type 2 diabetes patients to digital lifestyle intervention if it was easy to refer the patients and if easily understandable and accessible feedback was implemented into the electronic health record. It was important that the digital lifestyle intervention was flexible and offered healthcare providers in general practice an opportunity to follow the type 2 diabetes patient closely

Associations between patients' risk attitude and their adherence to statin treatment - a population based questionnaire and register study

Background: Poor adherence to medical treatment may have considerable consequences for the patients’ health and for healthcare costs to society. The need to understand the determinants for poor adherence has motivated several studies on socio-demographics and comorbidity. Few studies focus on the association between risk attitude and adherence. The aim of the present study was to estimate associations between patients’ adherence to statin treatment and different dimensions of risk attitude, and to identify subgroups of patients with poor adherence. Methods: Population-based questionnaire and register-based study on a sample of 6393 persons of the general. Danish population aged 20–79. Data on risk attitude were based on 4 items uncovering health-related as well as financial dimensions of risk attitude. They were collected through a web-based questionnaire and combined with register data on redeemed statin prescriptions, sociodemographics and comorbidity. Adherence was estimated by proportion of days covered using a cut-off point at 80 %. Results: For the dimension of health-related risk attitude, “Preference for GP visit when having symptoms”, riskneutral and risk-seeking patients had poorer adherence than the risk-averse patients, OR 0.80 (95 %-CI 0.68–0.95)and OR 0.83 (95 %-CI 0.71–0.98), respectively. No significant association was found between adherence and financial risk attitude. Further, patients in the youngest age group and patients with no CVD were less adherent to statin treatment. Conclusion: We find some indication that risk attitude is associated with adherence to statin treatment, and that risk-neutral and risk-seeking patients may have poorer adherence than risk-averse patients. This is important for clinicians to consider when discussing optimal treatment decisions with their patients. The identified subgroups with the poorest adherence may deserve special attention from their GP regarding statin treatment

Variation in suspected cancer referral pathways in primary care:comparative analysis across the International Benchmarking Cancer Partnership

BACKGROUND: International variations in cancer outcomes persist and may be influenced by differences in the accessibility and organisation of cancer patient pathways. More evidence is needed to understand to what extent variations in the structure of primary care referral pathways for cancer investigation contribute to differences in the timeliness of diagnoses and cancer outcomes in different countries. AIM: To explore the variation in primary care referral pathways for the management of suspected cancer across different countries. DESIGN AND SETTING: Descriptive comparative analysis using mixed methods across the International Cancer Benchmarking Partnership (ICBP) countries. METHOD: Schematics of primary care referral pathways were developed across 10 ICBP jurisdictions. The schematics were initially developed using the Aarhus statement (a resource providing greater insight and precision into early cancer diagnosis research) and were further supplemented with expert insights through consulting leading experts in primary care and cancer, existing ICBP data, a focused review of existing evidence on the management of suspected cancer, published primary care cancer guidelines, and evaluations of referral tools and initiatives in primary care. RESULTS: Referral pathway schematics for 10 ICBP jurisdictions were presented alongside a descriptive comparison of the organisation of primary care management of suspected cancer. Several key areas of variation across countries were identified: inflexibility of referral pathways, lack of a managed route for non-specific symptoms, primary care practitioner decision-making autonomy, direct access to investigations, and use of emergency routes. CONCLUSION: Analysing the differences in referral processes can prompt further research to better understand the impact of variation on the timeliness of diagnoses and cancer outcomes. Studying these schematics in local contexts may help to identify opportunities to improve care and facilitate discussions on what may constitute best referral practice