BackgroundDespite the extensive use of antibiotics and the growing challenge of antimicrobial resistance, there has been a lack of substantial initiatives aimed at diminishing the prevalence of infections in nursing homes and enhancing the detection of urinary tract infections (UTIs). ObjectiveThis study aims to systematize and enhance efforts to prevent health care–associated infections, mainly UTIs and reduce antibiotic inappropriateness by implementing a multifaceted intervention targeting health care professionals in nursing homes. MethodsA before-and-after intervention study carried out in a minimum of 10 nursing homes in each of the 8 European participating countries (Denmark, Greece, Hungary, Lithuania, Poland, Slovakia, Slovenia, and Spain). A team of 4 professionals consisting of nurses, doctors, health care assistants, or health care helpers are actively involved in each nursing home. Over the initial 3-month period, professionals in each nursing home are registering information on UTIs as well as infection and prevention control measures by means of the Audit Project Odense method. The audit will be repeated after implementing a multifaceted intervention. The intervention will consist of feedback and discussion of the results from the first registration, training on the implementation of infection and prevention control techniques provided by experts, appropriateness of the diagnostic approach and antibiotic prescribing for UTIs, and provision of information materials on infection control and antimicrobial stewardship targeted to staff, residents, and relatives. We will compare the pre- and postintervention audit results using chi-square test for prescription appropriateness and Student t test for implemented hygiene elements. ResultsA total of 109 nursing homes have participated in the pilot study and the first registration audit. The results of the first audit registration are expected to be published in autumn of 2024. The final results will be published by the end of 2025. ConclusionsThis is a European Union–funded project aimed at contributing to the battle against antimicrobial resistance through improvement of the quality of management of common infections based on evidence-based interventions tailored to the nursing home setting and a diverse range of professionals. We expect the intervention to result in a significant increase in the number of hygiene activities implemented by health care providers and residents. Additionally, we anticipate a marked reduction in the number of inappropriately managed UTIs, as well as a substantial decrease in the overall incidence of infections following the intervention. International Registered Report Identifier (IRRID)DERR1-10.2196/60099

Objective: To describe and compare the demographic and clinical characteristics of patients with acute or chronic low back pain across all health care settings treating this condition.Design and setting: Concurrent prospective survey registration of all consecutive consultations regarding low back pain at general practitioners, chiropractors, physiotherapists, and the secondary care spine centre in Southern Denmark.Subjects: Patients >= 16 years of age with low back pain.Main outcome measure: Demographic characteristics, symptoms, and clinical findings were registered and descriptively analysed. Pearson's chi-square tested differences between the populations in the four settings. Multiple logistic regression assessed the odds of consulting specific settings, and t-test assessed differences between patients attending for a first and later consultation.Results: Thirty-six general practitioners, 44 chiropractors, 74 physiotherapists, and 35 secondary care Spine Centre personnel provided information on 5645 consultations, including 1462 first-visit consultations. The patients differed significantly across the settings. Patients at the Spine Centre had the most severe symptoms and signs and were most often on sick leave. Compared to the other populations, the chiropractor population was younger, whereas the physiotherapist population was older, more often females, and had prolonged symptoms. In general practice, first-time consultations were with milder cases while patients who attended for a second or later consultation had the worst symptoms, findings, and risk of sick leave compared to the other primary care settings.Conclusion: The demographic and clinical characteristics of patients with low back pain differ considerably across the health care settings treating them.

OBJECTIVE:To examine the occurrence of and types of defensive medicine (DM), and the reasons for practicing DM in general practice.DESIGN:Prospective survey registration of consecutive consultations regarding defensive medicine defined as: Actions that are not professionally well founded but are carried out due to demands and pressure. The GPs registered the degree of defensiveness, the type(s) of defensive action(s) and the reason(s) for acting defensively.SETTING:Danish general practice.SUBJECTS:A total of 26 GPs registered a total of 1,758 consultations.MAIN OUTCOME MEASURES:Defensive medical actions.RESULTS:Defensive actions were performed in 12% (210/1749) of all consultations. A fifth (46/210) of the defensive actions were characterised by the GPs as 'moderately' or 'highly' defensive. Frequent types of defensive actions were: blood tests, point-of-care-tests (POCTs) and referrals. Common reasons for defensive actions were: Influence from patients, 37% (78/210), concerns of overlooking severe disease, 32% (67/210) and influence from patient relatives, 12% (25/210).CONCLUSION:Danish GPs registered self-perceived defensive actions in a prospective survey. DM was carried out in one out of eight consultations, most often due to patient influence. The most frequent defensive actions were blood tests, POCTs and referrals.

Background The increasing incidence of skin cancers poses a burden to health care systems. General practitioners (GPs) play an important role in triaging these diseases and referring relevant patients to specialists. It is challenging to distinguish benign from malignant skin lesions, and GPs may benefit from diagnostic support from teledermoscopy (TD). Objectives To assess whether the introduction of TD in general practice was feasible and might reduce the number of unnecessary referrals to specialists and to assess the diagnostic accuracy and confidence of participating GPs. Methods Fifty general practices in Southern Denmark participated. Adult patients presenting to their GP with suspected skin cancer could be included. Images including dermoscopy were taken by the GP and sent for evaluation by specialized dermatologists at a university hospital. Patients were simultaneously referred for a face-to-face evaluation at the university hospital. Diagnoses proposed by the GPs and by TD were compared to the final diagnoses obtained by histopathology or, if not available, face-to-face evaluation. Results Five hundred and nineteen patients with 600 suspected skin cancers were included. The final diagnosis was benign in 72.3%. The photo quality was good or fair in 90.5%. GPs reported uncertainty about their diagnoses in 41.5% of cases. The GPs’ positive predictive values for any malignancy and for malignant melanoma were 49.5% and 26.3%, respectively. On evaluation by TD, 31.5% of lesions did not need further in-person assessment. Conclusion Useful images of suspicious skin lesions were obtained from general practice, and GPs could benefit from TD to improve their diagnostic accuracy and confidence.

Background: Prescribing of proton-pump inhibitors has substantially increased. Information from clinical settings is warranted to gain insight into reasons for prescribing. Aim: To investigate Danish General Practitioners' management and reasons for prescribing of proton-pump inhibitors and to identify areas for quality improvement. Methods: All general practitioners in the Region of Southern Denmark and their staff were invited to participate in a 4-week audit on all contacts with patients prescribed proton-pump inhibitors. For each contact, patient characteristics, treatment duration, dose and causes of treatment, previous gastroscopy, Helicobacter pylori test, and decision about future treatment were recorded. Results: A total of 51 general practitioners and 47 staff members sampled information about 1101 and 741 patients, respectively. Proton-pump inhibitors had been taken for more than 2 years in 58% of the cases, and 64% of the patients used it daily. Treatment was based on an appropriate reason in three of the four patients, most often due to acid-related symptoms. No gastroscopy had been performed in 46% of the patients, and one of four had had a consultation with the general practitioner regarding proton-pump inhibitor within the last year. Conclusion: Most patients treated with proton-pump inhibitors are treated daily, on a long-term basis, and due to symptoms. Few consultations led to alterations in treatment, and only 25% of patients had a consultation regarding proton-pump inhibitor treatment with their general practitioner within the last year. Substantial variability between general practitioners with regard to management was detected.

Objectives Recent years have witnessed a progressive increase in defensive medicine (DM) in several Western welfare countries. In Danish primary and secondary care, documentation on the extent of DM is lacking. Before investigating the extent of DM, we wanted to explore how the phenomenon is understood and experienced in the context of general practice in Denmark. The objective of the study was to describe the phenomenon of DM as understood and experienced by Danish general practitioners (GPs). Design A qualitative methodology was employed and data were generated through six focus group interviews with three to eight GPs per group (n=28) recruited from the Region of Southern Denmark. Data were analysed using a thematic content analysis inspired by a hermeneutic-phenomenological focus on understanding and meaning. Results DM is understood as unnecessary and meaningless medical actions, carried out mainly because of external demands that run counter to the GP’s professionalism. Several sources of pressure to act defensively were identified by the GPs: the system’s pressure to meet external regulations, demands from consumerist patients and a culture among GPs and peers of infallibility and zero-risk tolerance. Conclusions GPs understand DM as unnecessary and meaningless actions driven by external demands instead of a focus on the patient’s problem. GPs consider defensive actions to be carried out as a result of succumbing to various sources of pressure deriving from the system, the patients, the GPs themselves and peers.

Background:Supplemental health insurances (SHI) cover 38% of the Danish population. SHI can give faster access to, and additional treatment from, private health providers. However, this is contingent on a referral from the general practitioner (GP), further complicating clinical decision-making.Objectives:To describe GPs' attitudes to SHI and their experiences with patients holding SHI. Moreover, we analysed associations between different GP characteristics; e.g. gender, age, practice type, own SHI status and their attitudes to and experiences with SHI.Methods:A questionnaire was mailed to 3321 GPs focusing on three issues: (i) Attitudes towards the public health care system. (ii) Perceptions of the impact of SHI. (iii) Experiences with patients holding SHIs.Results:The response rate was 64%. Overall, GPs found that SHIs contribute to inequality (83%) and overtreatment (90%). However, 46% often feel under pressure to refer SHI patients to specialist care, even though not medically indicated, while 11% always or often refer SHI patients unconditionally. Both groups perceive SHI patients more insistent on getting referrals than patients without SHI.Conclusion:Even though a majority of GPs associate SHI with overtreatment and inequality in health, many GPs feel under pressure to refer patients holding SHI for treatments or examinations that are not medically warranted. Some GPs even refer these patients without further examination or questioning. Insistent SHI patients may partly explain this paradox. Future research should illuminate SHI patients' courses in the private as well as the public healthcare system with regards to medical indications and health outcome measures focusing on inequality and overtreatment.

BackgroundTuberculosis screening of people living with HIV (PLHIV) can contribute to early tuberculosis diagnosis and improved patient outcomes. Evidence-based guidelines for tuberculosis screening are available, but literature assessing their implementation and the quality of clinical practice is scarce.ObjectivesTo assess tuberculosis screening practices and the effectiveness of audit and performance feedback to improve quality of tuberculosis screening at HIV care clinics in Ghana.DesignHealthcare providers at 10 large HIV care clinics prospectively registered patient consultations during May and October 2014, before and after a performance feedback intervention in August 2014. The outcomes of interest were overall tuberculosis suspicion rate during consultations and provider adherence to the International Standards for Tuberculosis Care and the World Health Organizations’ guidelines for symptom-based tuberculosis screening among PLHIV.ResultsTwenty-one healthcare providers registered a total of 2,666 consultations; 1,368 consultations before and 1,298 consultations after the feedback intervention. Tuberculosis suspicion rate during consultation increased from 12.6 to 20.9% after feedback (odds ratio, OR 1.83; 95% confidence interval, CI: 1.09–3.09). Before feedback, sputum smear microscopy was requested for 58.7% of patients with suspected tuberculosis, for 47.2% of patients with cough ≥2 weeks, and for 27.5% of patients with a positive World Health Organization (WHO) symptom screen (any of current cough, fever, weight loss or night sweats). After feedback, patients with a positive WHO symptom screen were more likely to be suspected of tuberculosis (OR 2.21; 95% CI: 1.19–4.09) and referred for microscopy (OR 2.71; 95% CI: 1.25–5.86).ConclusionsA simple prospective audit tool identified flaws in clinical practices for tuberculosis screening of PLHIV. There was no systematic identification of people with suspected active tuberculosis. We found low initial tuberculosis suspicion rate compounded by low referral rates of relevant patients for sputum smear microscopy. Adherence to recommended standards and guidelines for tuberculosis screening improved after performance feedback.

Objective: To compare the appropriateness of antibiotic prescribing for upper respiratory tract infections (URTIs) in two countries with different prevalence of antimicrobial resistance: Denmark and Iceland.Design: A cross-sectional study. Settings and subjects. General practitioners (GPs) in Denmark (n = 78) and Iceland (n = 21) registered all patients with URTI according to the Audit Project Odense (APO) method during a three-week period in the winter months of 2008 and 2009.Main outcome measures: Appropriateness of antibiotic prescribing in patients with URTI in Denmark and Iceland.Results: A total of 1428 patients were registered (Denmark: n = 1208; Iceland: n = 220). A majority of patients in both countries were prescribed antibiotics, and only a minority of the prescriptions could be classified as appropriate prescribing. In general, Icelandic GPs more often prescribed antibiotics (Iceland = 75.8% vs. Denmark = 59.3%), but Danish GPs had a higher percentage of inappropriate antibiotic prescribing for sinusitis, and Icelandic GPs for pharyngotonsillitis. No differences were found for acute otitis media (AOM). The different antibiotic prescribing patterns between Denmark and Iceland could not fully be explained by different symptoms and signs among patients.Conclusion: Icelandic GPs have a higher antibiotic prescribing rate compared with Danish GPs, but the percentage of inappropriate antibiotic prescribing is highest in Denmark for sinusitis, and in Iceland for pharyngotonsillitis.Key pointsWithin the Nordic countries there are marked differences in antimicrobial resistance and antibiotic use.Iceland differs from Denmark by a higher antibiotic prescribing rate and a higher prevalence of antimicrobial resistance.The majority of antibiotics are prescribed in primary care and most often for upper respiratory infections (URTIs).Only a minor amount of antibiotic prescriptions for URTIs can be classified as appropriate; inappropriate antibiotic prescribing is higher in Denmark than in Iceland for sinusitis and the opposite for pharyngotonsillitis.The different antibiotic prescribing patterns between Denmark and Iceland cannot be fully explained by different clinical criteria among patients.