Background General practitioners (GPs) do not see men with localised urinary tract infection (UTI) very often which limits their possibility of developing expertise in the area. To gain knowledge of male patients’ experiences and perspectives on localised UTIs, qualitative research is needed.Aim To explore expectations, experiences and symptoms in men with localised urinary tract infection in primary health care (PHC).Design and setting A qualitative study based on semi-structured interviews with men with a history of localised UTI treated in PHC was performed.Method Data were collected from patients with recent experience of localised UTI, using semi-structured interviews. An interview guide with open-ended questions was used. All interviews were audio recorded and transcribed verbatim. A thematic analysis was performed.Results The median age of the 18 patients was 77.5 years. The interviews lasted an average of 16 min. Four themes emerged: (1) stigma and self-blame in managing illness. (2) Adaptation, careful planning and normalization. (3) Gender and help seeking behaviour. (4) Healthcare experience-uncertainty and trust. Many patients reflected on the causes behind their infection and expressed aspects of self-infliction. They explained that symptoms from the localised UTI affected their daily lives and adjusted their way of living according to them.Conclusions Localised UTI symptoms in men affect their daily lives. GPs should be perceptive regarding any beliefs among patients with localised UTI, as well as any self-imposed guilt that could lead to unnecessary lifestyle changes. Although the patients in this study expressed good confidence in health care, they also found the care not individualized enough.

BACKGROUND:Personal continuity is a hallmark for GPs but there is insufficient evidence to support its benefits in ordinary primary care populations. AIM:To investigate the effects of GP personal continuity on the healthcare outcomes of primary care populations. DESIGN AND SETTING:Systematic review of quantitative studies investigating associations between personal continuity of care and outcomes such as mortality and healthcare utilisation. METHOD:Embase, PubMed, Scopus, and Web of Science were searched for studies published between 1 January 2000 and 31 October 2023. Owing to study heterogeneity the synthesis was conducted narratively; study results were summarised and expressed as having higher (compared with lower) continuity of care. Certainty of each summarised result was assessed using the GRADE framework. RESULTS:Out of 5792 unique references, 18 studies were included in the final analyses. The outcomes were grouped into three categories of summarised outcomes. Higher (when compared with lower) personal continuity with a GP/family physician probably prevents premature mortality (moderate certainty: four studies, 5 638 305 participants), probably reduces the risk of admission to hospital (moderate certainty: 11 studies, 13 642 684 participants), and probably lowers risk of emergency department visits (moderate certainty: seven studies, 3 855 487 participants). CONCLUSION:Higher, compared with lower, continuity in the relationship between GP and patients in primary care populations is associated with reduced mortality, admissions to hospital, and emergency department visits. Relatively small improvements in personal continuity, which may be achieved in most practices, significantly reduce healthcare consumption, and thus may have an impact on access to care, which has implications for healthcare policy.

Objective Quality measures in healthcare are crucial for improving outcomes and ensuring patient safety. This study investigated the evolution, implementation, and impact of Primary Care Quality (PCQ). The PCQ aims to facilitate nationwide quality benchmarking, serving as a tool for quality improvement (QI) and research.Design/Settings A descriptive design outlining the development and operationalisation of the PCQ, a national framework for automatic and systematic data collection and feedback.Results The national PCQ system is a tool for continuous QI in primary care in Sweden. PCQ has achieved extensive adoption, with over 97% of Swedish primary care centres, both private and public driven, utilising the platform for automatic data extraction from patient records and data visualisation. Quality indicators were developed through a structured approach involving primary care professionals, evidence-based clinical practices, and expert contributions from established knowledge organisations, reflecting the breadth of general practice. Data are automatically retrieved from medical records and visualised in real time, with the possibility of benchmarking at an aggregate level and identifying individuals locally at primary care centres. The PCQ has facilitated improvements by enabling quality dialogue among healthcare professionals and supporting continuous local QI. Regionally, the PCQ supports needs assessments and patient safety initiatives. Nationally, it establishes standardised indicators for quality measurement, enabling effective benchmarking and strategic healthcare planning.Conclusions The implementation of the national PCQ system provided a framework and tool for continuous QI in primary care. The system has influenced national standardization of primary care indicators, with quality improvement results demonstrated regionally and locally through the PCQ.

A considerable amount of spending in health care is deemed wasteful. Overdiagnosis, i.e. the labelling of a person with a diagnosis that lacks net benefit, is an entity within the overarching concept of »too much medicine«. Overdiagnosis includes overdetection and overdefinition. Disease mongering is a type of overdefinition with economic drivers. Overtesting and overtreatment are other aspects of »too much medicine«, but are not overdiagnosis per se. Medical research tends to focus on benefits of diagnostics and therapy, whereas overdiagnosis and other harms receive less attention, leading to overestimation of benefits. The international network Choosing Wisely has been successful in changing the diagnostic mindset in several countries and a Swedish campaign is under way, yielding new possibilities to counteract »too much medicine« and the specific problem of overdiagnosis.

Objectives Primary Care Quality (PCQ) is a tool that helps to decrease overdiagnosis and overmedication in primary health care. Examples on how PCQ has been used for quality improvement by primary health care professionals in Sweden will be presented. Method PCQ is a national system of quality indicators constructed by primary health care professionals which aim to deliver data for quality improvement by visualising automatically retrieved data from EMRs. The indicators are based on national guidelines for patients with chronic diseases and infections but also qualities like continuity, priority setting and care for multimorbidity. One challenge has been to balance disease specific recommendations on early diagnose and treatment from national authorities and secondary care with the risk of overmedication and overtreatment. Antibiotics and addictive substances are also at risk for being overprescribed. The indicators on infections in PCQ are developed together with the Public Health Agency and the Swedish strategic programme against antibiotic resistance. The novelty of PCQ is the ability to link prescribing data to certain diagnoses and laboratory tests. Two projects will be presented where PCQ have been used for quality improvement by reducing drug prescribing. Results Almost all Swedish primary health care centres (PHCC) now have access to PCQ and the use of PCQ for improvement is increasing. PCQ consists of around 200 quality indicators and approximately 30 of them concern preventing drug overtreatment (antibiotics, benzodiazepines, opioids, proton-pump inhibitors, and medication among elderly). Indicators on laboratory tests in common infections and indicators concerning prevalence/incidence of different diagnoses at different PHCCs can be used to prevent overdiagnosis. [SS1]. PCQ show improvement in several aspects. Two examples of use of PCQ is the decrease of prescribing of benzodiazepines in a PHCC in Region Jönköping and the reduction of prescribing antibiotics in a PHCC in Region Skåne. Conclusions Medical guidelines often concern 'what should be done', but quite a few indicators in PCQ concern overtreatment and overdiagnosis. Indicators for multimorbidity are constructed to balance disease specific indicators. The system is in use at more than 90% of Swedish PHCCs and results of the improvement efforts are visible in the figures at the PHCCs.

Abstract Background In previous studies, we investigated the effects of a care manager intervention for patients with depression treated in primary health care. At 6 months, care management improved depressive symptoms, remission, return to work, and adherence to anti-depressive medication more than care as usual. The aim of this study was to compare the long-term effectiveness of care management and usual care for primary care patients with depression on depressive symptoms, remission, quality of life, self-efficacy, confidence in care, and quality of care 12 and 24 months after the start of the intervention. Methods Cluster randomized controlled trial that included 23 primary care centers (11 intervention, 12 control) in the regions of Västra Götaland and Dalarna, Sweden. Patients ≥18 years with newly diagnosed mild to moderate depression (n = 376: 192 intervention, 184 control) were included. Patients at intervention centers co-developed a structured depression care plan with a care manager. Via 6 to 8 telephone contacts over 12 weeks, the care manager followed up symptoms and treatment, encouraged behavioral activation, provided education, and communicated with the patient’s general practitioner as needed. Patients at control centers received usual care. Adjusted mixed model repeated measure analysis was conducted on data gathered at 12 and 24 months on depressive symptoms and remission (MADRS-S); quality of life (EQ5D); and self-efficacy, confidence in care, and quality of care (study-specific questionnaire). Results The intervention group had less severe depressive symptoms than the control group at 12 (P = 0.02) but not 24 months (P = 0.83). They reported higher quality of life at 12 (P = 0.01) but not 24 months (P = 0.88). Differences in remission and self-efficacy were not significant, but patients in the intervention group were more confident that they could get information (53% vs 38%; P = 0.02) and professional emotional support (51% vs 40%; P = 0.05) from the primary care center. Conclusions Patients with depression who had a care manager maintained their 6-month improvements in symptoms at the 12- and 24-month follow-ups. Without a care manager, recovery could take up to 24 months. Patients with care managers also had significantly more confidence in primary care and belief in future support than controls. Trial registration ClinicalTrials.gov identifier: NCT02378272. Submitted 2/2/2015. Posted 4/3/2015.

In Swedish primary care patients are registered at health centres where different professions, such as general practitioners (GPs), nurses, assistant nurses, counsellors, physiotherapists, psychologists and biomedical analysts, work. In an international comparison personal physician continuity is low in Sweden. Several governmental inquiries propose that patients register with one GP or a care team. Do Swedish GPs want a personal patient list and how should this best be realised? A web survey was distributed to the members of the Swedish Union of General Practitioners and was answered by 838 GPs. 91% wanted a personal patient list if reasonably sized, the option to limit their list, and shared responsibility for the list with colleagues or a team. To be able to plan the working day themselves and designated time for collegial dialogue was considered essential for increased efficiency, well-being and reduced risk of patients harm due to their doctor's knowledge gaps.

This article was migrated. The article was marked as recommended. Introduction: Doctor-patient consultation is an essential element of high quality health care. Education and training of medical students in consultation skills is important. The aim of this study was to investigate the medical students' consultation skills before graduation by assessment of the students' video recordings of consultations with real patients at primary health care centres. Methods: All students had to make a video recording of a meeting with a real patient for formative examination. 26 students participated in the study and delivered a video recording and a self-assessment. Four general practitioners assessed the video recordings by Calgary-Cambridge Global Consultation Rating Scale (CC-GCRS). Statistical testing included comparisons between groups of students and assessors using non-parametric methods. Results: The average CC-GCRS-rating was higher for female students. The students' strengths were related to relation and problem exploration. Their limitations were related to patient's perspective, providing structure and providing information. The students assessed their consultation skills higher than the assessors did, while the relative levels were similar. The distribution of rating scores across the assessors was small. Conclusion:Consultation skills were acceptable for most medical students, although there was room for improvement regarding patient centeredness skills. CC-GCRS was feasible and might be a valuable instrument to assess consultation skills for medical students at the end of their medical education.

Background : Triage by registered nurses (RN) during office hours may be of great importance for the prescription of antibiotics according to guidelines. This, however, has hardly ever been the focus of scientific study. The aim of this study was to describe RNs' views on telephone consulting work with patients calling primary health care centers for respiratory tract infections. Methods : A descriptive and qualitative study was performed through interviews with twelve RNs in Sweden. Results : The RNs saw their daily work as a continuous challenge and reported that support structures were insufficient. The themes challenge and support were built on five categories. These were: the triage, assessment over the phone and to manage expectations, evidence-based knowledge and professional collaboration. The RN had to differentiate urgent cases from self-care advice, with a fear of maybe missing something serious. They described the difficulties in assessing both the symptoms and the person calling, relying only on what they were told, as well as managing patients’ expectations with special reference to patients with other cultural backgrounds. The RN described insufficient possibilities to keep up with an evidence-based knowledge, where decision support and guidelines were only partly known and used, while continuous medical education was not prioritized. Furthermore, professional collaboration was described as unstructured. Conclusions : The telephone triage in primary care health centres regarding common problems seems to be an invisible task, both for researchers, policy makers and the RNs themselves. The consequences may be decreased patient safety, occupational stress, and an increased workload for the RNs. Systematic work is needed to strengthen the different support structures.

Background: Telephone nursing in primary healthcare has been suggested as a solution to the increased demand for easy access to healthcare, increased number of patients with complex problems, and lack of general practitioners. Registered nurses’ assessments may also be of great importance for antibiotic prescriptions according to guidelines. The aim of this study was to describe registered nurses’ views of telephone nursing work with callers contacting primary healthcare centres regarding respiratory tract infections.Methods: A descriptive, qualitative study was performed through interviews with twelve registered nurses in Swedish primary healthcare. Results: The overarching themes for registered nurses’ views on telephone nursing were captured in two themes: professional challenges and professional support. These included three and two categories respectively: Communicate for optimal patient information; Differentiate harmless from severe problems; Cope with caller expectations; Use working tools; and Use team collaboration. Optimal communication for sufficiently grasping caller symptoms and assess whether harmful or not, without visual input, was underlined. This generated fear of missing something serious. Professional support used in work, were for example guidelines and decision support tool. Colleagues and teamwork collaboration were requested, but not always offered, support for the interviewed registered nurses.Conclusions: The study deepens the understanding of telephone nursing as an important factor for decreasing respiratory tract infection consultations with general practitioners, thus contributing to decreased antibiotic usage in Sweden. To cope with the challenges of telephone nursing in primary healthcare centres, it seems important to systematically introduce the use of the available decision support tool, and set aside time for inter- and intraprofessional discussions and feedback. The collegial support and team collaboration asked for is likely to get synergy effects such as better work environment and job satisfaction for both registered nurses and general practitioners. Future studies are needed to explore telephone nursing in primary healthcare centres in a broader sense to better understand the function and the effects in the complexity of primary healthcare.

Background: National guidelines are important instruments in reducing inappropriate antibiotic prescriptions. Low adherence to guidelines is an acknowledged problem that needs to be addressed. Method: We evaluated established characteristics for guidelines in the guidelines for lower respiratory tract infection, acute otitis media and pharyngotonsillitis in primary care. We studied how doctors used these guidelines by analysing interviews with 29 general practitioners (GPs) in Sweden. Results: We found important between-guidelines differences, which we believe affects adherence. The GPs reported persistent preconceptions about diagnosis and treatment, which we believe reduces their adherence to the guidelines. Conclusion: To increase adherence, it is important to consider doctors’ preconceptions when creating new guidelines.

Objective: Explore general practitioners’ (GPs’) views on and experiences of working with care managers for patients treated for depression in primary care settings. Care managers are specially trained health care professionals, often specialist nurses, who coordinate care for patients with chronic diseases. Design: Qualitative content analysis of five focus-group discussions. Setting: Primary health care centers in the Region of Västra Götaland and Dalarna County, Sweden. Subjects: 29 GPs. Main outcome measures: GPs’ views and experiences of care managers for patients with depression. Results: GPs expressed a broad variety of views and experiences. Care managers could ensure care quality while freeing GPs from case management by providing support for patients and security and relief for GPs and by coordinating patient care. GPs could also express concern about role overlap; specifically, that GPs are already care managers, that too many caregivers disrupt patient contact, and that the roles of care managers and psychotherapists seem to compete. GPs thought care managers should be assigned to patients who need them the most (e.g. patients with life difficulties or severe mental health problems). They also found that transition to a chronic care model required change, including alterations in the way GPs worked and changes that made depression treatment more like treatment for other chronic diseases. Conclusion: GPs have varied experiences of care managers. As a complementary part of the primary health care team, care managers can be useful for patients with depression, but team members’ roles must be clear.KEY POINTS A growing number of primary health care centers are introducing care managers for patients with depression, but knowledge about GPs’ experiences of this kind of collaborative care is limited. GPs find that care managers provide support for patients and security and relief for GPs. GPs are concerned about potential role overlap and desire greater latitude in deciding which patients can be assigned a care manager. GPs think depression can be treated using a chronic care model that includes care managers but that adjusting to the new way of working will take time.

OBJECTIVE:To evaluate the cost-effectiveness of a care manager (CM) programme compared with care as usual (CAU) for treatment of depression at primary care centres (PCCs) from a healthcare as well as societal perspective.DESIGN:Cost-effectiveness analysis.SETTING:23 PCCs in two Swedish regions.PARTICIPANTS:Patients with depression (n=342).MAIN OUTCOME MEASURES:A cost-effectiveness analysis was applied on a cluster randomised trial at PCC level where patients with depression had 3 months of contact with a CM (11 intervention PCCs, n=163) or CAU (12 control PCCs, n=179), with follow-up 3 and 6 months. Effectiveness measures were based on the number of depression-free days (DFDs) calculated from the Montgomery-Åsberg Depression Rating Scale-Self and quality-adjusted life years (QALYs). Results were expressed as the incremental cost-effectiveness ratio: ∆Cost/∆QALY and ∆Cost/∆DFD. Sampling uncertainty was assessed based on non-parametric bootstrapping.RESULTS:Health benefits were higher in intervention group compared with CAU group: QALYs (0.357 vs 0.333, p<0.001) and DFD reduction of depressive symptom score (79.43 vs 60.14, p<0.001). The mean costs per patient for the 6-month period were €368 (healthcare perspective) and €6217 (societal perspective) for the intervention patients and €246 (healthcare perspective) and €7371 (societal perspective) for the control patients (n.s.). The cost per QALY gained was €6773 (healthcare perspective) and from a societal perspective the CM programme was dominant.DISCUSSION:The CM programme was associated with a gain in QALYs as well as in DFD, while also being cost saving compared with CAU from a societal perspective. This result is of high relevance for decision-makers on a national level, but it must be observed that a CM programme for depression implies increased costs at the primary care level.TRIAL REGISTRATION NUMBER:NCT02378272; Results.

Objective To construct evidence based indicators, automatically retrieved from electronic medical records (EMR), for quality improvement including indicators to prevent overtreatment and overdiagnosis. Method ‘Primary Care Quality’ is a national system consisting of nationally specified quality indicators. The data for the indicators is automatically retrieved from EMRs. The indicators are presented at the HC centres for benchmarking but also to identify individual patients. The indicators reflect quality of care for patients with chronic diseases, infections as well as qualities like priority setting and multimorbidity. The project was initiated by the professional organisations in Primary Care and most of the indicators are built on evidence based national guidelines. In line with similar systems in many countries most indicators assess certain measures being taken, but in addition this system includes several indicators aiming to point out possible overdiagnosis and overtreatment. Result The indicators aiming to prevent overtreatment concern use of antibiotics, bensodiazepines, hypnotics, proton pump inhibitors and medication among the elderly. A few indicators concern overdiagnosis (laboratory test in common infections). However, comparing prevalence of different diagnoses at different HCs may a way to inspire discussion on possible overdiagnosis, especially prevalence of different infectious diseases as well as depression and anxiety. Moreover there are indicators for multimorbidity, which aim to balance disease specific indicators since guidelines usually have to be adjusted to the individual patient in patients with more than one chronic disease. Conclusion Although most indicators concern what should be done, quite a few concern overtreatment and overdiagnosis. Indicators for multimorbidity are constructed to balance disease specific indicators. It is possible to construct indicators from automatically retrieved data from the EMR for use in discussions on overtreatment and overdiagnosis in primary care. How effective the indicators are for reducing overtreatment and overdiagnosis is not known yet.

Depression is one of the leading causes of disability and affects 10-15% of the population. The majority of people with depressive symptoms seek care and are treated in primary care. Evidence internationally for high quality care supports collaborative care with a care manager. Our aim was to study clinical effectiveness of a care manager intervention in management of primary care patients with depression in Sweden.

Background As anticancer intravenous chemotherapies (AIVC) are high risk medications, there are different ways of securing the preparation circuit. In this context, an anticipated circuit of prescription and preparation (ACPP) for AIVC was developed. Purpose To evaluate the impact of the ACPP protocol on the quality and timing of medication preparations with the primary objective of 40% decrease in mean daily variances. Material and methods 210 patients were included in the before group and 207 patients in the after group (19% of them were included in the ACPP protocol). A 21% decrease in mean daily variances was observed with the ACPP (p=0.11, SD ranging from 1.27 to 0.83 (p=0.025)). The patient’s mean waiting time decreased from 128 to 114 min (p=0.005) between the before/after groups and to 60 min for the ACPP (p < 0.001). 1 of the 174 bags was lost in the ACPP. Results The mean daily variance enabled us to observe an improvement in the timing of production without reaching our 40% decrease objective. The mean waiting time significantly decreased but remained above 30 min. The losing rate in the ACPP protocol was <2%, as desired. Failure to reach our preset objectives can be explained by the fact that the ACPP is a new concept in the clinic. Conclusion The ACPP helped to improve pharmacy activities and to decrease patient waiting times but also helped maintain similar safety and avoided losses. However, the study should be conducted on a larger cohort and over a longer period to confirm the impact of the project. References and/or acknowledgements Scotte F, Oudard S, Aboudagga H, et al. A practical approach to improve safety and management in chemotherapy units based on the PROCHE–programme for optimisation of the chemotherapy network monitoring programme. Eur J Cancer2013;49:541–4. No conflict of interest

BACKGROUND:Uncertainty is inevitable in clinical practice in primary care and tolerance for uncertainty and concern for bad outcomes has been shown to vary between physicians. Uncertainty is a factor for inappropriate antibiotic prescribing. Evidence-based guidelines as well as near-patient tests are suggested tools to decrease uncertainty in the management of patients with respiratory tract infections. The aim of this paper was to describe strategies for coping with uncertainty in patients with pharyngotonsillitis in relation to guidelines.METHODS:An interview study was conducted among a strategic sample of 25 general practitioners (GPs).RESULTS:All GPs mentioned potential dangerous differential diagnoses and complications. Four strategies for coping with uncertainty were identified, one of which was compliant with guidelines, "Adherence to guidelines", and three were idiosyncratic: "Clinical picture and C-reactive protein (CRP)", "Expanded control", and "Unstructured". The residual uncertainty differed for the different strategies: in the strategy "Adherence to guidelines" and "Clinical picture and CRP" uncertainty was avoided, based either on adherence to guidelines or on the clinical picture and near-patient CRP; in the strategy "Expanded control" uncertainty was balanced based on expanded control; and in the strategy "Unstructured" uncertainty prevailed in spite of redundant examination and anamnesis.CONCLUSION:The majority of the GPs avoided uncertainty and deemed they had no problems. Their strategies either adhered to guidelines or comprised excessive use of tests. Thus use of guidelines as well as use of more near-patient tests seemed associated to reduced uncertainty, although the later strategy at the expense of compliance to guidelines. A few GPs did not manage to cope with uncertainty or had to put in excessive work to control uncertainty.

BACKGROUND:Prescribing of antibiotics for common infections varies widely, and there is no medical explanation. Systematic reviews have highlighted factors that may influence antibiotic prescribing and that this is a complex process. It is unclear how factors interact and how the primary care organization affects diagnostic procedures and antibiotic prescribing. Therefore, we sought to explore and understand interactions between factors influencing antibiotic prescribing for respiratory tract infections in primary care.METHODS:Our mixed methods design was guided by the Triangulation Design Model according to Creswell. Quantitative and qualitative data were collected in parallel. Quantitative data were collected by prescription statistics, questionnaires to patients, and general practitioners' audit registrations. Qualitative data were collected through observations and semi-structured interviews.RESULTS:From the analysis of the data from the different sources an overall theme emerged: A common practice in the primary health care centre is crucial for low antibiotic prescribing in line with guidelines. Several factors contribute to a common practice, such as promoting management and leadership, internalized guidelines including inter-professional discussions, the general practitioner's diagnostic process, nurse triage, and patient expectation. These factors were closely related and influenced each other. The results showed that knowledge must be internalized and guidelines need to be normative for the group as well as for every individual.CONCLUSIONS:Low prescribing is associated with adapted and transformed guidelines within all staff, not only general practitioners. Nurses' triage and self-care advice played an important role. Encouragement from the management level stimulated inter-professional discussions about antibiotic prescribing. Informal opinion moulders talking about antibiotic prescribing was supported by the managers. Finally, continuous professional development activities were encouraged for up-to-date knowledge.