Materials and methods. Baseline and follow-up data of a Dutch randomized controlled trial on the implementation of a locally adapted guideline were used. The study involved 30 general practices and 1283 patients. Treatment targets differed between study groups [HbA1c ≤ 8.0% and blood pressure (BP) < 140/85% versus HbA1c ≤ 8.5% and BP < 150/85]. Clinical inertia was defined as the failure to intensify therapy when indicated. A complete medication profile of all participating patients was obtained.

Results. In the intervention and control group, the percentages of patients with poor diabetes or lipid control who did not receive treatment intensification were 45% and 90%, approximately. More control group patients with BP levels above target were confronted with inertia (72.7% versus 63.3%, P < 0.05). In poorly controlled hypertensive patients, inertia was associated with the height of systolic BP at baseline [adjusted odds ratio (OR) 0.98, 95% confidence interval (CI) 0.98–0.99] and the frequency of BP control (adjusted OR 0.89, 95% CI 0.81–0.99). If a practice nurse managed these patients, clinical inertia was less common (adjusted OR 0.12, 95% CI 0.02–0.91). In both study groups, cholesterol decreased significantly more in patients who received proper treatment intensification.

Conclusion. GPs were more inclined to control blood glucose levels than BP or cholesterol levels. Inertia in response to poorly controlled high BP was less common if nurses assisted GPs.

Objective. The purpose of this study was to evaluate the ease of use and in vitro accuracy (sensitivity and specificity) of the five most commonly used RADTs in Europe (OSOM Ultra, Quickvue Dipstick, Streptatest, Clearview Exact Strep A and IMI Test Pack).

Methods. To ensure the RADTs were evaluated objectively, a standardized in vitro method using known concentrations of GABHS was used to remove the inherent biases associated with clinical studies.

Results. The IMI Test Pack was the easiest RADT to use overall. The ability to detect all positive GABHS (sensitivity) varied considerably between kits from 95% [95% confidence interval (CI): 88–98%], for the IMI Test Pack and OSOM, to 62% (95% CI: 51–72%) for Clearview, at the highest GABHS concentration. None of the RADTs gave any false-positive results with commensal flora—they were 100% specific.

Conclusions. The IMI Test Pack is most suitable for use in primary care, as it had high sensitivity, high specificity and was easy to use.

Objective. To estimate the prevalence of selected chronic illnesses based on electronic clinical records in primary care (ECRPC) and to assess its usefulness for epidemiological research, by comparing ECRPC data against those reported by a contemporary health survey.

Methods. Design: Descriptive cross-sectional study. Setting: All primary care medical consultations in the Madrid Regional Public Health System (PHS). Subjects: A total of 23 535 182 ECRPC-registered episodes of illness, generated by PHS patients over 15 years of age seeking medical care during 2005–06. Main outcome measures: Prevalences of chronic diseases estimated on the basis of medically examined cases registered in ECRPC and morbidity as reported by a contemporary health survey covering the same geographic area.

Results. A total of 52.5% of the adult population had some chronic health problem. The highest overall prevalences were hypertension (14.8%), mental disorders (12.0%) and allergy (11.6%). Prevalences were generally highest among women, elderly and the native population. Depending on the specific disease, ECRPC-based prevalences were similar to (e.g. diabetes), higher (e.g. chronic skin problems) or lower (e.g. asthma and dyslipidaemia) than those reported by surveys, with certain age- and sex-related variations.

Conclusions. Prevalences estimated from ECRPC and survey data present variations depending on the disease, age and sex. Both data sources provide complementary information about chronic disease prevalence. ECRPC have the advantage of generating an ongoing standardized register and entailing no additional effort for health professionals.

Methods. Prospective cohort study in general practice of patients presenting with a new UC. Data sources were case record forms, patient questionnaires and electronic medical registries at inclusion, 1, 6 and 12 months. Presence of complaints and diagnoses made over time were documented. Potential risk factors were assessed in mixed-effect logistic and linear regression models.

Results. Sixty-three GPs included 444 patients (73% women; median age 42) with unexplained fatigue (70%), abdominal complaints (14%) and musculoskeletal complaints (16%). At 12 months, 43% of the patients suffered from their initial complaints. Fifty-seven percent of the UCs remained unexplained. UCs had (non-life-threatening) somatic origins in 18% of the patients. QoL was often poor at presentation and tended to remain poor. Being a male [odds ratio (OR) 0.6; 95% confidence interval (CI) 0.4–0.8] and GPs’ being more certain about the absence of serious disease (OR 0.9; 95% CI 0.8–0.9) were the strongest predictors of a diminished probability that the complaints would still be present and unexplained after 12 months. The strongest determinants of complaint persistence [regardless of (un)explicability] were duration of complaints >4 weeks before presentation (OR 2.6; 95% CI 1.6–4.3), musculoskeletal complaint at baseline (OR 2.3; 1.2–4.5), while the passage of time acted positively (OR 0.8 per month; 95% CI 0.78–0.84). Musculoskeletal complaints, compared to fatigue, decreased QoL on the physical domain (4.6 points; 2.6–6.7), while presence of psychosocial factors decreased mental QoL (5.0; 3.1–6.9).

Conclusion. One year after initial presentation, a large proportion of newly presented UCs remained unexplained and unresolved. We identified determinants that GPs might want to consider in the early detection of patients at risk of UC persistence and/or low QoL.

Methods. Single-blinded randomized trial among all GPs in Copenhagen Municipality from 1 November 2006 to 1 May 2007.

Results. A total of 15 of 320 GPs (4.7%) had a web-based logon during the study period. The intervention group had a significantly increased frequency of web-based logons (P = 0.0192) equivalent to a hazard ratio of 8.0 (95% CI: 1.03–66.1; P = 0.047). NNT was calculated to 22.2. We could not detect any significant differences in any of the secondary outcomes.

Conclusions. Three reminder letters added to a nation-wide dissemination increased the probability for a GP logon in the ELP by a Factor 8. However, in total, only a small proportion used the ELP. Thus, further research is needed in order to consider future implementation strategies for Internet-based Continuous Medical Education activities among not primed GPs.

Objective. To examine the practices that surround euthanasia, particularly among vulnerable patients, using qualitative observation-based data.

Methods. A 15-month qualitative, observation-based study of home death and general practice in the greater Amsterdam region of The Netherlands. Study included observation and interviews with a sample of 15 (GPs and 650 of their patients, 192 of whom were living with terminal or life-threatening illness (with and without requests for euthanasia).

Results. Euthanasia practice typically involves extensive deliberations, the majority of which do not end in a euthanasia death. Euthanasia discussions or ‘euthanasia talk’ share at least two consequences: (i) the talk puts the onus on patients to continue discussions towards a euthanasia death and (ii) there is a socio-therapeutic component, which tends to affirm social bonds and social life.

Conclusion. While this qualitative evidence cannot disprove existence of abuse, it suggests that euthanasia practices have evolved in such a way that patients are more likely to talk about euthanasia than to die a euthanasia death.

Objective. Data from 2003 were analysed independently to reveal how often and in what way palliative sedation and euthanasia were discussed.

Methods. The telephone documentation forms and corresponding evaluation forms of two GP advisors were systematically analysed for problems relating to the role of sedation and/or euthanasia both quantitatively and qualitatively.

Results. In 87 (21%) of 415 analysed consultations, sedation and/or euthanasia were discussed either as the presenting question (sedation 26 times, euthanasia 37 times and both 10 times) or arising during discussion (sedation 11 times and euthanasia three times). Qualitative analysis revealed that GPs telephoned to explore therapeutic options and/or wanted specific information. Pressure on the GP (either internal or external) to relieve suffering (including shortening life by euthanasia) had often precipitated the call. On evaluation, 100% of the GPs reported that the advice received was of value in the patient's care.

Conclusion. GPs caring for patients dying at home encountered complex clinical dilemmas in end-of-life care (including palliative sedation therapy and euthanasia). They valued practical advice from, and open discussion with, GP advisors. The advice often helped the GP find solutions to the patient's problems that did not require deliberately foreshortening life.

Objective. To compare parental experiences and opinions regarding the management of AOM in children with AOM in Finland and The Netherlands.

Methods. We sent the questionnaires via public day care in Turku, Finland, and Utrecht, The Netherlands. We asked about family background, child's history of AOM and parental experiences and attitudes about AOM treatment and antimicrobial resistance.

Results. Of 1151 participants, 83% in Finland and 49% in The Netherlands had had at least one episode of AOM. Antibiotics were used more frequently in Finland than in The Netherlands, 99% versus 78%, respectively. More Finnish parents reported to believe that antibiotics are necessary in the treatment of AOM as compared to Dutch parents. Use of analgesics for AOM was similar (80% in Finland and 86% in The Netherlands). One-third of the parents had discussed resistance with their doctor. According to parental experiences, antimicrobial resistance had caused more problems in Finland than in The Netherlands (20% versus 2%). Finally, 88% of parents in Finland and 65% in The Netherlands were worried that bacteria could become resistant to antibiotics.

Conclusions. Treatment practices and parental expectations seem to interact with each other. Therefore, if we aim to change AOM treatment practices, we have to modify both guidelines and parental expectations.

Objectives. To describe demographic, behavioural and clinical characteristics of young women accessing services through FHP in Vitória, Brazil.

Methods. From March to December 2006, women aged 18–29 years were recruited into a population-based, household survey. Responses were analysed to assess previous 6 months utilization of FHP services in this population and characteristics associated with accessing care through this public family practice model.

Results. Of 1200 eligible women identified, 1029 enrolled (85.7%). Median age was 23 (interquartile range 20–26) years, 42.7% were married or cohabitating with a male partner. A majority (72%) accessed FHP services in the preceding 6 months, principally for routine and gynaecological visits. Factors independently associated with seeking FHP included: ever tested for human immunodeficiency virus, using anal sex as contraceptive method and reporting a current vaginal discharge. Prior commercial sex work, previous diagnosis with an sexually transmitted infection or using oral sex as a contraceptive method were associated with less use of FHP services.

Conclusions. A public option for delivery of FHP has attracted wide utilization across a cross-section of young women in Vitoria, Brazil. Greater sensitization to specific practices and needs of this population, especially around reproductive health, could further enhance the services provided by family practitioners.

Objective. We aimed to explore GPs’ experiences with lonely patients. We wanted to gain insight in GPs’ feelings regarding consultations with lonely patients and potential resulting behaviour from these feelings.

Methods. We performed a qualitative study based on semi-structured interviews. We interviewed 20 Dutch GPs. Transcripts were analysed according to a grounded theory-like method in order to bring to surface key concepts and relations between them.

Results. GPs considered loneliness as something subjective, a feeling. They found it relevant to know whether their patients were lonely. However, they had difficulty defining their task and experienced a lack of therapeutic options. Beside feelings of pity and interest, lonely patients could evoke feelings of frustration and powerlessness. These feelings were more pronounced when patients were chronically lonely and could cause GPs to spend less time on these patients or refer them more often. GPs did not constructively use their own emotions during consultation.

Conclusions. When confronted with lonely patients, a helpful distinction could be made between transitory and chronic loneliness. Chronically lonely patients are more likely to evoke negative feelings and behaviour in their GPs. GPs should try to recognize these emotions and make sure they do not harmfully influence consultation.

Objective. To compare US and UK practices on P4P measures prior to program implementation.

Methods. We analysed medical record data collected before QOF implementation from randomly selected patients with diabetes or coronary artery disease (CAD) in 42 UK and 55 US family medicine practices. We compared care processes and intermediate outcomes using hierarchical logistic regression.

Results. While we found gaps in chronic illness care quality across both samples, variation was lower in UK practices. UK patients were more likely to receive recommended care processes for diabetes [odds ratio (OR), 8.94; 95% confidence interval (CI), 4.26–18.74] and CAD (OR, 9.18; 95% CI, 5.22–16.17) but less likely to achieve intermediate diabetes outcome targets (OR, 0.50; 95% CI, 0.39–0.64).

Conclusions. Following National Health Service (NHS) investment in primary care preparedness, but prior to the QOF, UK practices provided more standardized care but did not achieve better intermediate outcomes than a sample of typical US practices. US policymakers should focus on reducing variation in care documentation to ensure the effectiveness of P4P efforts while the NHS should focus on moving from process documentation to better patient outcomes.

Objective. To examine the relation of three levels of HL (i.e. functional, communicative and critical HL) to patient–physician information exchange during a visit.

Methods. Participants were 134 outpatients with type 2 diabetes who were under continuous care by four attending physicians at a university-affiliated hospital. The visit communication was recorded and analysed using the Roter Interaction Analysis System. Patient HL was measured through a self-reported questionnaire using newly developed self-rated scales of functional, communicative and critical HL. Sociodemographic and clinical characteristics and patient's perception of the information exchange were assessed for each patient through self-reported questionnaires and review of electronic medical records.

Results. Patient HL levels were related to the information exchange process during the visit. Among the three HL scales, communicative HL (the capacity to extract information, derive meaning from different forms of communication and apply new information to changing circumstances) was related to patient's perceptions of the information exchange. Further, patient communicative HL had a modifying effect on the relationship between physician's information giving and patient's perception of it, suggesting that physician's communication may be perceived differently depending on the patient's HL.

Conclusion. The exploration of patient HL may provide a better understanding of potential barriers to patient–physician communication and patient's self-management of disease.

Methods. We performed three separate studies: (i) interviews plus a Delphi consensus procedure with FPs experienced in using pulse oximetry to elucidate indications for pulse oximetry; (ii) analysis of SpO₂ and clinical data in COPD patients who presented to FPs with deteriorating symptoms and (iii) analysis of SpO₂, spirometry and clinical data in patients with stable COPD.

Results. Interviewed FPs (n = 11) used their pulse oximeter for a range of acute (14) and non-acute (11) indications but valued it highest in acute (worsening of) dyspnoea, in suspected respiratory insufficiency/failure and in patients with COPD. In 88 patients with deteriorating COPD, 22% showed SpO₂ ≤92%. Correlation between baseline forced expiratory volume in 1 second % predicted and SpO₂ in patients presenting with acute COPD exacerbations was r = 0.55 (P = 0.001). In 207 patients with stable COPD, 6.3% showed SpO₂ values ≤92%. SpO₂ values were associated with Medical Research Council dyspnoea scores (P = 0.019).

Conclusions. FPs report a wide range of indications for pulse oximetry in acute as well as non-acute situations. In COPD, pulse oximetry appears to be especially useful in patients with severe disease and worsening of symptoms. Pulse oximetry may have a role in the monitoring of patients with COPD with exercise-related dyspnoea.

Methods. This feasibility study used a randomized controlled trial design where participating pharmacies were randomized into two groups (SP or PE, feedback). SP visits were audiotaped and questionnaire data collected from participants post-intervention. Each pharmacy received three covert visits from SPs. Feedback was provided immediately after the first and second visits. Data were collected on information gathering and advice provision. The visits were assessed for minimum standards of practice and appropriateness of outcome.

Results. Twenty-two pharmacists and 34 medicine counter assistants (MCAs) from 20 community pharmacies in Grampian, Scotland, participated. Sixty SP visits were completed (three per pharmacy) and were well received, particularly by the pharmacists. Similar results were shown across both study groups in terms of information gathering and information/advice provision during consultations. Few SP consultations achieved the minimum standard of practice although most resulted in an appropriate outcome.

Conclusions. SP visits with feedback were acceptable to pharmacists as a method of improving the quality of consultations for OTC medicines, irrespective of the person giving feedback (SP or PE). The process by which pharmacists and their staff derived their recommendations, in terms of information gathering, could be improved. A large-scale study is needed to assess the effectiveness and cost-effectiveness of SP visits with feedback.