How time consuming are general practitioners' home visits? Insights from a cross-sectional study in Switzerland.

BACKGROUND: Worldwide, the number of home visits has been decreasing over past decades. Lack of time and long journeys have been reported to hinder general practitioners (GPs) from conducting home visits. In Switzerland also, home visits have declined. Time constraints in a busy GP practice could be one reason. Therefore, the aim of this study was to analyse the time requirements of home visits in Switzerland. METHODS: A one-year cross-sectional study involving GPs from the Swiss Sentinel Surveillance System (Sentinella) was conducted in 2019. GPs provided basic information on all home visits performed throughout the year and additionally detailed reports of up to 20 consecutive home visits. Univariable and multivariable logistic regression analyses were run to identify factors affecting journey and consultation duration. RESULTS: In total, 95 GPs conducted 8489 home visits in Switzerland, 1139 of which have been characterised in detail. On average, GPs made 3.4 home visits per week. Average journey and consultation duration were 11.8 and 23.9 minutes, respectively. Prolonged consultations were provided by GPs working part-time (25.1 minutes), in group practice (24.9 minutes) or in urban regions (24.7 minutes). Rural environments and short journey to patient's home were both found to lower the odds of performing a long consultation compared to a short consultation (odds ratio [OR] 0.27, 95% confidence interval [CI] 0.16-0.44 and OR 0.60, 95% CI 0.46-0.77, respectively). Emergency visits (OR 2.20, 95% CI 1.21-4.01), out-of-hours appointments (OR 3.06, 95% CI 2.36-3.97) and day care involvement (OR 2.78, 95% CI 2.13-3.62) increased the odds of having a long consultation. Finally, patients in their 60s had markedly higher odds of receiving long consultations than patients in their 90s (OR 4.13, 95% CI 2.27-7.62), whereas lack of chronic conditions lowered the odds of a long consultation (OR 0.09, 95% CI 0.00-0.43). CONCLUSION: GPs perform rather few but long home visits, especially for multimorbid patients. GPs working part-time, in group practice or in urban regions devote more time to home visits.

Improvement Strategies for the Challenging Collaboration of General Practitioners and Specialists for Patients with Complex Chronic Conditions: A Scoping Review.

Introduction: Coordination of healthcare professionals seems to be particularly important for patients with complex chronic disease, as they present a challenging interplay of conditions and symptoms. As one solution, to counteract or prevent this, improving collaboration between general practitioners (GPs) and specialists has been the aim of studies by linking or coordinating their services along the continuum of care. This scoping review summarises role distributions and components of this collaboration that have potential for improvement for the care of patients with complex chronic conditions. Methods: Scoping review as a knowledge synthesis for components of collaboration and role distributions between medical specialists and GPs in intervention studies. The PubMed database was searched for literature from 2010-2020. Results: Literature search and reference screening generated 2,174 articles. 30 articles originating from 22 unique projects were included in our synthesis. In the interventions to improve collaboration, the GP is most commonly in charge of patient management and extends the scope of practice. The specialist provides support when needed. Clear definition of roles, resources for knowledge transfer and education from specialists are commonly utilised interventions. Typically, combinations of process and system changes addressing communication and coordination issues are applied. Most interventions improve provider and patient satisfaction, health outcomes, and reduce care fragmentation. Conclusion: This review showed that interventions to improve collaboration between GPs and medical specialists seem promising. Further efforts should be made to test and apply the findings systematically in broad clinical practice.

Role distribution and collaboration between specialists and rural general practitioners in long-term chronic care: a qualitative study in Switzerland.

INTRODUCTION: This study explores general practitioners' (GPs') and medical specialists' perceptions of role distribution and collaboration in the care of patients with chronic conditions, exemplified by spinal cord injury. METHODS: Semi-structured interviews with GPs and medical specialists caring for individuals with spinal cord injury in Switzerland. The physicians we interviewed were recruited as part of an intervention study. We used a hybrid framework of inductive and deductive coding to analyse the qualitative data. RESULTS: Six GPs and six medical specialists agreed to be interviewed. GPs and specialists perceived the role of specialists similarly, namely as an expert and support role for GPs in the case of specialised questions. Specialists' expectations of GP services and what GPs provide differed. Specialists saw the GPs' role as complementary to their own responsibilities, namely as the first contact for patients and gatekeepers to specialised services. GPs saw themselves as care managers and guides with a holistic view of patients, connecting several healthcare professionals. GPs were looking for relations and recognition by getting to know specialists better. Specialists viewed collaboration as somewhat distant and focused on processes and patient pathways. Challenges in collaboration were related to unclear roles and responsibilities in patient care. CONCLUSION: The expectations for role distribution and responsibilities differ among physicians. Different goals of GPs and specialists for collaboration may jeopardise shared care models. The role distribution should be aligned according to patients' holistic needs to improve collaboration and provide appropriate patient care.

Frequency of home visits where general practitioners are exposed to a problem different from that foreseen - a Swiss cross-sectional study.

BACKGROUND: When a home visit is considered, patients' suspected health problems are important for correct triage, the decision for or against the visit and allocation of the visit to a general practitioner (GP) or a nurse practitioner. Misjudgment might lead to suboptimal patient outcomes. OBJECTIVE: We aimed to evaluate the accuracy of suspected health problems (based on pre-visit assessments) by comparing them with the actual health problems (post-visit assessments) and investigating associated factors. METHODS: GPs of the Swiss Sentinel Surveillance Network (Sentinella) reported pre-visit and post-visit assessments and patient characteristics for up to 20 consecutive home visits, which they conducted in 2019. Using multivariable logistic regressions, we investigated associations between patient and clinical factors and unconfirmed suspected health problems from pre-visit assessments and unforeseen actual health problems from post-visit assessments. RESULTS: Overall, 114 GP practices participated. The GPs reported 1496 patient visits with a total of 1789 and 1762 health problems from pre-visit and post-visit assessments, respectively, that were included in the analysis. Musculoskeletal and circulatory problems were the most common in patients receiving home visits. The health problems from pre-visit and post-visit assessments were unconfirmed and unforeseen in15% and 13% of the cases, respectively. Older age (odds ratio [OR] 1.1 in 10-year steps; 95% confidence interval [95% CI] 1.0-1.3) and urgent visits (OR 1.7 compared with regular visits; 95% CI 1.1-2.6) showed a trend for more unforeseen health problems. CONCLUSION: When home visits were conducted, about one out of seven health problems from pre-visit and post-visit assessments were unconfirmed and unforeseen. Particularly when patients were older or visits were urgent, there were higher odds of unconfirmed and unforeseen health problems.These results should be considered when triaging patients.

Treating insomnia in Swiss primary care practices: A survey study based on case vignettes.

Guidelines recommend cognitive behavioural therapy for insomnia (CBT-I) as first-line treatment for chronic insomnia, but it is not clear how many primary care physicians (PCPs) in Switzerland prescribe this treatment. We created a survey that asked PCPs how they would treat chronic insomnia and how much they knew about CBT-I. The survey included two case vignettes that described patients with chronic insomnia, one with and one without comorbid depression. PCPs also answered general questions about treating chronic insomnia and about CBT-I and CBT-I providers. Of the 820 Swiss PCPs we invited, 395 (48%) completed the survey (mean age 54 years; 70% male); 87% of PCPs prescribed sleep hygiene and 65% phytopharmaceuticals for the patient who had only chronic insomnia; 95% prescribed antidepressants for the patient who had comorbid depression. In each case, 20% of PCPs prescribed benzodiazepines or benzodiazepine receptor agonists, 8% prescribed CBT-I, 68% said they knew little about CBT-I, and 78% did not know a CBT-I provider. In the clinical case vignettes, most PCPs treated chronic insomnia with phytopharmaceuticals and sleep hygiene despite their lack of efficacy, but PCPs rarely prescribed CBT-I, felt they knew little about it, and usually knew no CBT-I providers. PCPs need more information about the benefits of CBT-I and local CBT-I providers and dedicated initiatives to implement CBT-I in order to reduce the number of patients who are prescribed ineffective or potentially harmful medications.

Effect of a patient-centred deprescribing procedure in older multimorbid patients in Swiss primary care - A cluster-randomised clinical trial.

BACKGROUND: Management of patients with polypharmacy is challenging, and evidence for beneficial effects of deprescribing interventions is mixed. This study aimed to investigate whether a patient-centred deprescribing intervention of PCPs results in a reduction of polypharmacy, without increasing the number of adverse disease events and reducing the quality of life, among their older multimorbid patients. METHODS: This is a cluster-randomised clinical study among 46 primary care physicians (PCPs) with a 12 months follow-up. We randomised PCPs into an intervention and a control group. They recruited 128 and 206 patients if ≥60 years and taking ≥five drugs for ≥6 months. The intervention consisted of a 2-h training of PCPs, encouraging the use of a validated deprescribing-algorithm including shared-decision-making, in comparison to usual care. The primary outcome was the mean difference in the number of drugs per patient (dpp) between baseline and after 12 months. Additional outcomes focused on patient safety and quality of life (QoL) measures. RESULTS: Three hundred thirty-four patients, mean [SD] age of 76.2 [8.5] years participated. The mean difference in the number of dpp between baseline and after 12 months was 0.379 in the intervention group (8.02 and 7.64; p = 0.059) and 0.374 in the control group (8.05 and 7.68; p = 0.065). The between-group comparison showed no significant difference at all time points, except for immediately after the intervention (p = 0.002). There were no significant differences concerning patient safety nor QoL measures. CONCLUSION: Our straight-forward and patient-centred deprescribing procedure is effective immediately after the intervention, but not after 6 and 12 months. Further research needs to determine the optimal interval of repeated deprescribing interventions for a sustainable effect on polypharmacy at mid- and long-term. Integrating SDM in the deprescribing process is a key factor for success. TRIAL REGISTRATION: Current Controlled Trials, prospectively registered ISRCTN16560559 Date assigned 31/10/2014. The Prevention of Polypharmacy in Primary Care Patients Trial (4P-RCT).

Potentially inappropriate testing for vitamin D deficiency: a cross-sectional study in Switzerland.

BACKGROUND: There is consensus that vitamin D supplementation is often indicated but population-based screening by laboratory testing for vitamin D deficiency is inadequate. Testing should be restricted to people at high risk of severe deficiency. This study describes the current lab testing for vitamin D deficiency in the adult population of Switzerland. METHODS: We assessed Swiss health insurance data (SWICA) for incidence of lab testing for vitamin D levels, comparing the years 2015 and 2018. Claims were analyzed for associations between lab testing and age, sex, medical indications, insurance status and geographic location in multivariable regression analyses. We also estimated the costs of vitamin D testing. RESULTS: Data from 200,043 and 200,046 persons for 2015 and 2018, respectively, were analyzed. Vitamin D level was tested in 14% of the sample population in 2015 and 20% in 2018. Testing increased by 69% for individuals aged 26-30. Testing was associated with being middle-aged to young senior citizens, female, medical indications (pregnancy, renal disease, osteoporosis, hyperparathyroidism, HIV, glucocorticoid intake), more chronic conditions, having a mandatory insurance with a low deductible, additional insurance coverage, and living in urban areas. We estimate that the total laboratory cost to mandatory insurance was about 90 million Swiss francs in 2018. CONCLUSIONS: Despite recommendations for routine vitamin D supplementation, vitamin D testing of low risk individuals is common and increasing in Switzerland.

Oral corticosteroids for post-infectious cough in adults: study protocol for a double-blind randomized placebo-controlled trial in Swiss family practices (OSPIC trial).

BACKGROUND: Cough is a common reason for patients to visit general practices. So-called post-infectious cough is defined as lasting 3 to 8 weeks after an upper respiratory tract infection. It can be disabling in daily activities, with substantial impact on physical and psychosocial health, leading to impaired quality of life and increased health care costs. Recommendations for the management of post-infectious cough in primary care are scarce and incoherent. A systematic review and meta-analysis of randomized clinical trials (RCT) assessing patient-relevant benefits and potential harms of available treatments identified six eligible RCTs assessing different treatment regimens (i.e. inhaled fluticasone propionate, inhaled budesonide, salbutamol plus ipratropium-bromide, montelukast, nociception-opioid-1-receptor agonist, codeine, gelatine). No RCT found clear patient-relevant benefits and most had an unclear or high risk of bias. Post-infectious cough is thought to be mediated by inflammatory processes that are also present in exacerbations of asthma or chronic obstructive pulmonary diseases for which there is strong evidence that oral corticosteroids provide patient-relevant benefit without relevant harm. We therefore plan to conduct the first RCT evaluating the effectiveness of oral corticosteroids for post-infectious cough. METHODS: We are conducting a triple-blinded randomized-controlled and multicentred superiority trial in primary health care practices in Switzerland. We will include 204 adult patients who consult their general practitioner (GP) for a cough lasting 3 to 8 weeks following an upper respiratory tract infection. Participants will be randomly allocated to either the 5-day treatment with oral corticosteroids or placebo. The primary outcome is cough-related quality of life assessed by the Leicester Cough Questionnaire score 14 days after randomization. Secondary outcomes include cough-related quality of life at several time points, overall cessation of cough and adverse events. DISCUSSION: This RCT will provide evidence on whether oral corticosteroids are beneficial and safe in patients with post-infectious cough. Results can have a substantial impact on the well-being and management of these patients in Switzerland and beyond. An evidence-based treatment for this condition may reduce re-consultations with GPs and spending for antitussive drugs, thus possibly having an impact on health care spending. TRIAL REGISTRATION: ClinicalTrials.gov NCT04232449 . Prospectively registered on 18 January 2020.

Patients' experiences with the advanced practice nurse role in Swiss family practices: a qualitative study.

BACKGROUND: Considering shortages of general practitioners (GP) and strategies for improving the quality of health care provision, many countries have implemented interprofessional care models with advanced practice nurses (APN). International evidence suggests that APN care results in high patient satisfaction. In Switzerland, the role is still new, and the patient perspective has not yet been researched. Our aim was therefore to explore patients' experiences with the APN role in Swiss family practices. METHODS: We conducted 22 semi-structured interviews in four different family practices with patients aged 18 to 97 suffering from minor acute to multiple chronic diseases, and who had at least one consultation with an APN. All interviews were audiotaped, transcribed verbatim, and analysed using qualitative content analysis. RESULTS: The analysis resulted in five themes: Despite the unfamiliarity, all patients were willing to be consulted by an APN because it was recommended by their GP (1); after several encounters, most participants perceived differences between the APN and the GP consultation in terms of the length and style of the consultations as well as the complexity of their tasks (2); the interviewees emphasised coaching, guidance, care coordination, and GP-assisting tasks as APN core competencies and attributed the characteristics empathetic, trustworthy, and competent to the APN role (3); most patients especially valued home visits and the holistic approach of the APNs, but they also noticed that in certain cases GP supervision was required (4); and due to the close collaboration between the APN and the GP, patients felt safe, well cared for and experienced improvements in physical and psychological well-being as well as in daily activities (5). CONCLUSION: Our results suggested that patients value the APNs' competencies, despite their initial lack of role knowledge. Trust in the GP seemed to be the most important factor for patients' receptiveness toward the APN role. Overall, patients perceived an added value due to the enlargement of the scope of practice offered by APNs. The patient perspective might provide valuable insights for further APN role implementation in Swiss family practices.

Differences in patient population and service provision between nurse practitioner and general practitioner consultations in Swiss primary care: a case study.

BACKGROUND: Primary care systems around the world have implemented nurse practitioners (NPs) to ensure access to high quality care in times of general practitioner (GP) shortages and changing health care needs of a multimorbid, ageing population. In Switzerland, NPs are currently being introduced, and their exact role is yet to be determined. The aim of this study was to get insight into patient characteristics and services provided in NP consultations compared to GP consultations in Swiss primary care. METHODS: This case study used retrospective observational data from electronic medical records of a family practice with one NP and two GPs. Data on patient-provider encounters were collected between August 2017 and December 2018. We used logistic regression to assess associations between the assignment of the patients to the NP or GP and patient characteristics and delivered services respectively. RESULTS: Data from 5210 patients participating in 27,811 consultations were analyzed. The average patient age was 44.3 years (SD 22.6), 47.1% of the patients were female and 19.4% multimorbid. 1613 (5.8%) consultations were with the NP, and 26,198 (94.2%) with the two GPs. Patients in NP consultations were more often aged 85+ (OR 3.43; 95%-CI 2.70-4.36), multimorbid (OR 1.37; 95%-CI 1.24-1.51; p < 0.001) and polypharmaceutical (OR 1.28; 95%-CI 1.15-1.42; p < 0.001) in comparison to GP consultations. In NP consultations, vital signs (OR 3.05; 95%-CI 2.72-3.42; p < 0.001) and anthropometric data (OR 1.33; 95%-CI 1.09-1.63; p 0.005) were measured more frequently, and lab tests (OR 1.16; 95%-CI 1.04-1.30; p 0.008) were ordered more often compared to GP consultations, independent of patient characteristics. By contrast, medications (OR 0.35; 95%-CI 0.30-0.41; p < 0.001) were prescribed or changed less frequently in NP consultations. CONCLUSIONS: Quantitative data from pilot projects provide valuable insights into NP tasks and activities in Swiss primary care. Our results provide first indications that NPs might have a focus on and could offer care to the growing number of multimorbid, polypharmaceutical elderly in Swiss primary care.

The use of ultrasound in primary care: longitudinal billing and cross-sectional survey study in Switzerland.

BACKGROUND: Ultrasound imaging is utilized in Swiss primary care; however, little is known regarding the extent to which it is performed. With this study, we aim to (1) provide an overview of ultrasound use by general practitioners (GPs), and (2) determine the clinical indications of ultrasound in Swiss general practice. METHODS: This is a quantitative study, analyzing 15 years of billing data from 213 GPs in Central Switzerland, and cross-sectional survey data completed by 61 GPs attending 26 certification and refresher courses offered by the Swiss Society of Ultrasound in Medicine (SGUM). RESULTS: According to billing data, 49% of the GPs used ultrasound and provided 130,245 exams to 67,180 patients between 2004 and 2018. Over the years, ultrasound use became more frequent among GPs. Male GPs provide more ultrasound exams than female GPs. Patients that are female, ≥65 years, and multi-morbid had more ultrasound exams compared to males, patients < 65 years, and those with only one morbidity, respectively. GPs provided a mean of 129 ultrasound exams per physician-year. Abdominal ultrasound comprised almost 69% of all exams. According to survey data, indications covered many organ systems and clinical conditions, with abdominal indications being most frequent among them. CONCLUSIONS: The use of ultrasound is high among general practitioners and it covers a wide range of clinical indications. Ultrasound is utilized primarily in the diagnosis of clinical indications of the abdomen, and more often for female than male patients.

Prevalence and management of chronic insomnia in Swiss primary care: Cross-sectional data from the "Sentinella" practice-based research network.

We investigated the prevalence and treatment of patients with chronic insomnia presenting to Swiss primary care physicians (PCPs) part of "Sentinella", a nationwide practice-based research network. Each PCP consecutively asked 40 patients if they had sleep complaints, documented frequency, duration, comorbidities, and reported ongoing treatment. We analysed data of 63% (83/132) of the PCPs invited. The PCPs asked 76% (2,432/3,216) of included patients about their sleep (51% female); 31% (761/2,432) of these had had insomnia symptoms; 36% (875/2,432) had current insomnia symptoms; 11% (269/2,432) met the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria for chronic insomnia (61% female). In all, 75% (201/269) of patients with chronic insomnia had comorbidities, with 49% (99/201) reporting depression. Chronic insomnia was treated in 78% (209/269); 70% (188/268) took medication, 38% (102/268) benzodiazepines or benzodiazepine receptor agonists, 32% (86/268) took antidepressants. Only 1% (three of 268) had been treated with cognitive behavioural therapy for insomnia (CBT-I). A third of patients presenting for a non-urgent visit in Swiss primary care reported insomnia symptoms and 11% met the DSM-5 criteria for chronic insomnia. Hypnotics were the most common treatment, but almost no patients received first-line CBT-I. Reducing the burden of insomnia depends on disseminating knowledge about and access to CBT-I, and encouraging PCPs to discuss it with and offer it as a first-line treatment to patients with chronic insomnia.

Complexity as a factor for task allocation among general practitioners and nurse practitioners: a narrative review.

BACKGROUND: General practitioner (GP) shortages and increasing demand for care led to the introduction of nurse practitioners (NPs) to primary care. Many concepts for task sharing among health professionals feature complexity. The aim of this narrative review was to examine how complexity is used as a factor for task allocation between GPs and NPs. METHODS: According to the PRISMA statement, PubMed and CINAHL were searched systematically, and eligibility criteria were applied to detect literature concerning GPs and NPs in primary care and complexity in the context of task allocation. Relevant information was extracted, and a narrative analysis was performed. RESULTS: Thirty-seven studies from seven countries were included, comprising quantitative, qualitative, and mixed methods. Complexity was used to describe patients, their needs, and health professionals' tasks. The understanding of the use of complexity as a factor for task allocation between NPs and GPs was based on the patient population (specific vs. unspecific), the setting (specific vs. unspecific), the numbers of health professionals involved (two vs. more than two), and the NP role (distinct model of care vs. no model). Despite similarities in these areas, the tasks which NPs perform range from providing minor to complex care. However, there is a slight trend towards NPs treating socially complex patients and GPs focusing on medically complex cases. CONCLUSION: Complexity as a concept is prominent in primary care but remains broad and inconsistent as a factor for task allocation between NPs and GPs. This review can be used as a point of reference when practitioners are seeking methods for task allocation in a collaborative primary care setting.

Reduction of corticosteroid use in outpatient treatment of exacerbated COPD - Study protocol for a randomized, double-blind, non-inferiority study, (The RECUT-trial).

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a major public health issue affecting approximately 4% to 7% of the Swiss population. According to current inpatient guidelines, systemic corticosteroids are important in the treatment of acute COPD exacerbations and should be given for 5 to 7 days. Several studies suggest that corticosteroids accelerate the recovery of FEV1 (forced expiratory volume in 1 second), enhance oxygenation, decrease the duration of hospitalization, and improve clinical outcomes. However, the additional therapeutic benefit regarding FEV1 recovery appears to be most apparent in the first 3 to 5 days. No data are available on the optimum duration of corticosteroid treatment in primary-care patients with acute COPD exacerbations. Given that many COPD patients are treated as outpatients, there is an urgent need to improve the evidence base on COPD management in this setting. The aim of this study is to investigate whether a 3-day treatment with orally administered corticosteroids is non-inferior to a 5-day treatment in acute exacerbations of COPD in a primary-care setting. METHODS/DESIGN: This study is a prospective double-blind randomized controlled trial conducted in a primary-care setting. It is anticipated that 470 patients with acutely exacerbated COPD will be recruited. Participants are randomized to receive systemic corticosteroid treatment of 40 mg prednisone daily for 5 days (conventional arm, n = 235) or for 3 days followed by 2 days of placebo (experimental arm, n = 235). Antibiotic treatment for 7 days is given to all patients with CRP ≥ 50 mg/l, those with a known diagnosis of bronchiectasis, or those presenting with Anthonisen type I exacerbation. Additional treatment after inclusion is left at the discretion of the treating general practitioner. Follow-up visits are performed on days 3 and 7, followed by telephone interviews on days 30, 90, and 180 after inclusion in the study. The primary endpoint is the time to next exacerbation during the 6-month follow-up period. DISCUSSION: The study is designed to assess whether a 3-day course of corticosteroid treatment is not inferior to the conventional 5-day treatment course in outpatients with exacerbated COPD regarding time to next exacerbation. Depending on the results, this trial may lead to a reduction in the cumulative corticosteroid dose in COPD patients. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02386735. Registered on 12 March 2015.

General practitioners' willingness to participate in research: A survey in central Switzerland.

It is difficult to enlist the participation of medical general practitioners (GPs) in research studies. We aimed to determine the willingness of GPs in central Switzerland to participate in research, and to identify factors that facilitate or hinder research participation by GPs. To that end, we conducted a postal questionnaire survey of all 268 active GPs in the canton of Lucerne. The survey explored their interest in participating in research projects (yes/no) and factors that potentially influence their participation (5-point Likert scale from "very important" to "not at all important"). We contacted all non-responders by phone. Background information of the GPs was retrieved from the database of the cantonal association of physicians. Associations between willingness to participate in research and GP's age, gender, type and location of practice, and the perceived relevance of facilitators were investigated via multiple logistic regression. Out of 268 GPs, 115 (43%) agreed to be contacted for future research projects. Willingness was associated with age (willing: 55% ≤ 40 y vs. 33% > 60 y) and gender (44% male vs. 38% female), and to some degree with the type of practice (50% group vs. 31% single), and location (46% urban vs. 38% rural), independently from each other. Scientists should develop methods to motivate and support GPs in single and rural practices to participate so research is representative of primary care as a whole.

Patient Characteristics and General Practitioners' Advice to Stop Statins in Oldest-Old Patients: a Survey Study Across 30 Countries.

BACKGROUND: Statins are widely used to prevent cardiovascular disease (CVD). With advancing age, the risks of statins might outweigh the potential benefits. It is unclear which factors influence general practitioners' (GPs) advice to stop statins in oldest-old patients. OBJECTIVE: To investigate the influence of a history of CVD, statin-related side effects, frailty and short life expectancy, on GPs' advice to stop statins in oldest-old patients. DESIGN: We invited GPs to participate in this case-based survey. GPs were presented with 8 case vignettes describing patients > 80 years using a statin, and asked whether they would advise stopping statin treatment. MAIN MEASURES: Cases varied in history of CVD, statin-related side effects and frailty, with and without shortened life expectancy (< 1 year) in the context of metastatic, non-curable cancer. Odds ratios adjusted for GP characteristics (ORadj) were calculated for GPs' advice to stop. KEY RESULTS: Two thousand two hundred fifty GPs from 30 countries participated (median response rate 36%). Overall, GPs advised stopping statin treatment in 46% (95%CI 45-47) of the case vignettes; with shortened life expectancy, this proportion increased to 90% (95CI% 89-90). Advice to stop was more frequent in case vignettes without CVD compared to those with CVD (ORadj 13.8, 95%CI 12.6-15.1), with side effects compared to without ORadj 1.62 (95%CI 1.5-1.7) and with frailty (ORadj 4.1, 95%CI 3.8-4.4) compared to without. Shortened life expectancy increased advice to stop (ORadj 50.7, 95%CI 45.5-56.4) and was the strongest predictor for GP advice to stop, ranging across countries from 30% (95%CI 19-42) to 98% (95% CI 96-99). CONCLUSIONS: The absence of CVD, the presence of statin-related side effects, and frailty were all independently associated with GPs' advice to stop statins in patients aged > 80 years. Overall, and within all countries, cancer-related short life expectancy was the strongest independent predictor of GPs' advice to stop statins.

Burden of cardiovascular disease across 29 countries and GPs' decision to treat hypertension in oldest-old.

OBJECTIVES: We previously found large variations in general practitioner (GP) hypertension treatment probability in oldest-old (>80 years) between countries. We wanted to explore whether differences in country-specific cardiovascular disease (CVD) burden and life expectancy could explain the differences. DESIGN: This is a survey study using case-vignettes of oldest-old patients with different comorbidities and blood pressure levels. An ecological multilevel model analysis was performed. SETTING: GP respondents from European General Practice Research Network (EGPRN) countries, Brazil and New Zeeland. SUBJECTS: This study included 2543 GPs from 29 countries. MAIN OUTCOME MEASURES: GP treatment probability to start or not start antihypertensive treatment based on responses to case-vignettes; either low (<50% started treatment) or high (≥50% started treatment). CVD burden is defined as ratio of disability-adjusted life years (DALYs) lost due to ischemic heart disease and/or stroke and total DALYs lost per country; life expectancy at age 60 and prevalence of oldest-old per country. RESULTS: Of 1947 GPs (76%) responding to all vignettes, 787 (40%) scored high treatment probability and 1160 (60%) scored low. GPs in high CVD burden countries had higher odds of treatment probability (OR 3.70; 95% confidence interval (CI) 3.00-4.57); in countries with low life expectancy at 60, CVD was associated with high treatment probability (OR 2.18, 95% CI 1.12-4.25); but not in countries with high life expectancy (OR 1.06, 95% CI 0.56-1.98). CONCLUSIONS: GPs' choice to treat/not treat hypertension in oldest-old was explained by differences in country-specific health characteristics. GPs in countries with high CVD burden and low life expectancy at age 60 were most likely to treat hypertension in oldest-old. Key Points • General practitioners (GPs) are in a clinical dilemma when deciding whether (or not) to treat hypertension in the oldest-old (>80 years of age). • In this study including 1947 GPs from 29 countries, we found that a high country-specific cardiovascular disease (CVD) burden (i.e. myocardial infarction and/or stroke) was associated with a higher GP treatment probability in patients aged >80 years. • However, the association was modified by country-specific life expectancy at age 60. While there was a positive association for GPs in countries with a low life expectancy at age 60, there was no association in countries with a high life expectancy at age 60. • These findings help explaining some of the large variation seen in the decision as to whether or not to treat hypertension in the oldest-old.

Variation in GP decisions on antihypertensive treatment in oldest-old and frail individuals across 29 countries.

BACKGROUND: In oldest-old patients (>80), few trials showed efficacy of treating hypertension and they included mostly the healthiest elderly. The resulting lack of knowledge has led to inconsistent guidelines, mainly based on systolic blood pressure (SBP), cardiovascular disease (CVD) but not on frailty despite the high prevalence in oldest-old. This may lead to variation how General Practitioners (GPs) treat hypertension. Our aim was to investigate treatment variation of GPs in oldest-olds across countries and to identify the role of frailty in that decision. METHODS: Using a survey, we compared treatment decisions in cases of oldest-old varying in SBP, CVD, and frailty. GPs were asked if they would start antihypertensive treatment in each case. In 2016, we invited GPs in Europe, Brazil, Israel, and New Zealand. We compared the percentage of cases that would be treated per countries. A logistic mixed-effects model was used to derive odds ratio (OR) for frailty with 95% confidence intervals (CI), adjusted for SBP, CVD, and GP characteristics (sex, location and prevalence of oldest-old per GP office, and years of experience). The mixed-effects model was used to account for the multiple assessments per GP. RESULTS: The 29 countries yielded 2543 participating GPs: 52% were female, 51% located in a city, 71% reported a high prevalence of oldest-old in their offices, 38% and had >20 years of experience. Across countries, considerable variation was found in the decision to start antihypertensive treatment in the oldest-old ranging from 34 to 88%. In 24/29 (83%) countries, frailty was associated with GPs' decision not to start treatment even after adjustment for SBP, CVD, and GP characteristics (OR 0.53, 95%CI 0.48-0.59; ORs per country 0.11-1.78). CONCLUSIONS: Across countries, we found considerable variation in starting antihypertensive medication in oldest-old. The frail oldest-old had an odds ratio of 0.53 of receiving antihypertensive treatment. Future hypertension trials should also include frail patients to acquire evidence on the efficacy of antihypertensive treatment in oldest-old patients with frailty, with the aim to get evidence-based data for clinical decision-making.

Vitamin D Deficiency in Unselected Patients from Swiss Primary Care: A Cross-Sectional Study in Two Seasons.

BACKGROUND: As published data on 25-hydroxy-cholecalciferol (25(OH)D) deficiency in primary care settings is scarce, we assessed the prevalence of hypovitaminosis D, potential associations with clinical symptoms, body mass index, age, Vitamin D intake, and skin type in unselected patients from primary care, and the extent of seasonal variations of serum 25(OH)D concentrations. METHODOLOGY/PRINCIPAL FINDINGS: 25(OH)D was measured at the end of summer and/or winter in 1682 consecutive patients from primary care using an enzyme-linked immunosorbant assay. Clinical symptoms were assessed by self-report (visual analogue scale 0 to 10), and vitamin D deficiency was defined as 25(OH)D concentrations < 50 nmol/l. 25(OH)D deficiency was present in 995 (59.2%) patients. 25(OH)D deficient patients reported more intense muscle weakness (visual analogue scale 2.7, 95% confidence interval 2.5 to 2.9) and had a higher body mass index (25.9kg/m2, 25.5 to 26.2) than non-deficient patients (2.5, 2.3 to 2.7; and 24.2, 23.9 to 24.5, respectively). 25(OH)D concentrations also weakly correlated with muscle weakness (Spearman's rho -0.059, 95% confidence interval -0.107 to -0.011) and body mass index (-0.156, -0.202 to -0.108). Self-reported musculoskeletal pain, fatigue, and age were not associated with deficiency, nor with concentrations. Mean 25(OH)D concentrations in patients with vitamin D containing medication were higher (60.6 ± 22.2 nmol/l) than in patients without medication (44.8 ± 19.2 nmol/l, p < 0.0001) but still below the targeted level of 75 nmol/l. Summer and winter 25(OH)D concentrations differed (53.4 ± 19.9 vs. 41.6 ± 19.3nmol/l, p < 0.0001), which was confirmed in a subgroup of 93 patients who were tested in both seasons (p = 0.01). CONCLUSION/SIGNIFICANCE: Nearly 60% of unselected patients from primary care met the criteria for 25(OH)D deficiency. Self-reported muscle weakness and high body mass index were associated with lower 25(OH)D levels. As expected 25(OH)D concentrations were lower in winter compared to summer.