Investigating Patient Use and Experience of Online Appointment Booking in Primary Care: Mixed Methods Study.

BACKGROUND: Online appointment booking is a commonly used tool in several industries. There is limited evidence about the benefits and challenges of using online appointment booking in health care settings. Potential benefits include convenience and the ability to track appointments, although some groups of patients may find it harder to engage with online appointment booking. We sought to understand how patients in England used and experienced online appointment booking. OBJECTIVE: This study aims to describe and compare the characteristics of patients in relation to their use of online appointment booking in general practice and investigate patients' views regarding online appointment booking arrangements. METHODS: This was a mixed methods study set in English general practice comprising a retrospective analysis of the General Practice Patient Survey (GPPS) and semistructured interviews with patients. Data used in the retrospective analysis comprised responses to the 2018 and 2019 GPPS analyzed using mixed-effects logistic regression. Semistructured interviews with purposively sampled patients from 11 general practices in England explored experiences of and views on online appointment booking. Framework analysis was used to allow for comparison with the findings of the retrospective analysis. RESULTS: The retrospective analysis included 1,327,693 GPPS responders (2018-2019 combined). We conducted 43 interviews with patients with a variety of experiences and awareness of online appointment booking; of these 43 patients, 6 (14%) were from ethnic minority groups. In the retrospective analysis, more patients were aware that online appointment booking was available (581,224/1,288,341, 45.11%) than had experience using it (203,184/1,301,694, 15.61%). There were deprivation gradients for awareness and use and a substantial decline in both awareness and use in patients aged >75 years. For interview participants, age and life stage were factors influencing experiences and perceptions, working patients valued convenience, and older patients preferred to use the telephone. Patients with long-term conditions were more aware of (odds ratio [OR] 1.43, 95% CI 1.41-1.44) and more likely to use (OR 1.65, 95% CI 1.63-1.67) online appointment booking. Interview participants with long-term conditions described online appointment booking as useful for routine nonurgent appointments. Patients in deprived areas were clustered in practices with low awareness and use of online appointment booking among GPPS respondents (OR for use 0.65, 95% CI 0.64-0.67). Other key findings included the influence of the availability of appointments online and differences in the registration process for accessing online booking. CONCLUSIONS: Whether and how patients engage with online appointment booking is influenced by the practice with which they are registered, whether they live with long-term conditions, and their deprivation status. These factors should be considered in designing and implementing online appointment booking and have implications for patient engagement with the wider range of online services offered in general practice.

Trends in primary care blood tests prior to lung and colorectal cancer diagnosis-A retrospective cohort study using linked Australian data.

INTRODUCTION: Abnormal results in common blood tests may occur several months before lung cancer (LC) and colorectal cancer (CRC) diagnosis. Identifying early blood markers of cancer and distinct blood test signatures could support earlier diagnosis in general practice. METHODS: Using linked Australian primary care and hospital cancer registry data, we conducted a cohort study of 855 LC and 399 CRC patients diagnosed between 2001 and 2021. Requests and results from general practice blood tests (six acute phase reactants [APR] and six red blood cell indices [RBCI]) were examined in the 2 years before cancer diagnosis. Poisson regression models were used to estimate monthly incidence rates and examine pre-diagnostic trends in blood test use and abnormal results prior to cancer diagnosis, comparing patterns in LC and CRC patients. RESULTS: General practice blood test requests increase from 7 months before CRC and 6 months before LC diagnosis. Abnormalities in many APR and RBCI tests increase several months before cancer diagnosis, often occur prior to or in the absence of anaemia (in 51% of CRC and 81% of LC patients with abnormalities), and are different in LC and CRC patients. CONCLUSIONS: This study demonstrates an increase in diagnostic activity in Australian general practice several months before LC and CRC diagnosis, indicating potential opportunities for earlier diagnosis. It identifies blood test abnormalities and distinct signatures that are early markers of LC and CRC. If combined with other pre-diagnostic information, these blood tests have potential to support GPs in prioritising patients for cancer investigation of different sites to expedite diagnosis.

Public health audit of vaccine cold chain management in general practice and community pharmacy in Western Australia.

OBJECTIVE: To support immunisation providers through a cold chain management audit. METHODS: An electronic audit survey using the National Vaccine Storage Guidelines as a gold standard was developed for general practice (GP) and community pharmacy. It included automated feedback, with individualised support from a clinical nurse specialist as required. Responses were analysed to determine the proportion of providers meeting criteria in four categories: procedures, refrigerators and equipment, temperature monitoring and emergency storage. RESULTS: Of 818 providers invited, 420 GPs (89.6%) and 276 pharmacies (82%) responded. Over 70% met all procedural and emergency storage criteria. Although most providers (98.1% GPs, 97.0% pharmacies) used a data logger, the proportion measuring at 5-minute intervals, reviewing data logger printouts weekly and manually recording minimum and maximum temperatures was lower. In total, 58% of providers required follow-up by the clinical nurse specialist, most regarding the need for equipment. CONCLUSION: An electronic audit enabled public health to engage with a large number of immunisation providers. Most reported high compliance with the national guidelines although opportunities for education were identified and actioned. IMPLICATIONS FOR PUBLIC HEALTH: Electronic solutions can support public health units to engage with providers to ensure vaccines remain effective and wastage is limited.

Factors influencing the implementation of the CombiConsultation in Dutch clinical practice: a mixed-methods study.

OBJECTIVE: The CombiConsultation is an innovative concise clinical pharmacy service by the community pharmacist for patients with a chronic condition. We aimed to identify relevant factors influencing the implementation of the CombiConsultation in Dutch clinical practice. METHODS: A mixed-methods study involving interviews and a questionnaire. Content analysis topics within TDF domains were derived from the interview data and were related to the COM-B-model (capability-opportunity-motivation-Behaviour). The relevance of the resulting topics was explored using a questionnaire with 19 statements administered to all 27 pharmacists who performed CombiConsultations. KEY FINDINGS: Eighteen topics emerged from the interviews. The questionnaire was completed by 23 of the 27 pharmacists. In the domain 'capability', a small number of participants indicated that they need more expertise in pharmacotherapy (13%) and training in consultation skills (35%). In the domain 'opportunity', all participants indicated that an existing good collaboration with the general practitioner/practice nurse and access to all relevant medical data were necessary to implement the CombiConsultation. In terms of motivation, job satisfaction was most important to all participants, followed by adequate reimbursement (83%) and improving collaboration with other healthcare providers and the relationship with patients (78%). CONCLUSIONS: Capability, opportunity, and motivation were all considered relevant for the implementation of the CombiConsultation. There were crucial factors on the level of the individual pharmacist, on the level of the local collaboration and organization, and on the health system level.

Effectiveness of post-COVID-19 primary care attendance in improving survival in very old patients with multimorbidity: a territory-wide target trial emulation.

OBJECTIVES: Older individuals with multimorbidity are at an elevated risk of infection and complications from COVID-19. Effectiveness of post-COVID-19 interventions or care models in reducing subsequent adverse outcomes in these individuals have rarely been examined. This study aims to examine the effectiveness of attending general outpatient within 30 days after discharge from COVID-19 on 1-year survival among older adults aged 85 years or above with multimorbidity. DESIGN: Retrospective cohort study emulating a randomised target trial using electronic health records. SETTING: We used data from the Hospital Authority and the Department of Health in Hong Kong, which provided comprehensive electronic health records, COVID-19 confirmed case data, population-based vaccination records and other individual characteristics for the study. PARTICIPANTS: Adults aged 85 years or above with multimorbidity who were discharged after hospitalisation for COVID-19 between January 2020 and August 2022. INTERVENTIONS: Attending a general outpatient within 30 days of last COVID-19 discharge defined the exposure, compared to no outpatient visit. MAIN OUTCOME MEASURES: Primary outcome was all-cause mortality within one year. Secondary outcomes included mortality from respiratory, cardiovascular and cancer causes. RESULTS: A total of 6183 eligible COVID-19 survivors were included in the analysis. The all-cause mortality rate following COVID-19 hospitalisation was lower in the general outpatient visit group (17.1 deaths per 100 person-year) compared with non-visit group (42.8 deaths per 100 person-year). After adjustment, primary care consultations within 30 days after discharge were associated with a significantly greater 1-year survival (difference in 1-year survival: 11.2%, 95% CI 8.1% to 14.4%). We also observed significantly better survival from respiratory diseases in the general outpatient visit group (difference in 1-year survival: 6.3%, 95% CI 3.5% to 8.9%). In a sensitivity analysis for different grace period lengths, we found that the earlier participants had a general outpatient visit after COVID-19 discharge, the better the survival. CONCLUSIONS: Timely primary care consultations after COVID-19 hospitalisation may improve survival following COVID-19 hospitalisation among older adults aged 85 or above with multimorbidity. Expanding primary care services and implementing follow-up mechanisms are crucial to support this vulnerable population's recovery and well-being.

Multimorbidity and patient experience with general practice: A national cross-sectional survey in Norway.

BACKGROUND: Patient experience is an important indicator of the quality of healthcare. Patients with multimorbidity often face adverse health outcomes and increased healthcare utilisation. General practitioners play a crucial role in managing these patients. The main aim of our study was to perform an in-depth assessment of differences in patient-reported experience with general practice between patients living with chronic conditions and multimorbidity, and those with no chronic conditions. METHODS: We performed secondary analyses of a national survey of patient experience with general practice in 2021 (response rate 41.9%, n = 7,912). We described the characteristics of all survey respondents with no, one, two, and three or more self-reported chronic conditions. We assessed patient experience using four scales from the Norwegian patient experience with GP questionnaire (PEQ-GP). These scales were used as dependent variables in bivariate and multivariate analyses and for testing the measurement model, including confirmatory factor analysis and a multigroup CFA to assess measurement invariance. Sentiment and content analysis of free-text comments was also performed. RESULTS: Patients with chronic conditions consistently reported lower scores on the GP and GP practice experience scales, compared to those without chronic conditions. This pattern persisted even after adjustment for patient background variables. The strongest associations were found for the scale of "Enablement", followed by the scales of "GP" and "Practice". The subscale "Accessibility" did not correlate statistically significantly with any number of chronic conditions. The analysis of free-text comments echoed the quantitative results. Patients with multimorbidity stressed the importance of time spent on consultations, meeting the same GP, follow-up and relationship more often than patients with no chronic conditions. Our study also confirmed measurement invariance across patients with no chronic conditions and patients with multimorbidity, indicating that the observed differences in patient experience were a result of true differences, rather than artifacts of measurement bias. CONCLUSIONS: The findings highlight the need for the healthcare system to provide customised support for patients with chronic conditions and multimorbidity. Addressing the specific needs of patients with multimorbidity is a critical step towards enhancing patient experience and the quality of care in general practice.

An Analysis of Referrals Done by Primary Care Centers to Tertiary Care Institutions.

Background and aim Primary care is an important element for every healthcare system around the world. Providing and optimizing the connection between the primary care centers and advanced clinical centers is a key concept for a well-functioning healthcare system. Our aim in this study was to analyze and review the referral data of primary care centers located in Ankara, Türkiye. Materials and methods We collected the entire referral data from the primary care centers, totaling 8,746 patients between January 1, 2019 and December 31, 2023 by using emergency medical services (EMS) transfer in Ankara. Demographic data, call reasons, transfer centers and transfer-related characteristics of the patients were recorded retrospectively, grouped by year, using EMS data. Results Our findings have shown that most of the referrals were made for Turkish citizens with 8,360 (95.6%) (p<0.001). Healthcare centers located in inner city had the most referrals made with 7,087 (81.0%) (p<0.001). Majority of the referrals were made by physicians in family healthcare centers with 6,583 (75.3%) (p<0.001) with chest pain being the most common diagnosis for referral initiation with 1,429 (16.3%) (p<0.001). This was followed by trauma, with 1,172 (13.4%) (p<0.001). Most common cause for trauma was falls with 613 (52.3%) (p<0.001). Conclusion Our data revealed important elements of local referral patterns. According to our data, majority of the referrals were made by inner city healthcare facilities. Family healthcare centers formed most of the referral requests. For this reason, strengthening these centers is important to prevent unnecessary resource use and delays.

Diagnosing and managing prescription opioid use disorder in patients prescribed opioids for chronic pain in Australian general practice settings: a qualitative study using the theory of Planned Behaviour.

BACKGROUND: Chronic pain is a debilitating and common health issue. General Practitioners (GPs) often prescribe opioids to treat chronic pain, despite limited evidence of benefit and increasing evidence of harms, including prescription Opioid Use Disorder (pOUD). Australian GPs are worried about the harms of long-term opioids, but few are involved in the treatment of pOUD. There is little research on GPs' experiences diagnosing and managing pOUD in their chronic pain patients. METHODS: This qualitative research used semi-structured interviews and a case study to investigate GPs' experiences through the lens of the Theory of Planned Behaviour (TPB). TPB describes three factors, an individual's perceived beliefs/attitudes, perceived social norms and perceived behavioural controls. Participants were interviewed via an online video conferencing platform. Interviews were transcribed verbatim and thematically analysed. RESULTS: Twenty-four GPs took part. Participants were aware of the complex presentations for chronic pain patients and concerned about long-term opioid use. Their approach was holistic, but they had limited understanding of pOUD diagnosis and suggested that pOUD had only one treatment: Opioid Agonist Treatment (OAT). Participants felt uncomfortable prescribing opioids and were fearful of difficult, conflictual conversations with patients about the possibility of pOUD. This led to avoidance and negative attitudes towards diagnosing pOUD. There were few positive social norms, few colleagues diagnosed or managed pOUD. Participants reported that their colleagues only offered positive support as this would allow them to avoid managing pOUD themselves, while patients and other staff were often unsupportive. Negative behavioural controls were common with low levels of knowledge, skill, professional supports, inadequate time and remuneration described by many participants. They felt OAT was not core general practice and required specialist management. This dichotomous approach was reflected in their views that the health system only supported treatment for chronic pain or pOUD, not both conditions. CONCLUSIONS: Negative beliefs, negative social norms and negative behavioural controls decreased individual behavioural intention for this group of GPs. Diagnosing and managing pOUD in chronic pain patients prescribed opioids was perceived as difficult and unsupported. Interventions to change behaviour must address negative perceptions in order to lead to more positive intentions to engage in the management of pOUD.

Early-career general practitioners' career intentions in Estonia: A qualitative study.

BACKGROUND: The shortage of general practitioners (GPs) is a worsening problem in many countries and poses a threat to the services provided by primary care and by extension for the entire healthcare system. Issues with GP workforce recruitment and retention can be reasons for this shortage. OBJECTIVES: To describe GP trainees and newly qualified GPs experiences and perceptions on how their training and early experiences of work influence their career intentions in primary care in Estonia. METHODS: A qualitative study with GP trainees (n = 12) and newly qualified GPs (n = 13) using semi-structured group interviews (n = 6) was conducted. Interviews were conducted from October until November 2020. Data were analysed using thematic analysis with NVivo Software. RESULTS: Although early-career GPs in Estonia envision their future roles as GP practice owners with patient list, this is often postponed due to various reasons. Early-career GPs expressed a sense of unpreparedness to fill all the roles of GPs' and found the process of establishing a GP practice and taking on a patient lists very complicated. They value work-life balance and prefer workplaces, which offer flexible working conditions. CONCLUSION: Potential strategies were identified to enhance the willingness of early-career GPs to continue their career as GP practice owners with patient list: improving the GP training program by placing more emphasis on managing skills and making the process of establishing GP practice and taking on a patient list less bureaucratic and more accessible.

This study highlights the career intentions of GP trainees and newly qualified GPs in Estonia.Participants of this study perceive the many different roles of being a GP as very challenging.Understanding early-career GPs ideas about the future work environments can be helpful in shaping future workforce strategies.

The impact of the COVID-19 pandemic on students' views of a career in general practice.

BACKGROUND: General Practice (GP) is an essential part of healthcare systems in the UK and internationally but continues to struggle with recruitment. Despite these concerns about GP recruitment, few studies have explored factors that influence medical students' career choices around primary care. AIM: We aimed to re-visit factors previously proposed following new ways of working adopted since the COVID-19 pandemic, including the impact of these changes on learning experiences in primary care. DESIGN & SETTING: A qualitative study using focus groups across three English medical schools. METHOD: Eight focus groups involving thirty-three final and penultimate year medical students. Qualitative data analysed using a framework approach. Transcripts coded independently by two researchers from a different institution before themes identified. RESULTS: Six themes were identified: students' prior career aspirations, their experience of the medical school curriculum, conceptualisation of general practice, future career predictions, views on the school's curriculum philosophy and the influence of the COVID-19 pandemic. The curriculum philosophy of each school appeared was important in this journey and changes since the COVID-19 had an impact on all themes. CONCLUSION: Our study has confirmed previous findings that clinical experiences, the perceived narrative of the school, work-life balance and working environment remain important to students in making career plans. However, in addition, we have found the changing landscape in general practice since the covid pandemic, including remote consulting, workload, continuity of care and team-working are additional factors that concern students.

Fifty Years of Connection: Characterizing the Social Network of a Primary Care Research Organization.

PURPOSE: This study marks the 50th anniversary of NAPCRG (formerly the North American Primary Care Research Group) by examining social connections among members. METHODS: This descriptive social network analysis was conducted via the Program to Analyze, Record, and Track Networks to Enhance Relationships (PARTNER) survey tool. RESULTS: Responses from 906 participants resulted in 1,721 individuals with 5,196 partner relationships. Most relationships (60%) were characterized as having an integrated level of collaboration. Many relationships led to a research paper (58%) or a grant (34%). CONCLUSIONS: This social network analysis of NAPCRG members' relationships described over 5,000 relationships, many producing publications, grants, and perceived advancements in primary care.

Pulmonary manifestation of VEXAS syndrome.

This case report presents the diagnostic journey of a man in his mid-70s who experienced shortness of breath, cough, recurrent episodes of fever, weight loss, pruritic erythroderma, uveitis and macrocytic anaemia. The initial diagnosis of cryptogenic organising pneumonia was made based on antibiotic refractory infiltrates seen in the lung CT scan. The patient initially responded favourably to immunosuppression but experienced a recurrence of symptoms when the corticosteroid dose was tapered. Despite ongoing systemic inflammation and refractory symptoms, it took nearly a year to establish the diagnosis of VEXAS (vacuoles, E1 enzyme, X-linked, autoinflammatory and somatic) syndrome. This case highlights the challenges in diagnosing and managing VEXAS syndrome due to its recent discovery and limited awareness in the medical community, as well as the need to consider this syndrome as a rare differential diagnosis of therapy-refractory pulmonary infiltrates.

Gatekeeping and referral of patients holding private health insurance: a survey among general practitioners in Norway.

OBJECTIVE: Private health insurance is becoming more common in Norway. The aim of this study was to investigate GPs' opinions on private health insurance, and their experiences from consultations where health insurance can affect decisions about referring. DESIGN: A web based cross-sectional survey. SETTING: Norwegian general practice. SUBJECTS: All GPs in Norway were in 2019 invited to participate in an online survey. MAIN OUTCOME MEASURES: The GPs' opinions and experiences regarding health insurance were reported as proportions. Multiple logistic regression was used to test associations between how frequently GPs refer patients without further considerations and variables concerning their characteristics, opinions, and experiences. RESULTS: Of 1,309 GPs (response rate 27%), 93% stated that private health insurance raises the risk of overtreatment and 90% considered such insurance to contribute to inequality in health. Frequently being pressured to refer in the absence of a medical indication was reported by 42%. Moreover, 28% often or always chose to refer patients without further consideration, and this was associated with perceptions of pressure with an adjusted odds ratio (AOR) of 3.80, 95% confidence interval (CI) 2.73-5.29, and unpleasant reactions from patients following refusals (AOR 1.63, 95% CI 1.14-2.33). CONCLUSION: Although most participating GPs associated private health insurance with overtreatment and inequality in health, more than one in four choose to refer without further consideration. GPs' experience of pressure to refer and negative reactions from patients when they consider referrals not to be medically indicated, raises the risk of medical overuse for patients holding private health insurance.

Although most GPs had negative opinions regarding private health insurance, more than one quarter frequently referred insurance holders without further considerations.Perceived pressure and negative reactions from patients were associated with accommodating requests rather than acting as a gatekeeper.Private health insurance challenges the gatekeeping role of GPs in Norway and raises the risk of medical overuse.

Opting out of the Quality and Outcomes Framework (QOF) and impact on practices' performance.

Background: Financial incentives are being increasingly adopted to help improve standards of care within general practice. However their effects on care quality are unclear. This study aimed to evaluate the impact of practices opting out of the Quality and Outcomes Framework (QOF), a financial incentive scheme in UK general practice. Study design: A retrospective before and after study of all practices in Tower Hamlets, east London. Methods: Practices were given an option by local commissioners of opting out of QOF without a financial penalty and instead opting for a locally designed financial incentive scheme that promoted more holistic care. We compared those practices which opted out of QOF to those which continued. We used national, publicly available QOF achievement data from 2016/17 and 2017/18. We undertook a sub-analysis of 16 QOF indicators to better understand the impact of the intervention. Results: Of the 36 practices in Tower Hamlets, 7 decided to continue with QOF and 29 opted out. The intervention resulted in a small but statistically significant reduction in the total QOF achievement scores of practices which opted out of QOF. The sub-analysis of 16 QOF indicators showed statistically significant reductions in most of achievement scores net of exceptions for the practices that opted out. The differences in performance between the two cohorts of practices became smaller when exceptions were included. Conclusions: The removal of QOF financial incentives can result in a reduction in achievement of QOF-related indicators but the size of the effect seems to depend on the QOF exception rates. An alternative incentive scheme that promotes a more holistic approach to care seems to be welcomed by general practices.

Deprescribing as a Way to Reduce Inappropriate Use of Drugs for Overactive Bladder in Primary Care (DROP): Protocol for a Cluster Randomized Controlled Trial With an Embedded Explanatory Sequential Mixed Methods Study.

BACKGROUND: Potentially inappropriate medication remains a significant concern in general practices, particularly in the context of overactive bladder (OAB) treatment for individuals aged 65 years and older. This study focuses on the exploration of alternative options for treating OAB and the deprescribing of anticholinergic drugs commonly used in OAB. The research aims to comprehensively evaluate the efficiency of deprescribing through a mixed methods approach, combining quantitative assessment and qualitative exploration of perceptions, experiences, and potential barriers among patients and health care personnel. OBJECTIVE: This study aims to evaluate the efficiency and safety of the intervention in which health care staff in primary care encourage patients to participate in deprescribing their drugs for OAB. In addition, we aim to identify factors contributing to or obstructing the deprescribing process that will drive more informed decisions in the field of deprescribing and support effective and safe treatment of patients. METHODS: The drugs for overactive bladder in primary care (DROP) study uses a rigorous research design, using a randomized controlled trial (RCT) with an embedded sequential explanatory mixed methods approach. All general practices within the North Denmark Region will be paired based on the number of general practitioners (GPs) and urban or rural locations. The matched pairs will be randomized into intervention and control groups. The intervention group will receive an algorithm designed to guide the deprescribing of drugs for OAB, promoting appropriate medication use. Quantitative data will be collected from the RCT including data from Danish registries for prescription analysis. Qualitative data will be obtained through interviews and focus groups with GPs, staff members, and patients. Finally, the quantitative and qualitative findings are merged to understand deprescribing for OAB comprehensively. This integrated approach enhances insights and supports future intervention improvement. RESULTS: The DROP study is currently in progress, with randomization of general practices underway. While they have not been invited to participate yet, they will be. The inclusion of GP practices is scheduled from December 2023 to April 2024. The follow-up period for each patient is 6 months. Results will be analyzed through an intention-to-treat analysis for the RCT and a thematic analysis for the qualitative component. Quantitative outcomes will focus on changes in prescriptions and symptoms, while the qualitative analysis will explore experiences and perceptions. CONCLUSIONS: The DROP study aims to provide an evidence-based intervention in primary care that ensures the deprescription of drugs for OAB when there is an unfavorable risk-benefit profile. The DROP study's contribution lies in generating evidence for deprescribing practices and influencing best practices in health care. TRIAL REGISTRATION: ClinicalTrials.gov NCT06110975; https://clinicaltrials.gov/study/NCT06110975. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/56277.

Quality improvement work in general practice; a Norwegian focus group study.

BACKGROUND: Quality improvement work is an essential feature of healthcare services, including general practice. In this study, we aimed to gain more knowledge regarding general practitioners' (GPs) motivation for such work in their practices, as well as what kind of measures were considered motivating and feasible. MATERIALS AND METHODS: We conducted five focus group interviews among Norwegian GPs between November 2021 and November 2022. We included 21 GPs of varying age, gender, experience, and geographic situation. The data were transcribed verbatim and analysed by Systematic Text Condensation, a thematic cross-case analysis. RESULTS: Many GPs had a diverse and imprecise understanding of the term quality improvement, and sound routines in everyday practice were often given as examples of quality improvement measures. There was a universal attitude that quality improvement initiatives should be close to practice, professionally relevant, and sufficiently small to be manageable. The availability of professional communities, either in the GP practices or in continuous medical education groups, was important for motivation. The role of nurses and health secretaries was highlighted as essential to achieve change. Participants commonly described negative reactions to programs that were imposed by external actors without regard for the GPs' perceived needs. CONCLUSION: GPs were motivated for quality improvement measures provided feasibility within the framework of general practice. Well-functioning professional communities, including involvement of nurses and health-secretaries, were emphasised as requisite for quality improvement. Small scale quality improvement programs suited for the needs of general practice were well received and should be further developed.

Diagnostic accuracy of the Brief Assessment of Impaired Cognition case-finding instrument in a general practice setting and comparison with other widely used brief cognitive tests-a cross-validation study.

BACKGROUND AND PURPOSE: The aim of this study was to examine the discriminative validity of the Brief Assessment of Impaired Cognition (BASIC) case-finding instrument in a general practice (GP) setting and compare it with other widely used brief cognitive instruments. METHODS: Patients aged ≥70 years were prospectively recruited from 14 Danish GP clinics. Participants were classified as having either normal cognition (n = 154) or cognitive impairment (n = 101) based on neuropsychological test performance, reported instrumental activities of daily living, and concern regarding memory decline. Comparisons involved the Mini-Mental State Examination (MMSE), the Montreal Cognitive Assessment (MoCA), the Rowland Universal Dementia Assessment Scale (RUDAS), the Mini-Cog, the 6-item Clock Drawing Test (CDT-6) and the BASIC Questionnaire (BASIC-Q). RESULTS: BASIC demonstrated good overall classification accuracy with an area under the receiver operating characteristic curve (AUC) of 0.88 (95% confidence interval [CI] 0.84-0.92), a sensitivity of 0.72 (95% CI 0.62-0.80) and a specificity of 0.86 (95% CI 0.79-0.91). Pairwise comparisons of the AUCs of BASIC, MMSE, MoCA and RUDAS produced non-significant results, but BASIC had significantly higher classification accuracy than Mini-Cog, BASIC-Q and CDT-6. Depending on the pretest probability of cognitive impairment, the positive predictive validity of BASIC varied from 0.83 to 0.36, and the negative predictive validity from 0.97 to 0.76. CONCLUSIONS: BASIC demonstrated good discriminative validity in a GP setting. The classification accuracy of BASIC is equivalent to more complex, time-consuming instruments, such as the MMSE, MoCA and RUDAS, and higher than very brief instruments, such as the CDT-6, Mini-Cog and BASIC-Q.

Aortic root dilation in acromegaly.

Previous studies have linked persistent elevations in growth hormone (GH) and insulin-like growth factor-1 (IGF-1) to cardiac abnormalities including aortic root dilation. Guidelines in the management of this dilation below the size recommended for surgery have not been well defined but follow-up and intervention when appropriate could be life-saving. We report the case of a man in his 60s who had been living with undiagnosed acromegaly for many years. His initial assessment through point-of-care ultrasound raised concerns about potential cardiac enlargement, prompting further investigation with a formal echocardiogram, which revealed a significant aortic root dilation measuring 4.5 cm. Subsequent blood tests confirmed elevated levels of IGF-1. Brain MRI showed a focal lesion in the pituitary gland, which was surgically resected, confirming the diagnosis of a GH-secreting pituitary adenoma. One year after surgery, a repeat CT angiogram of the chest demonstrated a stable size of the aortic root aneurysm.