How GPs adapted their practices and organisations at the beginning of COVID-19 outbreak: a French national observational survey.

OBJECTIVES: To describe how general practitioners (GPs) adapted their practices to secure and maintain access to care in the epidemic phase. A secondary objective was to explore if GPs' individual characteristics and type of practice determined their adaptation. DESIGN: Observational study using an online questionnaire. Organisational changes were measured by a main question and detailed in two specific outcomes. To identify which GPs' characteristics impacted organisational changes, successive multivariate logistic modelling was performed. First, we identified the GPs' characteristics related to organisational changes with a univariate analysis. Then, we tested the adjusted associations between this variable and the following GPs' characteristics: age, gender and type of practice. SETTING: The questionnaire was administered online between 14 March and 21 March 2020. Practitioners were recruited by email using the contact lists of different French scientific GP societies. PARTICIPANTS: The target population was GPs currently practising in France (n=46 056). We obtained a total of 7481 responses. PRIMARY AND SECONDARY OUTCOME MEASURES: Primary outcome: Proportion of GPs who adapted their practice. Secondary outcome: GPs' characteristics related to organisational changes. RESULTS: Among the 7481 responses, 5425 were complete and were analysed. 3849 GPs (70.9%) changed their activity, 3605 GPs (66.5%) increased remote consultations and 2315 GPs (42.7%) created a specific pathway for probable patients with COVID-19. Among the 3849 GPs (70.9%) who changed their practice, 3306 (91.7%) gave more answers by phone, 996 (27.6%) by email and 1105 (30.7%) increased the use of video consultations. GPs working in multi-professional group practices were more likely to have changed their activity since the beginning of the epidemic wave than GPs working in mono-professional group or single medical practices (adjusted OR: 1.32, 95% CI 1.12 to 1.56, p=0.001). CONCLUSIONS: French GPs adapted their practices regarding access to care for patients in the context of the COVID-19 epidemic. This adaptation was higher in multi-professional group practices.

Development and validation of a generic questionnaire for the implementation of complex medical interventions.

INTRODUCTION: The implementation of complex medical interventions in daily practice is often fraught with difficulties. According to the iterative phase model proposed by the British Medical Research Council (MRC), the development, implementation and evaluation of complex interventions should be theory-driven. A conceptual model that seems to be a promising framework is the Theory of planned behaviour (TPB). In our study we aimed to develop and validate a generic and multifaceted questionnaire based on the TPB to detect physicians' willingness to implement complex medical interventions and the factors influencing this willingness. METHODS: The questionnaire was developed according to the literature and was informed by previous qualitative research of our department. It was validated on the example of an electronic library of decision aids, arriba-lib. The sample consisted of 181 General Practitioners (GPs) who received a training regarding arriba-lib and subsequently filled in the questionnaire, assessing the TPB variables attitude, subjective norm, perceived behaviour control and intention. Follow-up assessments were conducted after two (assessing retest reliability) and eight weeks (assessing target behaviour). We performed a confirmatory factor analysis investigating the factorial structure of our questionnaire according to the TPB. Beside the calculation of the questionnaire's psychometric properties we conducted a structural equation model and an ordinal regression to predict actual behaviour regarding the installation and application of arriba-lib. RESULTS: The postulated three factorial model (attitude, subjective norm, perceived behaviour control) of our questionnaire based on the TPB was rejected. A two factorial model with a combined factor subjective norm/perceived behaviour control was accepted. The explained variance in the ordinal regression was low (Nagelkerke's R(2)=.12). Neither attitude nor intention were able to predict the use or non-use of arriba-lib (attitude: p=.68, intention: p=.44). For the combined factor subjective norm/perceived behaviour control a significant, but small effect (p=.03) was shown. CONCLUSIONS: The TPB is not an adequate theoretical framework to guide the development of a generic questionnaire in the context of the implementation of complex interventions. To enable the successful implementation of complex medical interventions evaluators have to go through the whole development and evaluation process according to the MRC-model, without short cuts. Further, it has to be discussed if a generic instrument can be valid and useful. Regarding the TPB a publication bias regarding the theory's applicability might have to be considered.

[The image of general practitioners from the perspective of patients with and without a Turkish migration background - a qualitative study]. / Das Image von Hausärzten aus Perspektive von Patienten mit und ohne türkischem Migrationshintergrund - eine qualitative Studie.

OBJECTIVE: In order to improve the medical care of people with migration background, the existing specialties in medical understanding must be taken into account. The aim of this study was to explore the image of general practitioners from the viewpoint of patients and to evaluate possible differences in the perception of patients with and without a Turkish migration background. METHODS: 5 focus groups with participants with and without migration background were assessed in German language. In addition to a predefined interview guideline, the collage technique was used in order to explore the image of the practitioners through pictures. The content analysis was conducted according to Mayring using the software program ATLAS.ti. RESULTS: The patients revealed a highly positive image about the general practitioners. By means of the collage technique some negative aspects could be identified which were not discussed in the focus groups. Only minimal differences in the opinions of participants with and without Turkish migration background could be observed. These were a strongly negative attribution to the general practitioners with regard to financial aspects by the participants without migration background on the one hand and a rather paternalistic viewpoint by the participants with Turkish migration background on the other hand. Asked about an image change of general practitioners, the overall opinion has changed over the years from doctors being considered to be "powerful" and "unapproachable" to a "normal" level. Major reasons for this image change were attributed to the fact that patients are becoming increasingly informed about medical issues through the internet and the high work pressure of general practitioners. The image of general practitioners in Turkey was perceived more negative as compared to Germany. CONCLUSION: The image of general practitioners from the perspective of patients is predominantly positive. Altogether, only minor differences in the perception of German speaking patients with and without Turkish migration background could be identified. Therefore, specific ways of proceeding or qualification measures for general practitioners do not seem necessary in this context.

A taxonomy of primary health care practices: an avenue for informing management and policy implementation.

Health policy and practice managers often treat primary practices as being homogenous, despite evidence that these organisations vary along multiple dimensions. This treatment can be a barrier to the development of a strong health care system. Therefore, a more sophisticated taxonomy of organisations could inform management and policy to better cater to the diversity of practice contexts, needs and capabilities. The purpose of this study was to categorise primary practices using practice features and characteristics associated with the job satisfaction of GPs. The current study uses data from 3906 GPs from the 2008 wave of the MABEL survey. Seven configurations of primary health care practices emerged from multivariate cluster analyses. The configurations incorporate, yet move beyond, simplistic categorisations such as geographic location and highlight the complexity facing managers and health policy interventions. The multidimensional configurations in the taxonomy are a mechanism for informing health care management and policy. The process of deriving configurations can be applied in a variety of countries and contexts.