Perspectives on low-value care and barriers to de-implementation among primary care physicians: a multinational survey.

BACKGROUND: Healthcare costs are rising worldwide. At the same time, a considerable proportion of care does not benefit or may even be harmful to patients. We aimed to explore attitudes towards low-value care and identify the most important barriers to the de-implementation of low-value care use in primary care in high-income countries. METHODS: Between May and June 2022, we email surveyed primary care physicians in six high-income countries (Austria, Finland, Greece, Italy, Japan, and Sweden). Physician respondents were eligible if they had worked in primary care during the previous 24 months. The survey included four sections with categorized questions on (1) background information, (2) familiarity with Choosing Wisely recommendations, (3) attitudes towards overdiagnosis and overtreatment, and (4) barriers to de-implementation, as well as a section with open-ended questions on interventions and possible facilitators for de-implementation. We used descriptive statistics to present the results. RESULTS: Of the 16,935 primary care physicians, 1,731 answered (response rate 10.2%), 1,505 had worked in primary care practice in the last 24 months and were included in the analysis. Of the respondents, 53% had read Choosing Wisely recommendations. Of the respondents, 52% perceived overdiagnosis and 50% overtreatment as at least a problem to some extent in their own practice. Corresponding figures were 85% and 81% when they were asked regarding their country's healthcare. Respondents considered patient expectations (85% answered either moderate or major importance), patient's requests for treatments and tests (83%), fear of medical error (81%), workload/lack of time (81%), and fear of underdiagnosis or undertreatment (79%) as the most important barriers for de-implementation. Attitudes and perceptions of barriers differed significantly between countries. CONCLUSIONS: More than 80% of primary care physicians consider overtreatment and overdiagnosis as a problem in their country's healthcare but fewer (around 50%) in their own practice. Lack of time, fear of error, and patient pressures are common barriers to de-implementation in high-income countries and should be acknowledged when planning future healthcare. Due to the wide variety of barriers to de-implementation and differences in their importance in different contexts, understanding local barriers is crucial when planning de-implementation strategies.

Effects of task shifting from primary care physicians to nurses: a protocol for an overview of systematic reviews.

INTRODUCTION: Task-shifting from primary care physicians (PCPs) to nurses is one option to better and more efficiently meet the needs of the population in primary care and to overcome PCP shortages. This protocol outlines an overview of systematic reviews to assess the effects of delegation or substitution by nurses of PCPs' activities regarding clinical, patient-relevant, professional and health services-related outcomes. METHODS AND ANALYSIS: We will conduct a systematic literature search for secondary literature in PubMed/MEDLINE, EMBASE, CINAHL and Cochrane databases. Systematic reviews, meta-analyses and Health Technology Assessments in German and English comprising randomised controlled trials and prospective controlled trials will be considered for inclusion. Search terms will include Medical Subject Headings combined with free text words. At least one-third of abstracts and full-text articles are reviewed by two independent reviewers. Methodological quality will be assessed using the Overview Quality Assessment Questionnaire. We will only consider reviews if they include controlled trials, if the profession that substituted or delegated tasks was a nurse, if the profession of the control was a PCP, if the assessed intervention was the same in the intervention and control group and if the Overview Quality Assessment Questionnaire score is ≥5. The corrected covered area will be calculated to describe the degree of overlap of studies in the reviews included in the study. We will report the overview according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. ETHICS AND DISSEMINATION: The overview of secondary literature does not require the approval of an Ethics Committee and will be published in a peer-reviewed journal. PROSPERO REGISTRATION NUMBER: CRD42020183327.

Palliative Care Survey: Awareness, Knowledge and Views of the Styrian Population in Austria.

BACKGROUND: No population-based data on awareness and knowledge of palliative care currently exist in Austria. We therefore conducted a survey to determine the general awareness and knowledge of palliative care in Styria, a federal state in Austria. We also asked participants to imagine what services they would need as a patient or family member, where they themselves would like to receive such services, and what fears they imagined patients with a terminal illness would have. METHODS: A descriptive cross-sectional survey consisting of 18 questions that address several aspects of palliative care was carried out in the adult population of Styria, Austria, from October 2019 to March 2020. RESULTS: A total of 419 questionnaires were analyzed, whereby 70.3% of respondents had at least heard of palliative care. Of these, significantly more were female, had a university degree and were aged 50 to 64. The main goal of palliative care was chosen correctly by 67.1% of participants, with the proportion of correct answers increasing in line with education and reaching 82.0% among university graduates. Overall, 73.2% believed that the greatest need of terminally ill persons was a reduction in physical suffering, whereas the greatest perceived need of relatives was the availability of specialist care around the clock. About one-third believed that the greatest fear of palliative patients was that of death, which was chosen significantly more often by men than women. If terminally ill, some 39% of respondents would wish to be looked after at home by professional carers, and women and people that had completed high school chose this answer significantly more often. The most desired service that should be provided to patients and relatives was home pain management at 69.9%, followed by time off for family caregivers at 58.0%. This item was chosen significantly more often by women. CONCLUSIONS: To facilitate the care of severely ill patients at home, it would make sense to develop targeted information campaigns. These should also attempt to deliver targeted information to less informed groups of people, such as young, poorly educated men, in order to raise their awareness of the difficulties and challenges of providing care to terminally ill patients and thus increase the acceptance of support options.

Identifying key policy objectives for strong primary care: a cross-sectional study.

AIM: The aim of this study was to identify key policy objectives by investigating the perception of important stakeholders and affected professionals concerning relevance and feasibility of a successful primary care (PC) reform. BACKGROUND: Since 2013, the Austrian PC system has been undergoing a reform process to establish multiprofessional primary care units. The reforms have various defined objectives and lack clear priorities. METHODS: After the definition and consensus-based selection of 12 policy objectives, a cross-sectional online survey on their relevance and feasibility was distributed via email and social media to PC and public health networks. The survey was conducted in the period from January to February 2020. Results were analyzed descriptively, and further, Pearson Chi-Square Test or Fisher's Exact Test was performed for group comparison regarding respondents' characteristics. Open-ended responses were analyzed using qualitative content analysis. FINDINGS: In total, 169 questionnaires were completed. A total of 46.3% of the responders had more than 20 years of professional experience (female: 60.5%). A mandatory internship in general practice, vocational training for general practice, and a modern remuneration system were the three top-rated policy objectives regarding relevance. A mandatory internship in general practice, specialization in general practice, and coding of services and diagnosis were assessed as the most feasible objectives. The group comparisons regarding working field, years of professional experience, age, and sex did not show any meaningful results in the evaluation of relevance and feasibility. DISCUSSION: In the view of the study participants, easily obtainable objectives include adapting the duration and setting of internships for medical students, as well as mandatory vocational training for GP trainees. Further efforts are necessary to achieve complex objectives such as the adoption of a modern remuneration scheme and a comprehensive quality assurance program. Building capacity and creating team-oriented environments are also important aspects of a successful PC reform.

Facilitators and barriers in general practitioners' choice to work in primary care units in Austria: a qualitative study.

BACKGROUND: Recent reforms in Austria have focused on establishing team-based care within multiprofessional primary care units, to enhance amongst others, the work attractiveness of general practice. Nearly 75% of qualified general practitioners are not working as contracted physicians with the social health insurance. This study aims to explore the facilitators of and barriers to non-contracted general practitioners to work in a primary care unit. METHODS: We conducted twelve semi-structured, problem-centered interviews among purposively sampled non-contracted general practitioners. To extract categories of facilitators and barriers for working in a primary care unit, transcribed interviews were inductively coded using qualitative content analysis. Subcategories were grouped into factors (facilitators and barriers) of thematic criteria and mapped on the macro-, meso-, micro-, and individual levels. RESULTS: We identified 41 categories, including 21 facilitators and 20 barriers. Most facilitators were located at the micro-level, while most barriers were located at the macro-level. Teamwork and associated conditions made primary care units attractive as workplaces and corresponded with individual demands. In contrast, system factors tended to reduce the attractiveness of working as a general practitioner. CONCLUSIONS: Multifaceted efforts are needed to address relevant factors at all of the levels mentioned above. These need to be carried out and consistently communicated by all stakeholders. Efforts to strengthen the holistic approach in primary care, like modern remuneration and patient steering mechanisms, are essential. Financial support, consulting services as well as training on entrepreneurship, management, leadership, and team-based care may help to reduce the risk and burden of founding and running a primary care unit.

Quality of chronic care in general practices in Salzburg, Austria, and South Tyrol, Italy: a comparative process of care intervention study.

BACKGROUND: Quality indicators to assess the quality of primary care have only been applied on a national or regional level in European countries, and there have been no comparisons between regions of different countries. In the interventional pre-post-study "Improvement of Quality by Benchmarking - IQuaB" (level of evidence: 3), we aimed to improve and compare quality of process care in 57 participating general practices in Salzburg, Austria, and South Tyrol, Italy. METHODS: The intervention consisted of self-audit, benchmarking and quality circles. Quality indicators for eight common chronic diseases (e. g., diabetes) were extracted from the electronic health records in 2012, 2013 and 2014. Based on 19 quality indicators, a supra-regional quality score was calculated and compared using Mann-Whitney U tests. RESULTS: A relatively weak baseline performance was identified in both regions. In all three assessments, the median quality score increased in both regions and was significantly higher in South Tyrol than in Salzburg. During the study period the median supra-regional quality score increased from 20.00 to 38.00 in the Salzburg sample and from 47.00 to 79.50 in the South Tyrolian sample. The differences between the two regions were significant at baseline and after intervention (2012: p=0.015, 2014: p=0.001). DISCUSSION: Despite data extraction challenges in Austria, we are convinced that our data highlight real differences in (processual) quality of care between the two regions. CONCLUSIONS: The reasons underlying the persisting differences between the two regions may include: (1) different functions in electronic health records, (2) benchmarking as an integral part of the electronic health record, (3) gate-keeping system and use of registration lists, (4) state-supported quality initiatives.

Are quality promotion initiatives in Austrian and Italian general practices associated with higher patient satisfaction and quality of life? Results from the interventional study 'IQuaB'.

The objective was to assess the changes in quality of life (QoL) and patient satisfaction of chronically ill patients in general practices in Salzburg (Austria) and South Tyrol (Italy) after implementation of a combined intervention addressing quality of care of general practitioners (GPs). Furthermore, the correlation between QoL/patient satisfaction and quality of care provided by the GPs (measured by a quality score based on quality indicators [QIs]) was investigated. The non-controlled pre-post study involved GPs and patients with chronic conditions. The intervention consisted of self-audit, benchmarking and quality circles. QIs were extracted in the participating practices in 2012 (preintervention) and 2014 (postintervention). Before and after the intervention, a patient survey was conducted including EQ-5D (measuring health-related QoL), a patient participation scale and parts of the European Task Force on Patient Evaluations of General Practice questionnaire (measuring patient satisfaction). Mann-Whitney U-tests, chi-square tests and Spearman's rank correlation were applied for statistical analysis. Fifty-six GPs participated in the study. 1,710 patients returned the questionnaire in 2012, and 1,374 in 2014. Mean EQ-5D index (QoL) was similar in Salzburg and South Tyrol in both years: 2012 Salzburg 0.85 (95% CI 0.84-0.87), South Tyrol 0.85 (95% CI 0.84-0.86); 2014 Salzburg 0.84 (95% CI 0.83-0.86), South Tyrol 0.84 (95% CI 0.83-0.86). Patient satisfaction was higher in Salzburg than in South Tyrol at baseline (EUROPEP: mean percentage of best response 61.5% vs. 49.1%, p < 0.000) and also at follow-up (61.9% vs. 49.2%; p < 0.000). No significant correlation between quality score and QoL/patient satisfaction was detected. Thus, the impact of the intervention was not significant within the intermediate time periods analysed in the study. Improvements in quality of care do not necessarily also improve patient-relevant outcomes, which are probably more associated with other factors than with medical quality (e.g. availability of the GP, waiting times and communication-related issues).

Quality improvement in chronic care by self-audit, benchmarking and networking in general practices in South Tyrol, Italy: results from an interventional study.

BACKGROUND: Systematic strategies promoting quality of care in general practice are yet under-represented in several European countries. OBJECTIVE: This interventional study assessed whether a combined intervention (self-audit, benchmarking, quality circles) improved quality of care in Salzburg, Austria and South Tyrol, Italy. The present publication reports the Italian results. METHODS: We developed quality indicators for general practice in a consensus process based on pre-existing quality programmes. The indicators addressed diagnosis and treatment regarding eight common chronic conditions. A quality score comprising 91 indicators was calculated (0-5 points per indicator depending on fulfilment, maximum 455 points). We collected anonymous data from the electronic health records of the participating physicians in 2012, 2013 and 2014. Wilcoxon signed-rank tests were used for pre-post analysis. RESULTS: Thirty-six GPs participated in the study. The median quality score increased significantly from 177.0 points at baseline to 272.0 points at the second follow-up (P = 0.000). Improvements concerned process and intermediate outcome indicators particularly between baseline and the first follow-up. CONCLUSION: Performance was relatively low at baseline and improved considerably, mainly in the first study period. The intervention investigated in this study can serve as a model for future quality programmes. A customized electronic health record for the implementation of this intervention as well as standardized and consistent documentation by GPs is a prerequisite. Use of a limited set of quality indicators (QIs) and regular QI modification is probably advisable to increase the benefits. Long-term prospective studies should investigate the impact of QI-based interventions on end-result outcomes.

[Quality Indicators of Primary Health Care Facilities in Austria]. / Qualitätsindikatoren für Primary-Health-Care-Einrichtungen in Österreich.

BACKGROUND: The strengthening of primary health care is one major goal of the current national health reform in Austria. In this context, a new interdisciplinary concept was developed in 2014 that defines structures and requirements for future primary health care facilities. OBJECTIVE: The aim of this project was the development of quality indicators for the evaluation of the scheduled primary health care facilities in Austria, which are in accordance with the new Austrian concept. METHODS: We used the RAND/NPCRDC method for the development and selection of the quality indicators. We conducted systematic literature searches for existing measures in international databases for quality indicators as well as in bibliographic databases. All retrieved measures were evaluated and rated by an expert panel in a 2-step process regarding relevance and feasibility. RESULTS: Overall, the literature searches yielded 281 potentially relevant quality indicators, which were summarized to 65 different quality measures for primary health care. Out of these, the panel rated and accepted 30 measures as relevant and feasible for use in Austria. Five of these indicators were structure measures, 14 were process measures and the remaining 11 were outcome measures. Based on the Austrian primary health care concept, the final set of quality indicators was grouped in the 5 following domains: Access to primary health care (5), quality of care (15), continuity of care (5), coordination of care (4), and safety (1). CONCLUSION: This set of quality measures largely covers the four defined functions of primary health care. It enables standardized evaluation of primary health care facilities in Austria regarding the implementation of the Austrian primary health care concept as well as improvement in healthcare of the population.

Choosing Wisely: assessment of current US top five list recommendations' trustworthiness using a pragmatic approach.

OBJECTIVES: Identification of sufficiently trustworthy top 5 list recommendations from the US Choosing Wisely campaign. SETTING: Not applicable. PARTICIPANTS: All top 5 list recommendations available from the American Board of Internal Medicine Foundation website. MAIN OUTCOME MEASURES/INTERVENTIONS: Compilation of US top 5 lists and search for current German highly trustworthy (S3) guidelines. Extraction of guideline recommendations, including grade of recommendation (GoR), for suggestions comparable to top 5 list recommendations. For recommendations without guideline equivalents, the methodological quality of the top 5 list development process was assessed using criteria similar to that used to judge guidelines, and relevant meta-literature was identified in cited references. Judgement of sufficient trustworthiness of top 5 list recommendations was based either on an 'A' GoR of guideline equivalents or on high methodological quality and citation of relevant meta-literature. RESULTS: 412 top 5 list recommendations were identified. For 75 (18%), equivalents were found in current German S3 guidelines. 44 of these recommendations were associated with an 'A' GoR, or a strong recommendation based on strong evidence, and 26 had a 'B' or a 'C' GoR. No GoR was provided for 5 recommendations. 337 recommendations had no equivalent in the German S3 guidelines. The methodological quality of the development process was high and relevant meta-literature was cited for 87 top 5 list recommendations. For a further 36, either the methodological quality was high without any meta-literature citations or meta-literature citations existed but the methodological quality was lacking. For the remaining 214 recommendations, either the methodological quality was lacking and no literature was cited or the methodological quality was generally unsatisfactory. CONCLUSIONS: 131 of current US top 5 list recommendations were found to be sufficiently trustworthy. For a substantial number of current US top 5 list recommendations, their trustworthiness remains unclear. Methodological requirements for developing top 5 lists are recommended.

Improving quality of care in general practices by self-audit, benchmarking and quality circles.

Guideline adherence of general practitioners (GP) regarding treatment of chronic conditions shows room for improvement. Thus, concepts have to be designed to promote quality of care. The aim of the interventional study "Improvement of Quality by Benchmarking" was to assess whether quality can be improved by self-auditing, benchmarking and quality circles in Salzburg (Austria) and South Tyrol (Italy). In this publication we present the Austrian results. Quality indicators were developed in a consensus process for eight chronic diseases based on pre-existing quality management systems. A quality score consisting of 35 indicators was calculated (0-5 points per indicator depending on fulfilment, maximum 175 points). Data were extracted from the electronic health records of participating practices in 2012, 2013 and 2014. A statistical pre-post analysis was performed using Wilcoxon signed-rank tests. A total of 20 GPs participated in the project. The mean quality score increased from 62.0 at baseline to 84.0 at the second follow-up (p = 0.003). Regarding the individual quality indicators, strong improvements were achieved between baseline and first follow-up, especially in process indicators concerning documentation. Between the first and second follow-up, quality remained in most cases at the same level. The validity of results is limited because of structural and technical problems. Due to the uncontrolled pre-post design we cannot exclude external influences on the results. Nevertheless, the intervention was able to improve measured quality of care. Barriers were detected that should be considered in a possible implementation of quality control programs.

Impact of strategies to reduce polypharmacy on clinically relevant endpoints: a systematic review and meta-analysis.

AIM: The aim of the present study was to explore the impact of strategies to reduce polypharmacy on mortality, hospitalization and change in number of drugs. METHODS: Systematic review and meta-analysis: a systematic literature search targeting patients ≥65 years with polypharmacy (≥4 drugs), focusing on patient-relevant outcome measures, was conducted. We included controlled studies aiming to reduce polypharmacy. Two reviewers independently assessed studies for eligibility, extracted data and evaluated study quality. RESULTS: Twenty-five studies, including 10 980 participants, were included, comprising 21 randomized controlled trials and four nonrandomized controlled trials. The majority of the included studies aimed at improving quality or the appropriateness of prescribing by eliminating inappropriate and non-evidence-based drugs. These strategies to reduce polypharmacy had no effect on all-cause mortality (odds ratio 1.02; 95% confidence interval 0.84, 1.23). Only single studies found improvements, in terms of reducing the number of hospital admissions, in favour of the intervention group. At baseline, patients were taking, on average, 7.4 drugs in both the intervention and the control groups. At follow-up, the weighted mean number of drugs was reduced (-0.2) in the intervention group but increased (+0.2) in controls. CONCLUSIONS: There is no convincing evidence that the strategies assessed in the present review are effective in reducing polypharmacy or have an impact on clinically relevant endpoints. Interventions are complex; it is still unclear how best to organize and implement them to achieve a reduction in inappropriate polypharmacy. There is therefore a need to develop more effective strategies to reduce inappropriate polypharmacy and to test them in large, pragmatic randomized controlled trials on effectiveness and feasibility.

Traditional knowledge of wild edible plants used in Palestine (Northern West Bank): a comparative study.

BACKGROUND: A comparative food ethnobotanical study was carried out in fifteen local communities distributed in five districts in the Palestinian Authority, PA (northern West Bank), six of which were located in Nablus, two in Jenin, two in Salfit, three in Qalqilia, and two in Tulkarm. These are among the areas in the PA whose rural inhabitants primarily subsisted on agriculture and therefore still preserve the traditional knowledge on wild edible plants. METHODS: Data on the use of wild edible plants were collected for one-year period, through informed consent semi-structured interviews with 190 local informants. A semi-quantitative approach was used to document use diversity, and relative importance of each species. RESULTS AND DISCUSSION: The study recorded 100 wild edible plant species, seventy six of which were mentioned by three informants and above and were distributed across 70 genera and 26 families. The most significant species include Majorana syriaca, Foeniculum vulgare, Malvasylvestris, Salvia fruticosa, Cyclamen persicum, Micromeria fruticosa, Arum palaestinum, Trigonella foenum-graecum, Gundelia tournefortii, and Matricaria aurea. All the ten species with the highest mean cultural importance values (mCI), were cited in all five areas. Moreover, most were important in every region. A common cultural background may explain these similarities. One taxon (Majoranasyriaca) in particular was found to be among the most quoted species in almost all areas surveyed. CI values, as a measure of traditional botanical knowledge, for edible species in relatively remote and isolated areas (Qalqilia, and Salfit) were generally higher than for the same species in other areas. This can be attributed to the fact that local knowledge of wild edible plants and plant gathering are more spread in remote or isolated areas. CONCLUSION: Gathering, processing and consuming wild edible plants are still practiced in all the studied Palestinian areas. About 26 % (26/100) of the recorded wild botanicals including the most quoted and with highest mCI values, are currently gathered and utilized in all the areas, demonstrating that there are ethnobotanical contact points among the various Palestinian regions. The habit of using wild edible plants is still alive in the PA, but is disappearing. Therefore, the recording, preserving, and infusing of this knowledge to future generations is pressing and fundamental.