Welcome to the 26th WONCA Europe Virtual Conference Programme Scheduling

Abstract Body

Background and purpose
In close collaboration between science and practice, the Dutch TARGET program was developed. TARGET aims to offer more integrated and personalized primary care for chronically ill, and simultaneously lower professionals’ workload, by amongst others optimizing opportunities for referral. As first step towards learning how and why TARGET works in a realist evaluation (RE), this study elicited the hypothesized functioning of TARGET, i.e. the initial program theory (IPT).

Methods
A phased process was employed to elicit the IPT, using a combination of abstract theories on integrated care, insights from scientific studies that underpin TARGET, and interviews with seven experts in RE.

Results
For professionals and patients, a separate but linked IPT was formulated. For professionals, we hypothesized: IF the program offers professionals support to identify chronically ill with complex needs, engage in a person-centered needs assessment with these patients, and enhance their network, THEN they are enabled to engage in person-centered, cooperative healthcare with the right target population and strengthen their network, BECAUSE professionals’ confidence (e.g. to identify patients with complex needs) and mutual trust is increased, in a context where all involved parties have sufficient resources for integrated care. We expect long-term goals, such as reduced work pressure, to be achieved stepwise.

Conclusions
The current study underlines the complexity of TARGET and the potential importance of enhancing confidence and mutual trust – in both professionals and patients – for the program to be successful. By evaluating programs like TARGET according to RE principles, the ‘black box’ of integrated care functioning can be gradually opened.

Abstract Body

The evaluation of biopsychosocial determinants or holistic approach is core competence of family doctors. Although the application of the biopsychosocial model improves the clinical outcomes for chronic diseases, it is not sufficiently implemented yet. Hypertension - the major public health problem at the international and national level, which requires holistic approach in our vision, is proposed as the object of research. Hypertension incidence and prevalence increases, and the prognosis is alarming. In the Republic of Moldova, as in other low-income countries, the mortality caused by Hypertension is not decreasing. Hypertension causes 50 % of Myocardial infarction and 80% of the Strokes.

The study aim is to evaluate the role of biopsychosocial determinants in hypertensive patients to argue for personalised management at the primary health care level. The main objectives are evaluation of biopsychosocial profiles in hypertensive patients and estimation of the biopsychosocial determinants role in relation with treatment outcomes.

The hypertensive patient examination is going to be performed by testing each component of the biopsychosocial model. The biological component will be assessed by traditional physical and paraclinical examination, but also includes genetic tests. Psychological assessment includes screening for anxiety and depression using TAG-2 and PHQ-2. The social component will identify the socio-economic status of patients and behavioural risk factors.

The knowledge of the biopsychosocial profile of patients with hypertension; modeling treatment according to biopsychosocial determinants in patients with hypertension; scientific arguments regarding the personalised conduct of patients with hypertension at the level of primary health care are expected results.

Abstract Body

Background/purpose:

Medical guidelines often describe the initiation of chronic medication but usually not the process of discontinuation in aging patients. Just like prescribing medication, reducing or stopping medication should be part of daily medical practice, especially in vulnerable of elderly patients. The aim was to develop a generic guideline on deprescribing in the elderly, supported by 10 factsheets on deprescribing of frequently used medicines in the elderly.

Methods:

The guideline has been developed by a multidisciplinary working group. The development process was based on the AGREE-II model.

Since there is still little research from the perspective of patients and care providers on depresrcibing a mixed-method was followed with the following steps:

- literature review

- focus groups: patients and caregivers

- focus groups: health care providers

- narrative summary of publications on ethical and disciplinary aspects of reduction and stopping medication

Results:

A multidisciplinary guideline was developed with recommendations on:

- the impeding and facilitating factors for deprescribing;

- the effects of deprescribing;

- instruments for deprescribing;

- suitable patients and suitable moments

- division of roles among healthcare providers in deprescribing

In addition, 10 fact sheets have been developed detailing the above points about deprescribing common medicines in the elderly.

Conclusions:

The goal of reducing and stopping medication is to optimize drug treatment and thus improve the quality of life and health of the patient. The development of the guideline "deprescribing in the elderly" and 10 corresponding factsheets offers GPs, other prescribers, pharmacists and patients tools for reduction and discontinuation of medicines in elderly patients (≥70 years) in daily practice.

Abstract Body

Abstract

Background and purpose:

Dizziness is a common and challenging clinical presentation in general practice. A GPs approach is important in reducing misdiagnosis and ensuring appropriate resource allocation. We aimed to establish frequency and associations of GP trainees’ (registrars’) specific vertigo provisional diagnoses and their non-specific symptomatic problem formulations.

Method:

A cross-sectional analysis of Registrar Clinical Encounters in Training (ReCEnT) cohort study data, 2010-2018. The outcome factor was whether dizziness- or vertigo-related presentations resulted in a specific vertigo or a non-specific symptomatic problem formulation. Associations with patient, practice, registrar, and consultation independent variables were assessed by univariate and multivariable logistic regression.

Results:

2,333 registrars recorded 1,734 (0.34%) new problems related to dizziness or vertigo. Of these, 546 (31.5%) involved a specific vertigo diagnosis and 1,188 (68.5%) a non-specific symptom diagnosis. Variables associated with a non-specific symptom diagnosis on multivariable analysis were longer consultation duration (OR 1.02, 95% CIs 1.00,1.04), and pathology (8.25 [95% CI: 4.94,13.8]) and imaging (4.09 [95% CI: 2.26,7.41]) being ordered. A specific vertigo diagnosis was associated with performing a procedure (OR 0.52, 95% CIs 0.27,1.00), prescribing medicine (0.32 [95% CI: 0.24,0.43]) and with some evidence for seeking information from a non-supervisor source (OR 1.39, 95% CIs 0.92,2.09; p=0.12).

Conclusion:

The frequency and associations of a non-specific diagnosis are consistent with the acknowledged difficulty of making diagnoses in these presentations. Registrars are appropriately calling on their supervisors for diagnostic purposes. Continuing emphasis on this area in GP training and encouragement of supervisor involvement in registrars’ diagnostic processes is indicated.

Abstract Body

Background: An app-based treatment for stress-, urgency- and mixed urinary incontinence (UI) is non-inferior to care-as-usual. This study illustrates the development of a tool, based on patient characteristics, that personalizes this treatment-desicion.

Methods: Prediction model study based on data from a randomized controlled, non-inferiority trial. Conducted in primary care in the Netherlands from 2015 to 2018. Eligible women had ≥2 episodes of UI per week, access to mobile apps, and wanted treatment. Based on a given sample size of 262 participants, the model could include a maximum of 28 parameters. We selected 13 potential candidate predictors based on literature review and expert opinion. Prognostic factors (irrespective of treatment type): Severity of incontinence, postmenopausal state, vaginal births, general health status, pelvic floor muscle function, body mass index. Modifiers (dependent on treatment type): Age, UI type,UIduration, UI impact on quality of life, previous physical therapy, recruitment method and educational level. The primary outcome was symptom severity after 4 months, measured with the ICIQ-Urinary Incontinence Short Form. Prognostic factors and modifiers were combined into a final prognostic model. Both treatment outcomes for each patient were predicted, the difference between these predictions (Personalized advantage index, PAI) was calculated and its benefit assessed.

Results: UI severity (prognostic) and age, educational level and UI impact on Quality of life (modifiers) predicted treatment outcome. Mean PAI was 0.99 points (SD 0.79) and of clinical relevance in 21% of individuals. Application of the PAI significantly improved treatment outcomes on the group level.

Conclusions: Personalized prediction of treatment outcomes has the potential to directly support treatment-decision between eHealth and care-as-usual .

Abstract Body

Background and purpose

For consultation length the UK is an outlier, with shorter GP consultations than most countries. Over the last twenty years Uk consultations have moved from seven minute to an average of twelve minutes. At the same time the consultation has become more complex with most chronic conditions managed in primary care. Longer consultations have been shown to be more patient centred, but the UK has disincentives to a longer consultation. Policymakers do not actively support a model of longer consultations and general practitioners are not aware that a twenty minute model of consultation can work in practice.

Methods

This presentation includes a review of the literature on the impact of consultation length, and a description of a models of care that provide the option of twenty minute routine appointments to all, or part of, a list of registered primary care patients in England.

Results

We will outline the existing pattern of consultation length in England compared to Europe, and the literature associated with the benefits, disadvantages and disincentives to achieving longer consultation length.

This will be followed by the description of working models for the application of twenty minute appointments, the blocks overcome, and the development of resources to support these.

Conclusions

The benefits of longer consultations outweigh the disadvantages, but limited overall capacity for healthcare and reduced income are key drivers that oppose an increase in consultation length. This is the first report that models for routine twenty minute appointments in the UK NHS do exist and can be applied more widely in UK general practice.