BACKGROUND: In the context of an ageing population and increasing health needs, primary care reform is needed and several new models have emerged, including the introduction of case managers in general practitioner practices.
OBJECTIVE: To describe the frequency of case managers in general practices in eleven Western countries between 2012 and 2019 and to investigate the characteristics of general practitioners and their practices associated with case manager frequency.
METHODS: A secondary analysis of the Commonwealth Fund International Health Policy Surveys of Primary Care Physicians, which were international cross-sectional studies conducted in 2012, 2015 and 2019. Random samples of general practitioners were selected in 11 Western countries (2012: n = 9776; 2015: n = 12,049; 2019: n = 13,200). The use of case managers in general practitioner practices was determined with the question \"Does your practice use personnel, such as nurses or case managers, to monitor and manage care for patients with chronic conditions that need regular follow-up care?\", with possible answers \"Yes, within the practice\", \"Yes, outside the practice\", \"Yes, both within and outside the practice\" or \"No\". Other variables characterising general practitioners and their practices were considered. Mixed-effects logistic regression was performed.
RESULTS: The frequency of case managers within general practitioner practices varied greatly by country, with an overall trend towards an increase from 2012 to 2019. In the multivariate analysis, more case managers were found in practices located in small towns (odds ratio [OR] 1.4; 95% confidence interval [CI] 1.2-1.7) and in rural areas (OR 1.9; 95% CI 1.5-2.4) compared to cities. The frequency of case managers was higher in larger practices, as shown in comparisons of practices in the second, third and fourth quartile of full-time equivalent employee counts compared to those in the first quartile (Q2: OR 1.7, 95% CI 1.4-1.9; Q3: OR 2.1, 95% CI 1.6-2.9; Q4: OR 3.8, 95% CI 3.0-4.9). There was no significant difference in frequency with respect to the age and sex of the general practitioners.
CONCLUSIONS: The use of case managers in general practitioner practices is a promising approach, but its practice varies greatly. This practice has been developing in Western countries and is tending to increase. The implementation of case managers seems to be associated with certain characteristics linked to general practitioner practices (practice location, practice size), whereas it does not seem to depend on the personal characteristics of general practitioners, such as age or sex.

BACKGROUND: The topic of patient safety has been a subject of much discussion since the end of the last millennium. Ensuring patient safety is a central challenge in health care. An important tool to raise awareness for and learn from adverse events and thus promote patient safety are error-reporting and learning systems (Critical Incident Reporting System = CIRS).
METHODS: More than 17 years after its establishment, the CIRS \"jeder-fehler-zaehlt.de\" (JFZ) for German primary care has undergone a revision in terms of content and technology. The revised web-based system can be used for reporting as well as for classifying and analyzing incident reports. During this process, a descriptive analysis of the current report inventory was carried out, with a focus on serious medication errors. This included all 781 valid incident reports received between September 2004 and December 2021.
RESULTS: In 576 of the 781 reports (73.8%), the GP practice was directly involved in the critical incident. Among error types, process errors predominated (79.8% of the classifications, 99.1% of the reports) compared with knowledge and skills errors (20.2% of the classifications, 39.7% of the reports). Communication errors (63.0%) were the most common contributing factor to critical incidents, followed by flaws in tasks and measures (39.7%). Serious and permanent patient harm was rarely reported (8.3% of the reports), whereas temporary patient harm was more common (40.3% of the reports). Incident reports about medication errors with at least serious patient harm included, in particular, substances that affected blood clotting, corticosteroids, and opiates.
CONCLUSIONS: Our results complement the rates that are reported internationally for error types, patient harm, and contributing factors. Serious but preventable adverse events, so-called never events, are frequently associated with the medication process in both JFZ reports and the literature.
CONCLUSIONS: Critical incident reporting systems cannot provide accurate information about the frequency of errors in health care, but they can offer important insights into, for example, serious medication errors. Therefore, they offer both employees and healthcare institutions an opportunity for individual and institutional learning.

BACKGROUND: Consultation with primary healthcare professionals may provide an opportunity to identify patients at higher suicide risk.
OBJECTIVE: To explore primary care consultation patterns in the 5 years before suicide to identify suicide high-risk groups and common reasons for consulting.
METHODS: This was a case-control study using electronic health records from England, 2001 to 2019.
METHODS: An analysis was undertaken of 14 515 patients aged ≥15 years who died by suicide and up to 40 matched live controls per person who died by suicide (n = 580 159), (N = 594 674).
RESULTS: Frequent consultations (>1 per month in the final year) were associated with increased suicide risk (age- and sex -adjusted odds ratio [OR] 5.88, 95% confidence interval [CI] = 5.47 to 6.32). The associated rise in suicide risk was seen across all sociodemographic groups as well as in those with and without psychiatric comorbidities. However, specific groups were more influenced by the effect of high-frequency consultation (>1 per month in the final year) demonstrating higher suicide risk compared with their counterparts who consulted once: females (adjusted OR 9.50, 95% CI = 7.82 to 11.54), patients aged 15-<45 years (adjusted OR 8.08, 95% CI = 7.29 to 8.96), patients experiencing less socioeconomic deprivation (adjusted OR 6.56, 95% CI = 5.77 to 7.46), and those with psychiatric conditions (adjusted OR 4.57, 95% CI = 4.12 to 5.06). Medication review, depression, and pain were the most common reasons for which patients who died by suicide consulted in the year before death.
CONCLUSIONS: Escalating or more than monthly consultations are associated with increased suicide risk regardless of patients\' sociodemographic characteristics and regardless of the presence (or absence) of known psychiatric illnesses.

Australian cardiovascular disease (CVD) prevention guidelines recommend absolute CVD risk assessment, but less than half of eligible patients have the required risk factors recorded due to fragmented implementation over the last decade. Co-designed decision aids for general practitioners (GPs) and consumers have been developed that improve knowledge barriers to guideline-recommended CVD risk assessment and management. This study used a stakeholder consultation process to identify and pilot test the feasibility of implementation strategies for these decision aids in Australian primary care.
This mixed methods study included: (1) stakeholder consultation to map existing implementation strategies (2018-20); (2) interviews with 29 Primary Health Network (PHN) staff from all Australian states and territories to identify new implementation opportunities (2021); (3) pilot testing the feasibility of low, medium, and high resource implementation strategies (2019-21). Framework Analysis was used for qualitative data and Google analytics provided decision support usage data over time.
Informal stakeholder discussions indicated a need to partner with existing programs delivered by the Heart Foundation and PHNs. PHN interviews identified the importance of linking decision aids with GP education resources, quality improvement activities, and consumer-focused prevention programs. Participants highlighted the importance of integration with general practice processes, such as business models, workflows, medical records and clinical audit software. Specific implementation strategies were identified as feasible to pilot during COVID-19: (1) low resource: adding website links to local health area guidelines for clinicians and a Heart Foundation toolkit for primary care providers; (2) medium resource: presenting at GP education conferences and integrating the resources into audit and feedback reports; (3) high resource: auto-populate the risk assessment and decision aids from patient records via clinical audit software.
This research identified a wide range of feasible strategies to implement decision aids for CVD risk assessment and management. The findings will inform the translation of new CVD guidelines in primary care. Future research will use economic evaluation to explore the added value of higher versus lower resource implementation strategies.

Neisseria meningitidis causes life-threatening invasive diseases, such as sepsis, pneumonia, and meningitis. In Italy, as in many other countries, despite vaccination programs, the misdiagnosis of meningococcal infections and the persistence of vaccination hesitancy and of unvaccinated people can lead to possible epidemics. Following the CARE Guidelines, this case-report describes a young woman presented with fever and a strange rash to the General Practice out-of-hours in the island of Grado (Gorizia - Italy), lately recognized as Neisseria meningitidis infection. After a prompt evaluation, she was referred to a central hospital for correct diagnosis and treatment. Study and management of the case and its close-contacts was also carried out by the Prevention Department to provide prophylaxis. The Italian Ooh service is active every night, weekend and on holidays, representing an aid to limit improper access to the Emergency Department, but especially in rural areas, patients with urgent conditions also mainly go to the Ooh, first or alternatively to reach a hospital equipped with ER. The presented case underlines the fundamental role played by Ooh in the timely identification of a meningococcal infection in a patient presenting with non-neurological symptoms, making the correct referral to the specialist department of the nearest central hospital. It is essential to conduct a detailed medical history, even by telephone, and carry out a visit to evaluate the opportunity for hospital admission, especially to achieve early identification of life-threatening communicable diseases. It is also important that medical training, even after graduation, emphasizes the importance of maintaining awareness and making rapid recognition of the key symptoms of these conditions, although rare.

BACKGROUND: Despite longstanding problems of access to general practice, attempts to understand and address the issues do not adequately include perspectives of the people providing or using care, nor do they use established theories of access to understand complexity.
OBJECTIVE: To understand problems of access to general practice from the multiple perspectives of service users and staff using an applied theory of access.
METHODS: A qualitative participatory case study in an area of northwest England.
METHODS: A community-based participatory approach was used with qualitative interviews, focus groups, and observation to understand perspectives about accessing general practice. Data were collected between October 2015 and October 2016. Inductive and abductive analysis, informed by Levesque et al\'s theory of access, allowed the team to identify complexities and relationships between interrelated problems.
RESULTS: This study presents a paradox of problems in accessing general practice, in which the demand on general practice both creates and hides unmet need in the population. Data show how reactive rules to control demand have undermined important aspects of care, such as continuity. The layers of rules and decreased continuity create extra work for practice staff, clinicians, and patients. Complicated rules, combined with a lack of capacity to reach out or be flexible, leave many patients, including those with complex and/or unrecognised health needs, unable to navigate the system to access care. This relationship between demand and unmet need exacerbates existing health inequities.
CONCLUSIONS: Understanding the paradox of access problems allows for different targets for change and different solutions to free up capacity in general practice to address the unmet need in the population.

BACKGROUND: Digital applications that automatically extract information from electronic medical records and provide comparative visualizations of the data in the form of quality indicators to primary care practices may facilitate local quality improvement (QI). A necessary condition for such QI to work is that practices actively access the data. The purpose of this study was to explore the use of an application that visualizes quality indicators in Swedish primary care, developed by a profession-led QI initiative (\"Primärvårdskvalitet\"). We also describe the characteristics of practices that used the application more or less extensively, and the relationships between the intensity of use and changes in selected performance indicators.
METHODS: We studied longitudinal data on 122 primary care practices\' visits to pages (page views) in the application over a period up to 5 years. We compared high and low users, classified by the average number of monthly page views, with respect to practice and patient characteristics as well as baseline measurements of a subset of the performance indicators. We estimated linear associations between visits to pages with diabetes-related indicators and the change in measurements of selected diabetes indicators over 1.5 years.
RESULTS: Less than half of all practices accessed the data in a given month, although most practices accessed the data during at least one third of the observed months. High and low users were similar in terms of most studied characteristics. We found statistically significant positive associations between use of the diabetes indicators and changes in measurements of three diabetes indicators.
CONCLUSIONS: Although most practices in this study indicated an interest in the automated feedback reports, the intensity of use can be described as varying and on average limited. The positive associations between the use and changes in performance suggest that policymakers should increase their support of practices\' QI efforts. Such support may include providing a formalized structure for peer group discussions of data, facilitating both understanding of the data and possible action points to improve performance, while maintaining a profession-led use of applications.

Pharmacists are increasingly joining the general practice skill-mix. Research is still in relative infancy, but barriers and facilitators to their integration are emerging, as well as indications that pharmacists\' skillset remain underutilised. This study explores first-hand experiences and perspectives among general practice teams of the processes that underpin the effective integration and sustained contribution of pharmacists in general practice.
This research employed a qualitative case study approach involving general practice teams in Wales. Data were collected from eight general practices where each practice represented one case study. Data were collected via online interviews (one-to-one or group) and written feedback. Data were pattern coded and analysed thematically through a constant comparative approach. Data interpretations were confirmed with participants and wider general practice teams.
Eight general practice teams across Wales (comprising combinations of practice and business managers, general practitioners (GPs) and general practice pharmacists) represented eight case studies. Cases were required to have had experience of working with a general practice pharmacist.
Data were yielded from five practice managers, two GPs, three general practice pharmacists and a business manager. A total of 3 hours and 2 min of interview data was recorded as well as 2038 words of written feedback. Three foundations to pharmacists\' effective contribution to general practice were identified: defining the role (through identifying the right pharmacist, mapping skillset to demand and utilising the increasing need for specialist skills), appropriate infrastructure and workforce review, and an appropriate employment model.
Pharmacists are becoming increasingly critical to the general practice skill-mix and utilisation of their specialist skillset is crucial. This paper identifies how to enable the effective integration and sustained contribution of pharmacists to general practice.

OBJECTIVE: In 2018, NHS England mandated that all patients in England should be able to access general practice services outside of ordinary hours. While some patients would access additional hours at their own practice, others would need supra-practice level provision - that is, they would be seen in a different location and by a different care team. The policy aim was to enhance patient access to care, with a particular focus on those who work during the day. This study examines (a) how supra-practice level provision of extended access appointments for general medical problems are operationalised and (b) whether the aims of the policy are being met.
METHODS: This study presents qualitative comparative case studies of two contrasting service providers offering extended access. The data collected included 30 hours of clinician-patient observations, 25 interviews with staff, managers, and commissioners, 20 interviews with patients, organisational protocols/documentation, and routinely collected appointment data. Thematic analysis ran concurrently with data gathering and facilitated the iterative adaptation of data collection.
RESULTS: Three cross-cutting themes were identified: extended access is being used to bolster a struggling primary care system, extended access provides a different service to in-hours general practice, and it is difficult for extended access to provide seamless care.
CONCLUSIONS: Supra-practice access models can provide effective care for most patients with straightforward issues. When ongoing management of complex problems is required, this model of patient care can be problematic.

Rural medical training along all components of the medical training continuum has been shown to enhance rural workforce outcomes. However, due to the maldistribution of the Australian medical workforce, health services of increased rurality are limited in their ability to fulfil the supervision requirements for all levels of trainees, especially junior doctor training. Although longitudinal program design and pedagogy has flourished in medical school education through the Longitudinal Integrated Clerkship model, this has not yet been widely translated to prevocational training. This study describes how a longitudinal program design was conceptualised and implemented within a rural health service to create a novel internship program.
A descriptive case study methodology was employed to describe and evaluate the longitudinal integrated internship program. Relevant program documents such as rosters and accreditation submissions were reviewed to aid in describing the program. Interviews with participants involved in the program were conducted during the middle (May) and end (November) points of the program\'s first year (2021) to investigate perspectives and experiences of the internship model.
Each week, interns were rostered for 1 day in the hospital\'s emergency department and 3 days in general surgery or general medicine, swapping disciplines after 6 months. In this way, interns completed core rotations longitudinally, meeting accreditation and supervision requirements. Additionally, 1 day per week was spent parallel consulting in general practice. Participants described program enablers as the organisational vision and staff buy-in, as well as the longitudinal attachments to disciplines. Barriers identified were the tenuous nature of the medical workforce and long-term sustainability of the program. Benefits of the program included value-adding and preparedness for practice, particularly in a rural context.
Intern programs that meet the accreditation, supervision and learning requirements can be successfully delivered at rural health services through longitudinal models of medical education. As the intern year is a key component of the rural generalist training pathway, development of similar innovative models provides the opportunity for rural communities to grow their own future medical workforce.