European Primary Care Research Articles

Alcohol dependence and treatment utilization in Europe - a representative cross-sectional study in primary care.

BackgroundAlcohol dependence (AD) in Europe is prevalent and causes considerable health burden. Recognition by general practitioners (GPs) and provision of or referral to treatment may contribute to reduce this burden. This paper studied AD prevalence in varying European primary care settings and examined who received treatment.MethodsIn a cross-sectional multi-centre study in six European countries, 358 general practitioners assessed 13,003 primary care patients between January 2013 and January 2014, of which 8,476 patients were interviewed, collecting information on socio-demographics, physical and mental problems, and on alcohol use, problems and treatment. AD diagnoses were determined by GPs’ clinical judgement and a standardized interview. A wide definition for AD treatment included individual and group interventions provided by different health professionals. Descriptive as well as inferential statistics were employed.ResultsAD was prevalent among patients in European primary health care settings (8.7 %, 95 % confidence interval (CI): 8.1-9.3 %). Treatment rates were low (22.3 % of all AD cases, 95 % CI: 19.4-25.2 %). For both prevalence and treatment utilization, considerable country variations were observed. AD was associated with a number of socio-economic disadvantages (e.g. higher unemployment rate) and higher physical (e.g., liver disease, hypertension) and mental comorbidities (e.g., depression, anxiety). Liver problems, mental distress and daily amount of alcohol used were higher among treated versus untreated male patients with AD.ConclusionA minority of people identified as having AD received treatment, showing heavier drinking patterns and a higher level of co-morbidity. Different types of treatment, depending on severity of AD, should be considered.Electronic supplementary materialThe online version of this article (doi:10.1186/s12875-015-0308-8) contains supplementary material, which is available to authorized users.

Is a practice-based rural research network feasible in Europe?

Research in family medicine is a well-established entity nationally and internationally, covering all aspects of primary care including remote and isolated practices. However, due to limited capacity and resources in rural family medicine, its potential is not fully exploited yet. An idea to foster European rural primary care research by establishing a practice-based research network has been recently put forward by several members of the European Rural and Isolated Practitioners Association (EURIPA) and the European General Practice Research Network (EGPRN). Two workshops on why, and how to design a practice-based research network among rural family practices in Europe were conducted at two international meetings. This paper revisits the definition of practice-based research in family medicine, reflects on the current situation in Europe regarding the research in rural family practice, and discusses a rationale for practice-based research in rural family medicine. A SWOT analysis was used as the main tool to analyse the current situation in Europe regarding the research in rural family practice at both meetings. The key messages gained from these meetings may be employed by the Wonca Working Party on research, the International Federation of Primary Care Research Network and the EGPRN that seek to introduce a practice-based research approach. The cooperation and collaboration between EURIPA and EGPRN creates a fertile ground to discuss further the prospect of a European practice-based rural family medicine research network, and to draw on the joint experience.

Hip/femur fractures associated with the use of benzodiazepines (anxiolytics, hypnotics and related drugs): a methodological approach to assess consistencies across databases from the PROTECT-EU project.

Results from observational studies may be inconsistent because of variations in methodological and clinical factors that may be intrinsically related to the database (DB) where the study is performed. The objectives of this paper were to evaluate the impact of applying a common study protocol to study benzodiazepines (BZDs) (anxiolytics, hypnotics, and related drugs) and the risk of hip/femur fracture (HFF) across three European primary care DBs and to investigate any resulting discrepancies. To measure the risk of HFF among adult users of BZDs during 2001-2009, three cohort and nested case control (NCC) studies were performed in Base de datos para la Investigación Farmacoepidemiológica en Atención Primaria (BIFAP) (Spain), Clinical Practice Research Datalink (CPRD) (UK), and Mondriaan (The Netherlands). Four different models (A-D) with increasing levels of adjustment were analyzed. The risk according to duration and type of BZD was also explored. Adjusted hazard ratios (cohort), odds ratios (NCC), and their 95% confidence intervals were estimated. Adjusted hazard ratios (Model C) were 1.34 (1.23-1.47) in BIFAP, 1.66 (1.54-1.78) in CPRD, and 2.22 (1.55-3.29) in Mondriaan in cohort studies. Adjusted odds ratios (Model C) were 1.28 (1.16-1.42) in BIFAP, 1.60 (1.49-1.72) in CPRD, and 1.48 (0.89-2.48) in Mondriaan in NCC studies. A short-term effect was suggested in Mondriaan, but not in CPRD or BIFAP. All DBs showed an increased risk with the concomitant use of anxiolytic and hypnotic drugs. Applying similar study methods to different populations and DBs showed an increased risk of HFF in BZDs users but differed in the magnitude of the risk, which may be because of inherent differences between DBs.

Conceptual framework of integrated care and options for integration in primary care

Nowadays, several countries' health governments have recognized that the complex treatment of chronic diseases, prevention and rehabilitation requires a new approach. This study presents the possible solution of integrated service delivery in health and other sectors. Furthermore, it shows how the integration of primary care services was implemented and how the integration of different levels of providers changes the organization of care. This study is based on an overview of the relevant international literature, as well as the 5th European Primary Care Forum. The comprehensive approach of integrated care and adaption of the needs of local communities encourage the development of new organizational forms and services in primary care. The integrated service forms are more suitable to satisfy the needs of patients and communities and provide wide range of services, but it is important to find the appropriate dimensions of integration which would fit our goals.

A cross-sectional study of socio-demographic factors associated with patient access to primary care in Slovenia.

IntroductionPrimary care (PC) is the provision of universally accessible, integrated, person-centred, comprehensive health and community services. Professionals active in primary care teams include family physicians and general practitioners (FP/GPs). There is concern in Slovenia that the current economic crisis might change the nature of PC services. Access, one of the most basic requirements of general practice, is universal in Slovenia, which is one of the smallest European countries; under national law, compulsory health insurance is mandatory for its citizens. Our study examined access to PC in Slovenia during a time of economic crisis as experienced and perceived by patients between 2011 and 2012, and investigated socio-demographic factors affecting access to PC in Slovenia.MethodsData were collected as a part of a larger international study entitled Quality and Costs of Primary Care in Europe (QUALICOPC) that took place during a period of eight months in 2011 and 2012. 219 general practices were included; in each, the aim was to evaluate 10 patients. Dependent variables covered five aspects of access to PC: communicational, cultural, financial, geographical and organizational. 15 socio-demographic factors were investigated as independent variables. Descriptive statistics, factor analysis and multilevel analysis were applied.ResultsThere were 1,962 patients in the final sample, with a response rate of 89.6%. The factors with the most positive effect on access to PC were financial and cultural; the most negative effects were caused by organizational problems. Financial difficulties were not a significant socio-demographic factor. Greater frequency of visits improves patients’ perception of communicational and cultural access. Deteriorating health conditions are expected to lower perceived geographical access. Patients born outside Slovenia perceived better organizational access than patients born in Slovenia.ConclusionsUniversal medical insurance in Slovenia protects most patients from PC inaccessibility. However, problems perceived by patients may indicate the need for changes in the organization of PC.Electronic supplementary materialThe online version of this article (doi:10.1186/s12939-015-0166-y) contains supplementary material, which is available to authorized users.

General practitioners recognizing alcohol dependence: a large cross-sectional study in 6 European countries.

Although alcohol dependence causes marked mortality and disease burden in Europe, the treatment rate is low. Primary care could play a key role in reducing alcohol-attributable harm by screening, brief interventions, and initiating or referral to treatment. This study investigates identification of alcohol dependence in European primary care settings. Assessments from 13,003 general practitioners, and 9,098 interviews (8,476 joint number of interviewed patients with a physician's assessment) were collected in 6 European countries. Alcohol dependence, comorbidities, and health service utilization were assessed by the general practitioner and independently using the Composite International Diagnostic Interview (CIDI) and other structured interviews. Weighted regression analyses were used to compare the impact of influencing variables on both types of diagnoses. The rate of patients being identified as alcohol dependent by the CIDI or a general practitioner was about equally high, but there was not a lot of overlap between cases identified. Alcohol-dependent patients identified by a physician were older, had higher rates of physicial comorbidity (liver disease, hypertension), and were socially more marginalized, whereas average consumption of alcohol and mental comorbidity were equally high in both groups. General practitioners were able to identify alcohol dependence, but the cases they identified differed from cases identified using the CIDI. The role of the CIDI as the reference standard should be reexamined, as older alcohol-dependent patients with severe comorbidities seemed to be missed in this assessment.

Clinicians' views and experiences of interventions to enhance the quality of antibiotic prescribing for acute respiratory tract infections.

Evidence shows a high rate of unnecessary antibiotic prescriptions in primary care in Europe and the United States. Given the costs of widespread use and associated antibiotic resistance, reducing inappropriate use is a public health priority. We aimed to explore clinicians' experiences of training in communication skills and use of a patient booklet and/or a C-reactive protein (CRP) point-of-care test to reduce antibiotic prescribing for acute respiratory tract infections (RTIs). We used a qualitative research approach, interviewing clinicians who participated in a randomised controlled trial (RCT) testing two contrasting interventions. General practice clinicians in Belgium, England, The Netherlands, Poland, Spain and Wales participated in the study. Sixty-six semi-structured interviews were transcribed verbatim, translated into English where necessary, and analysed using thematic and framework analysis. Clinicians from all countries attributed benefits for themselves and their patients to using both interventions. Clinicians reported that the communication skills training and use of the patient booklet gave them greater confidence in addressing patient expectations for an antibiotic by providing answers to common questions and supporting the clinician's own explanations. Clinicians felt the booklet could be used for a variety of patients and for different types of infections. The CRP test was viewed as a tool to decrease diagnostic uncertainty, to support non-prescription decisions, and to reassure patients, but was only necessary when clinicians were uncertain about the need for antibiotics. Providing clinicians with training and support tools for use in practice was received positively and was valued by clinicians across countries. Interventions seemed to have influenced behaviour by increasing clinician knowledge about illness severity and prescribing, increasing confidence in making non-prescribing decisions when antibiotics were unnecessary, and enabling clinicians to anticipate positive outcomes when making such decisions. Addressing such determinants of behaviour change enabled interventions to be relevant for clinicians working across different contexts.

Primary care workforce development in Europe

Background: There is a large variation in the organization of primary care in Europe. In some health care systems, primary care is the gatekeeper to more specialized care, whilst in others patients have the choice between a wide range of providers. Primary care has increasingly become teamwork. Methods: To describe the composition of primary care teams in European countries and to describe urban-rural differences. We will present data from the EU co-funded QUALICOPCstudy that collected information about primary care in 34 countries mainly in Europe, but also including Australia, New Zealand and Canada. The study is based on a sample of GPs in each country. The total number of GPs is approximately 6,500. Results: In some European countries, primary care is mainly provided by GPs in single-handed practices who work together with a nurse or receptionist, e.g. in Austria and Slovakia. However, there are also countries, such as Spain, where on average 12 GPs and more than 6 different professional groups work together. The most common non-physicians in primary care teams are practice nurses, receptionists/medical secretaries, community/home care nurses and midwives. With respect to professional groups working in rural and urban primary care practices, some countries have more diversity in urban primary care practices (Cyprus 5.6 different professional groups in urban settings vs 3.0 in rural) whereas other countries have more diversity in rural practices (Norway 1.6 in urban vs 3.2 in rural settings). Conclusion: This paper is included in the Workshop because the integration challenges facing primary care are common to all countries. Comparative analysis of the organization of primary care, and the available skill mix variation, contribute to the understanding of the limitations and opportunities of integration. Key messages The organizational scale of primary care and its level of integration is highly context dependent. There is room for optimization of the primary care skill mix in many countries.

IS-057 Cutting On Antibiotics In Primary Care: What Can Be Done?

Antibiotics are the most common prescription drugs given to children, 75% percent of which are for acute respiratory tract infections (ARTIs). Since antibiotic prescribing is linked with antibiotic resistance, an ongoing effort is taking place to reduce prescribing and use of these medications. Although a decline in antibiotic prescribing for ARTIs has been recently documented in the US and UK, prescription of broad instead of narrow spectrum antibiotics is a major problem. A survey examining European primary care paediatricians’ knowledge attitude and practice regarding ARTIs and antibiotics will be presented. The study pointed at a need for an educational intervention based on the risk-benefit analysis associated with the antibiotic prescribing for minor URIs, to reduce inappropriate prescribing. Several strategies aimed either at clinicians to reduce prescribing or at caregivers to reduce antibiotic use will be presented. Multi-faceted approaches aimed at clinicians and parents have proven most effective in reducing prescribing. The effectiveness increased if structuring the clinician-parent interaction during the visit took place, and when computerised automatic prescribing prompts were used. The use of waiting room material was ineffective. Use of antibiotics by caregivers was reduced when delayed prescriptions were given. Report from an antibiotic stewardship program in the US has recently been published. A one year program of personalised quarterly audit and feedback on prescribing through the computerised health record system succeeded to reduce broad spectrum antibiotic prescribing for ARTIs.

Under the same roof: co-location of practitioners within primary care is associated with specialized chronic care management.

BackgroundInternational and national bodies promote interdisciplinary care in the management of people with chronic conditions. We examine one facilitative factor in this team-based approach - the co-location of non-physician disciplines within the primary care practice.MethodsWe used survey data from 330 General Practices in Ontario, Canada and New Zealand, as a part of a multinational study using The Quality and Costs of Primary Care in Europe (QUALICOPC) surveys. Logistic and linear multivariable regression models were employed to examine the association between the number of disciplines working within the practice, and the capacity of the practice to offer specialized and preventive care for patients with chronic conditions.ResultsWe found that as the number of non-physicians increased, so did the availability of special sessions/clinics for patients with diabetes (odds ratio 1.43, 1.25–1.65), hypertension (1.20, 1.03–1.39), and the elderly (1.22, 1.05–1.42). Co-location was also associated with the provision of disease management programs for chronic obstructive pulmonary disease, diabetes, and asthma; the equipment available in the centre; and the extent of nursing services.ConclusionsThe care of people with chronic disease is the ‘challenge of the century’. Co-location of practitioners may improve access to services and equipment that aid chronic disease management.Electronic supplementary materialThe online version of this article (doi:10.1186/1471-2296-15-149) contains supplementary material, which is available to authorized users.

Do pediatricians apply the 2009 NASPGHAN-ESPGHAN guidelines for the diagnosis and management of gastroesophageal reflux after being trained?

According to a recent survey, the 2009 North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition-European Society for Pediatric Gastroenterology, Hepatology, and Nutrition gastroesophageal reflux guidelines are poorly adhered to by European primary care pediatricians. The main issue raised from the survey was the prescription of unnecessary acid suppressive medications, especially in infants. No inquiry into the reasons was made. The primary objective of the present study was to assess the applicability of the guidelines in European primary care pediatricians undergoing specific trainings. One hundred pediatricians involved in the previous survey agreed to participate and were randomly divided into 2 groups: one group was trained in the guidelines through an online podcast and the other group was trained through a synopsis. During the following 3 months, each involved pediatrician was asked to enroll every consecutive infant, child, or adolescent with suggestive reflux symptoms. For every enrolled patient, pediatricians filled in a report concerning their diagnostic and therapeutic choices. A total of 382 patients (boys/girls 186/196, infants/children/adolescents 194/123/65) were enrolled by pediatricians. Infants with unexplained crying and/or distressed behavior who were prescribed proton-pump inhibitors were 3.7% compared with 45.2% of the survey data obtained before the training (P < 0.05). Infants with uncomplicated recurrent regurgitation and vomiting who were prescribed proton-pump inhibitors were 4.5% against 37.1% of the baseline survey data (P < 0.05). The overall rate of children managed in full compliance with the guidelines was 46.1% after the training compared with 1.8% before the training (P < 0.05). No significant differences were seen between pediatricians from podcast and synopsis group. The North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition-European Society for Pediatric Gastroenterology, Hepatology, and Nutrition gastroesophageal reflux guidelines have good applicability, despite that they are presently poorly adhered to by European primary care pediatricians. Simple, inexpensive trainings were proven to be effective in increasing adherence by pediatricians. The increase in compliance clearly favors the role of continuous medical education through simple educational tools and subsequent assessment of practice.

Vitamin K Antagonist Treatment in Patients With Atrial Fibrillation and Time in Therapeutic Range in Four European Countries

PurposePatients with atrial fibrillation are at increased risk for stroke and thus require anticoagulant prophylaxis with vitamin K antagonists. However, many such patients fail to achieve target coagulation status. The objective of this study was to evaluate time in the therapeutic range and its relationship to clinical outcomes in patients with nonvalvular atrial fibrillation prescribed a vitamin K antagonist in everyday clinical practice in 4 European countries (France, Germany, Italy and the United Kingdom). MethodsData were extracted from the European electronic primary care database, the Longitudinal Patient Database. Included in the analysis were 6250 adult patients for whom data on monitoring of coagulation time and international normalized ratio were available. The time within the therapeutic range was estimated by using the Rosendaal method. Patients spending >70% of time within the therapeutic range were considered to have well-controlled treatment. Data on stroke and bleeding events occurring during the study period were taken from patient records. Stroke risk was calculated by using the CHA2DS2-VASc score (i.e. 2 points for a history of stroke or TIA and age >75years, and 1 point for age between 65 and 74 years, hypertension, diabetes mellitus, a recent cardiac failure, vascular disease and female sex). FindingsThe proportion of patients with poorly controlled treatment varied from 34.6% in the United Kingdom to 55.8% in Germany. The incidence of stroke was 0.5/100 person-years in well-controlled patients, compared with 1.0/100 in poorly controlled patients. After adjustment for stroke risk factors, the odds ratio was 1.38 (95% CI, 0.93–2.06; P = 0.110). The incidence of hemorrhage was 1.1 and 1.3 events/100 person-years, respectively (odds ratio, 0.91 [95% CI, 0.72–1.16]). ImplicationsMany patients receiving prophylaxis with vitamin K antagonists in everyday community care have poorly controlled anticoagulation treatment with vitamin K antagonists. Their international normalized ratio is frequently outside the therapeutic range, and they are thus exposed to an unnecessary risk of stroke or bleeding complications.

Ascertainment of acute liver injury in two European primary care databases.

The purpose of this study was to ascertain acute liver injury (ALI) in primary care databases using different computer algorithms. The aim of this investigation was to study and compare the incidence of ALI in different primary care databases and using different definitions of ALI. The Clinical Practice Research Datalink (CPRD) in UK and the Spanish "Base de datos para la Investigación Farmacoepidemiológica en Atención Primaria" (BIFAP) were used. Both are primary care databases from which we selected individuals of all ages registered between January 2004 and December 2009. We developed two case definitions of idiopathic ALI using computer algorithms: (i) restrictive definition (definite cases) and (ii) broad definition (definite and probable cases). Patients presenting prior liver conditions were excluded. Manual review of potential cases was performed to confirm diagnosis, in a sample in CPRD (21%) and all potential cases in BIFAP. Incidence rates of ALI by age, sex and calendar year were calculated. In BIFAP, all cases considered definite after manual review had been detected with the computer algorithm as potential cases, and none came from the non-cases group. The restrictive definition of ALI had a low sensitivity but a very high specificity (95% in BIFAP) and showed higher rates of agreement between computer search and manual review compared to the broad definition. Higher incidence rates of definite ALI in 2008 were observed in BIFAP (3.01 (95% confidence interval (CI) 2.13-4.25) per 100,000 person-years than CPRD (1.35 (95% CI 1.03-1.78)). This study shows that it is feasible to identify ALI cases if restrictive selection criteria are used and the possibility to review additional information to rule out differential diagnoses. Our results confirm that idiopathic ALI is a very rare disease in the general population. Finally, the construction of a standard definition with predefined criteria facilitates the timely comparison across databases.

ARE ROMANIAN FAMILY DOCTORS READY FOR HEALTH 2020

CONTEXT: Primary care has the potential to effectively address the most pressing challenges to the Romanian health system. A series of international health systems surveys have recently been conducted to evaluate primary care in the country. We present selected findings from a recent European Commission-funded study: Quality and Costs of Primary Care in Europe ( QUALICOPC). METHOD: We have selected findings from this study which we believe are key in addressing Romania’s health system challenges. To do this, we used the priority area recommendations from the World Health Organization European Region’s Health 2020 strategic policy framework as a guide. RESULTS: Study results are presented for primary care provision to the elderly, harmful alcohol use, mental health, service integration and professional relations in primary care. CONCLUSIONS: Using Health 2020 to explore survey results was helpful in framing the QUALICOPC results. Our analysis shows that family doctors in Romania have improved their performance and are better positioned towards strengthening primary health care. Keywords: Health 2020, family doctors, primary health care, management, health policies, health care study, health systems

Patient-centred interprofessional collaboration in primary care: challenges for clinical, educational and health services research. An EGPRN keynote paper

The theme ‘patient-centred interprofessional collaboration’ of the EGPRN conference in October 2012, captures in just three words important challenges for European primary care and its research agenda. Challenges for future research are formulated, in three domains: clinical, educational and health services research. Transferability of research, based upon advanced computational infrastructure, will facilitate a rapid learning health care system. In educational research, this includes the use of observational and reflexivity methods. Outcomes should be defined in terms of improvement of functional status and social participation rather than in terms of disease-specific outcomes. Partnership with all stakeholders, patients, GPs and their health care colleagues and students, can help in reducing avoidable waste in the production and reporting of research evidence.

Development of an algorithm to predict the incidence of major depression among primary care consultants

The reduction of major depression incidence is a public health challenge. To develop an algorithm to estimate the risk of occurrence of major depression in patients attending primary health centers (PHC). Prospective cohort study of a random sample of 2832 patients attending PHC centers in Concepción, Chile, with evaluations at baseline, six and twelve months. Thirty nine known risk factors for depression were measured to build a model, using a logistic regression. The algorithm was developed in 2,133 patients not depressed at baseline and compared with risk algorithms developed in a sample of 5,216 European primary care attenders. The main outcome was the incidence of major depression in the follow-up period. The cumulative incidence of depression during the 12 months follow up in Chile was 12%. Eight variables were identified. Four corresponded to the patient (gender, age, depression background and educational level) and four to patients' current situation (physical and mental health, satisfaction with their situation at home and satisfaction with the relationship with their partner). The C-Index, used to assess the discriminating power of the final model, was 0.746 (95% confidence intervals (CI = 0,707-0,785), slightly lower than the equation obtained in European (0.790 95% CI = 0.767-0.813) and Spanish attenders (0.82; 95% CI = 0.79-0.84). Four of the factors identified in the risk algorithm are not modifiable. The other two factors are directly associated with the primary support network (family and partner). This risk algorithm for the incidence of major depression provides a tool that can guide efforts towards design, implementation and evaluation of effectiveness of interventions to prevent major depression.

Medication use in European primary care patients with lower respiratory tract infection: an observational study

BACKGROUND It is largely unknown what medication is used by patients with lower respiratory tract infection (LRTI). AIM To describe the use of self-medication and prescribed medication in adults presenting with LRTI in different European countries, and to relate self-medication to patient characteristics. DESIGN AND SETTING An observational study in 16 primary care networks in 12 European countries. METHOD A total of 2530 adult patients presenting with LRTI in 12 European countries filled in a diary on any medication used before and after a primary care consultation. Patient characteristics related to self-medication were determined by univariable and multivariable logistic regression analysis. RESULTS The frequency and types of medication used differed greatly between European countries. Overall, 55.4% self-medicated before consultation, and 21.5% after consultation, most frequently with paracetamol, antitussives, and mucolytics. Females, non-smokers, and patients with more severe symptoms used more self-medication. Patients who were not prescribed medication during the consultation self-medicated more often afterwards. Self-medication with antibiotics was relatively rare. CONCLUSION A considerable amount of medication, often with no proven efficacy, was used by adults presenting with LRTI in primary care. There were large differences between European countries. These findings should help develop patient information resources, international guidelines, and international legislation concerning the availability of over-the-counter medication, and can also support interventions against unwarranted variations in care. In addition, further research on the effects of symptomatic medication is needed.

Healthcare for migrants, participatory health research and implementation science—better health policy and practice through inclusion. The RESTORE project

Background: This is a time of unprecedented mobility across the globe. Healthcare systems need to adapt to ensure that primary care is culturally and linguistically appropriate for migrants. Evidence-based guidelines and training interventions for cultural competence and the use of professional interpreters are available across European healthcare settings. However, in real-world practice migrants and their healthcare providers ‘get by’ with a range of informal and inadequate strategies. RESTORE is an EU FP7 funded project, which is designed to address this translational gap.Objectives: The objective of RESTORE is to investigate and support the implementation of guidelines and training initiatives to support communication in cross-cultural consultations in selected European primary care settings.Design: RESTORE is a qualitative, participatory health project running from 2011–2015. It uses a novel combination of normalization process theory and participatory learning and action research to follow and shape the implementation journeys of relevant guidelines and training initiatives. Research teams in Ireland, England, the Netherlands, Austria and Greece are conducting similar parallel qualitative case study fieldwork, with a complementary health policy analysis led by Scotland. In each setting, key stakeholders, including migrants, are involved in participatory data generation and analysis.Expected results: RESTORE will provide knowledge about the levers and barriers to the implementation of guidelines and training initiatives in European healthcare settings and about successful, transferrable strategies to overcome identified barriers. RESTORE will elucidate the role of policy in shaping these implementation journeys; generate recommendations for European policy driving the development of culturally and linguistically appropriate healthcare systems.

The strength of primary care in Europe: an international comparative study

A suitable definition of primary care to capture the variety of prevailing international organisation and service-delivery models is lacking. Evaluation of strength of primary care in Europe. International comparative cross-sectional study performed in 2009-2010, involving 27 EU member states, plus Iceland, Norway, Switzerland, and Turkey. Outcome measures covered three dimensions of primary care structure: primary care governance, economic conditions of primary care, and primary care workforce development; and four dimensions of primary care service-delivery process: accessibility, comprehensiveness, continuity, and coordination of primary care. The primary care dimensions were operationalised by a total of 77 indicators for which data were collected in 31 countries. Data sources included national and international literature, governmental publications, statistical databases, and experts' consultations. Countries with relatively strong primary care are Belgium, Denmark, Estonia, Finland, Lithuania, the Netherlands, Portugal, Slovenia, Spain, and the UK. Countries either have many primary care policies and regulations in place, combined with good financial coverage and resources, and adequate primary care workforce conditions, or have consistently only few of these primary care structures in place. There is no correlation between the access, continuity, coordination, and comprehensiveness of primary care of countries. Variation is shown in the strength of primary care across Europe, indicating a discrepancy in the responsibility given to primary care in national and international policy initiatives and the needed investments in primary care to solve, for example, future shortages of workforce. Countries are consistent in their primary care focus on all important structure dimensions. Countries need to improve their primary care information infrastructure to facilitate primary care performance management.

Political, cultural and economic foundations of primary care in Europe

This article explores various contributing factors to explain differences in the strength of the primary care (PC) structure and services delivery across Europe. Data on the strength of primary care in 31 European countries in 2009/10 were used. The results showed that the national political agenda, economy, prevailing values, and type of healthcare system are all important factors that influence the development of strong PC. Wealthier countries are associated with a weaker PC structure and lower PC accessibility, while Eastern European countries seemed to have used their growth in national income to strengthen the accessibility and continuity of PC. Countries governed by left-wing governments are associated with a stronger PC structure, accessibility and coordination of PC. Countries with a social-security based system are associated with a lower accessibility and continuity of PC; the opposite is true for transitional systems. Cultural values seemed to affect all aspects of PC. It can be concluded that strengthening PC means mobilising multiple leverage points, policy options, and political will in line with prevailing values in a country.