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The Research Agenda for General Practice/Family
Medicine and Primary Health Care in Europe.
Part 1. Background and methodology 1
Article in The European journal of general practice · December 2009
DOI: 10.3109/13814780903452184 · Source: PubMed

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European Journal of General Practice, 2009; 15: 243–250

BACKGROUND PAPER

Eur J Gen Pract Downloaded from informahealthcare.com by Universiteit Antwerpen Bibliotheek
For personal use only.

The Research Agenda for General Practice/Family Medicine and
Primary Health Care in Europe. Part 1. Background and methodology1

EVA HUMMERS-PRADIER1, MARTIN BEYER2, PATRICK CHEVALLIER3,
SOPHIA EILAT-TSANANI4,5, CHRISTOS LIONIS6, LIEVE PEREMANS7,8,
DAVORINA PETEK9, IMRE RURIK10, JEAN KARL SOLER11, HENRI EJH STOFFERS12,
PINAR TOPSEVER13, MEHMET UNGAN14 & PAUL VAN ROYEN15
1Institute

of General Practice, Hannover Medical School, Hannover, Germany, 2Institute for General Practice, University of
Frankfurt, Frankfurt, Germany, 3Department of General Practice, Saint-Quentin University Versailles, France, 4Department of
Family Medicine, Emek Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Israel, 5Afula and the
valleys, Clalit Health Services, Northern District, 6Clinic of Social and Family Medicine, and Department of Social Medicine,
University of Crete, Crete, Greece, 7Department of Primary and Interdisciplinary University of Antwerp, Antwerp, Belgium,
8Department of Youth Health,Vrije Universiteit of Brussels, Brussels, Belgium, 9Department of Family Medicine, Medical School,
University of Ljubljana, Slovenia, 10Department of Family Medicine, University Debrecen, Hungary, 11Mediterranean Institute of
Primary Care, Attard, Malta, 12Department of General Practice, School of Public Health and Primary Care (CAPHRI),
Maastricht University Medical Centre, Maastricht, The Netherlands, 13Department of Family Medicine, Acibadem University,
Istanbul, Turkey, 14Middle East Technical University Medical Centre, Ankara, Turkey, 15Department of Primary and
Interdisciplinary Care, University of Antwerp, Belgium

Abstract
At the WONCA Europe conference 2009 the recently published ‘Research Agenda for General Practice/Family Medicine and
Primary Health Care in Europe’ was presented. The Research Agenda is a background paper and reference manual for GPs/
family doctors, researchers and policy makers, providing advocacy of general practice/family medicine GP/FM in Europe. The
Research Agenda summarizes the evidence relating to the core competencies and characteristics of the WONCA Europe
definition of GP/FM, and its meaning for researchers and policy makers. Evidence gaps and research needs are pointed out
to provide a basis for planning research for which there is a need and for action that may influence health and research policy,
i.e. applying/lobbying for research funds. WONCA Europe and its associated networks and special interest groups could
consider the agenda’s research priorities when planning future conferences, courses, or projects, and for funding purposes.
The European Journal of General Practice will publish a series of articles based on this document. In this first article, background,
objectives, methodology and relevant literature are discussed. In subsequent articles, the results will be presented.
Key words: General practice/family medicine, research agenda

The European General Practice Research Network
(EGPRN, www.egprn.org) recently published their
‘Research Agenda for General Practice/Family Medicine and Primary Health Care in Europe’ and presented it at the WONCA Europe conference in Basel
in September 2009 (1). The Research Agenda was
developed upon request of WONCA Europe, using
both a systematic methodology and expertise from

many European countries. It could also serve as a
reference paper worldwide, as no such documents
exist for other WONCA regions yet. The Research
1Based on: Hummers-Pradier E, et al. Research Agenda for
General Practice/Family Medicine and Primary Health Care in
Europe. Maastricht: European General Practice Research
Network; 2009. pp. 7–12, 37–9.

Correspondence: Eva Hummers-Pradier, Institute of General Practice, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany. E-mail:
hummers-pradier.eva@mh-hannover.de

(Received 30 October 2009; accepted 30 October 2009)
ISSN 1381-4788 print/ISSN 1751-1402 online © 2009 Informa UK Ltd. (Informa Healthcare, Taylor & Francis AS)
DOI: 10.3109/13814780903452184

This teamwork concept. background. It’s potential is large: the large majority of European citizens have a general practitioner (GP) and regular contact with him or her. or as independent or community nurses in others. It informs policy makers. A gatekeeper role of the GP is seen to be an important cost-control measure and prevents harm due to unnecessary hospitalization and over-investigation (18). however. thus exclusively ensuring primary medical care. a European definition of general practice/ family medicine was published. which addresses academic and vocational training. In 2002.244 E. all-cause premature mortality and cause-specific premature mortality from asthma and bronchitis. where forms of organisation vary a lot. such as geographic regulation. Most of these papers refer to primary health care as being delivered by a cooperating multi-professional team. Agenda intends to complement the EURACT Teaching Agenda (2). and intends to guide the agendas for teaching. emphysema and pneumonia. Whereas GPs in some countries have patients registered at their practice and the doctors perform a gate-keeping function. Eur J Gen Pract Downloaded from informahealthcare. The definition describes eleven essential characteristics of the discipline and translates them into six core competencies (Figure 1). 90–95% of all patient complaints remain in long time primary care (even when specialists are temporarily involved). and primary care (in contrast to specialist care) is associated with a more equitable distribution of health in populations (16. Strong primary care systems and practice characteristics. General practice/family medicine and primary health care play an important role in the functioning of the whole system of healthcare. Nurses work as part of a primary health care team in some countries. has been conducted in general practice settings as well as in nursing and sometimes also within Figure 1. cardiovascular disease and heart disease (13–15). Background General practice/family medicine is the core discipline of primary medical care and the cornerstone of many healthcare systems in Europe. is not yet implemented fully in all European countries. The WONCA tree: Core competencies and characteristics of general practice/family medicine. coordinated by GPs. and revised in 2005. methodology and relevant literature are discussed.4). consequently. objectives. 80% can definitely be solved in primary care (3. Hummers-Pradier et al. which was only recently emphasized by WHO and several reviews (7–12). The European Journal of General Practice will publish a series of articles based on this document. . Starfield has shown that the strength of a country’s primary care system is inversely associated with all-cause mortality. continuity of care over time.6). in other countries primary care is a territory which is debated between GPs and multiple community based specialists that patients can access on their own initiative. funding organisations and others outside the field about the essential role of family medicine within health systems at both national and pan-European levels.17). coordination and community orientation are correlated with improved population health.com by Universiteit Antwerpen Bibliotheek For personal use only. research and quality assurance in GP/FM in Europe (5. In healthcare systems where the GP acts as a gate keeper. Of all reasons for encounter. Research labelled as primary health care research. In this first article.

outlining its content and research domains and its role for the twenty-first century. Many others pointed out that most clinical and preventive care is delivered in primary care and needs to be underpinned by appropriate evidence. The general pattern is that individual pioneers perform practice-based research and obtain degrees (stage 1). summarized as: (a) clinical research (with outcomes at a patient level. • Indicating issues of imminent importance for countries with a low capacity for research in view of a development plan for GP/FM research in a start-up setting. The Research Agenda for GP/FM and Primary Health Care in Europe. European countries show various stages of development of general practice research capacity: countries where academic family medicine is virtually non-existent (stage 1). more extensive research projects are developed through which further research capacity can be built (stage 3). starting from the domain of general practice in Europe as described in the six core competencies (and the 11 characteristics) of the WONCA Definition (Figure 1) (5). The focus of the research agenda. It was first developed in those (mainly north-western European) countries that have built their health care systems on the principles of generalist-based access to the more specialized levels of health care (‘gate-keeper’. the ability to research in general practice settings was more difficult to initiate and develop. • Appraising the methodology used in current GP/FM research. it had not been lined systematically with research evidence (26). i.20). Methodology Starting points The basis for the European Research Agenda were the prerequisites. Aims and objectives of the ‘Research Agenda for General Practice/Family Medicine and Primary Health Care in Europe’. • Providing a basis for proactive. Currently. therefore. and countries where—clinical or health services— research in general practice is developing (stages 2–3) (19. countries where university departments of family medicine are mainly involved in medical education (stage 2).e. positive action thereby influencing health and research policy. They also emphasize that GP/ FM research enhances the role of GPs in health care systems.com by Universiteit Antwerpen Bibliotheek For personal use only. thus giving an overview of research activity of European GPs presenting in EGPRN (WONCA Europe abstracts could not be classified likewise. and advocacy of GP/FM in Europe (Table I).e. • Highlighting research needs and evidence gaps.25). The research agenda is a reference paper • Summarizing the existing evidence on aspects of the definition of GP/FM and related tasks of GPs. Part 1 community specialist settings or within other healthcare professions. A second perspective was formed by the core areas of GP/FM research. all abstracts presented in EGPRN conferences from 2001–2007 were classified for theme and methodology. Framework for literature review The Research Agenda authors then performed a comprehensive literature review of GP/FM research. applying/ lobbying for research funds. the application of genomic knowledge in preventive and . GP research as reflected by several key informant surveys and SWOT analyses on research needs and perceived barriers. General practice research has been a subject of animated discussion in recent years (21–23). and it’s meaning for researchers and policy makers.25). However. Additionally. then gradually academic chairs focussing on medical education are installed (stage 2). for the purpose of research planning and funding or for funding decisions. General practice research has reached different stages of professionalization and capacity in different European countries. is primary care delivered by GPs and multiprofessional practice teams coordinated by them. The European definition of GP/FM has been important in shaping the discipline. i. and the semi-structured annual reports of the EGPRN national representatives. Challenges for primary care which were not mentioned in the original document of the WONCA Definition but of potential importance for future GP/FM were added to the research domains and topics to be searched (i.e. ‘referral’). and improves the effectiveness and efficiency of health care services as well as the health of populations (24. Some authors have even questioned whether GP/FM research has any future. and (c) research on education and teaching in general practice (20. to date. Countries where GPs work in parallel with other community based specialists found that the academic establishment and. (b) health services research (focussing on doctor or system related questions and outcomes). as they are neither published in a scientific journal nor archived systematically) (27). measuring patients’ health issues including function or quality of life). however. Adequate research methodology was added as a fourth area. These areas were then superposed to the core competencies to form a virtual grid of research domains. and finally. The objectives of developing the research agenda were to provide guidance for further research and policy. needs and priorities of European 245 Table I. in particular an initial EGPRN national representatives’ workshop (20).Eur J Gen Pract Downloaded from informahealthcare.

They will be presented in the next articles of this series. Hummers-Pradier et al. appropriate methodology and setting. All feedback was discussed and incorporated into the final document. The outcomes.246 E. This mainly applied to the research domains focussed on personcentred care and partly to specific problem solving. additional filters were used and reviews limited to meta-analyses. Eur J Gen Pract Downloaded from informahealthcare. In domains with a large volume of references. clinical trials or randomized controlled trials (RCTs). searches were not limited to articles labelled with ‘family practice’. systematic reviews. Each authorgroup then summarized its results with regard to the research domains and concepts. as well as the type of study and methods/instruments used. These were then classified according to clinical or diseaserelated or else system related/public health theme groups. • MeSH terms of relevant articles were used for further searches. both in small group and plenary author group discussions. or Dutch language papers. and published since 2003. Articles which were only related to nursing (and not to general practice) were also excluded. ‘general practice’ or ‘primary health care’. consistent results. as well as clearly presented. Literature review related to core competencies Each research domain related to a core competency was reviewed by a subgroup of the author team. and if the study was considered relevant for European general practice/primary care. Literature searches were mostly limited to English and to some extent French. holistic approach. • In some instances. community orientation. in order to consent the Research Agenda. Conclusions were drawn after reflection and repeated small group discussion until consensus was reached. disease management programmes). . Landmark articles were identified if present. the proposed research priorities together with appropriate methodologies for their study. and quality of care related research. Several strategies were used to extend searches where findings were either scarce or a domain seemed poorly covered: • Keywords of relevant studies for each core competency were retrieved in addition to MeSH terms and included into the searches. each comprising a definition of the domain and a summary overview of the literature review. missing evidence and research gaps were identified by comparing the search results to the particular domain description. Subsequently. Selected abstracts were compared to the domain descriptions and the methodologies used. ‘general practice’ or ‘primary health care’ in order to extend coverage of the domain. results. and point out research aims and needs as well as appropriate methodologies. • All related MeSH terms for each entry term (or key word) were identified and included in the search strategy. if aspects of research capacity are taken into account. All articles identified through the searches were initially screened by title and abstract. Abstracts and full text articles were then reviewed and methodology. A draft version had been made available on the internet and feedback on a draft version was sought from office holders of WONCA and its networks.com by Universiteit Antwerpen Bibliotheek For personal use only. i. namely diagnosis. comprehensive approach. Additionally. their findings and resulting summaries and conclusions. medico-ethical and medicolegal implications. therapeutic health care. and ‘explode’ searches for related articles of relevant papers. German. a rough semi-quantitative overview of research themes was performed in order to identify well-covered topics and blank spots. Preliminary and full results of the whole process were presented and discussed in various workshops and council or executive meetings at several WONCA Europe and EGPRN conferences. mostly crossed with ‘family practice’. chronic care. and some subchapters of specific problem solving (genetics.e. This was achieved by searching PubMed for RCTs or clinical trials labelled with the MeSH term ‘family practice’ or ‘general practice’. unsystematic reviews or opinion papers. thus excluding editorials. therapy. and the subsequent articles of this series). Discussion of the methodology The Research Agenda utilized the European definition of GP/FM to provide information on the current state of the evidence and research needs related to it. should be applicable in most European countries and possibly also countries outside Europe. Existing evidence on competencies and related research questions was identified and summarized. Results and conclusions were then compiled in separate chapters for each research domain and core competency. The whole author team iteratively discussed search strategies. and conclusions from the texts compiled. They searched PubMed using MeSH terms related to the core competencies or specific sub-fields (for details see the appendices of the full text version. • This mainly applied to the research domains of primary care management. national colleges of GP/FM and other European opinion leaders in GP/FM. and selected if having a well defined research question. and the use and potential of electronic medical records or information technology).

a number of opinion articles and some research papers have contributed to the discussion.25). as well as the relationship between the family doctor and the patient and his or her family. In the following decades. and consider factors which influence the implementation of results.53). However. and to health services and policy (36–38).55).com by Universiteit Antwerpen Bibliotheek For personal use only. Results of GP/FM research inform policy makers on how evidence-based healthcare can be delivered in a sustainable. and forms a link between medical research and the humanistic sciences. and thus underpin social and ethical decision making in order to improve health globally. Additionally. Some articles evaluated specific or local situations.e. This approach excluded many national GP/ FM journals. There is a considerable difference between this approach and the way research develops normally.46. as well as some subsequent articles (54. as well as research needs concerning rural practice (27). The output of UK programmes to promote GP/FM research was also evaluated (43. or literature on critical appraisal. cost-effective and equitable way.40).46). Social conditions and policy in developing countries were reviewed (45. PubMed was used as the primary search engine.Eur J Gen Pract Downloaded from informahealthcare. or effectiveness of a defined preventive intervention. other literature databases. 37. the authors did neither use a systematic quality appraisal checklist nor a fully identical procedure. access to research instruments and in facilitating training and networking of researchers. It helps to bridge the gap between fundamental biomedical or clinical research and the delivery of care to a general population. and to provide the specific contribution of GP/FM to medicine as a science (26). topics are usually chosen locally with regard to local interests. The family physicians’ responsibility towards the community was also highlighted (34. as well as research on educational methods. funding should be adequate and directed at research projects which meet patients’ needs. International professional organisations or scientific societies have a role as clearing houses providing databases of information. implying different literature search strategies based on individual research questions (for example.25.48–53). To select and appraise the literature for all domains. generally acknowledged criteria were applied to select and appraise research papers. Early in the 1990s. Since 2000. and its published reports (26. The Research Agenda for GP/FM and Primary Health Care in Europe. However. They point out that the contribution of high quality GP/ FM—led primary care is essential for an effective healthcare system and that stakeholders increasingly recognize this fact. An alternative structure. during the WONCA Research Conference in Kingston. Part 1 The six core competencies of the European Definition were chosen to structure the literature review and the text of the Research Agenda as an original approach to evidence. on management of a disease. health services and policy related studies (29–33). clinical strategies and a focus on the family were added to this agenda.38. this framework is not the only possible way to structure an agenda and it might be considered unusual. The European Definition is generally accepted. content and expected outcomes of GP/ FM research have been considered in a more general perspective by international experts in the field. The aims. This simply was not feasible or appropriate. would have given more detailed or in-depth results on the individual question. specific questions and incentives. each chosen approach would have presupposed a certain view of the discipline. appraisals and summaries were reviewed and discussed several times by various members of the author team until consensus was reached. the author team was multinational and drew on their expertise and overview of local and grey literature. as described in peer review procedures of research journals.44). which would probably not be equally acceptable or relevant everywhere in Europe.35). in 2003.42). Search procedures. This Research Agenda is mainly based on a comprehensive literature review. When planning research projects. However. US researchers studied the position of GP/FM researchers compared to other specialties when applying for research grants (39. Ontario. It is generally . It featured the epidemiology of illness in primary care. Several experts have called for a research agenda in order to clarify and prioritise research needs in GP/FM (20. McWhinney described the research domain of family medicine for the first time. The historical development of research and research agendas has been reviewed (35. In order to achieve this. Nevertheless. or research capacity as reflected by trainees or faculty of US family medicine departments (41. such as Embase and ERIC were not searched systematically. Discussion of other literature on research in GP/FM In 1966. summarizes the essentials of the discipline and thus provided a feasible and relevant framework. it would have been impossible to cover the entire field of GP/ FM this way. All of these papers define infrastructural requirements and highlight the importance of GP/FM and related research for health services and health policy. or comparing national healthcare systems). 247 the importance of researching the patient’s perspective in addition to the doctor’s view was emphasized. i. diagnostic signs or tests and psychosocial aspects (28). address conditions which contribute significantly to a populations’ burden of illness. clinical aspects such as the evaluation of symptoms.

The probability of specific diagnoses for patients presenting with common symptoms to Dutch family physicians. health services in rural areas (47). 2005. Okkes I. Since the document is open to amendments. Oskam. Crebolder H. In fact. et al. 6.46. MD PhD. Implications The research agenda summarizes the evidence relating to the core competencies and characteristics of the WONCA Europe Definition of GP/FM.unimaas. namely the Council and individual members of EGPRN.prick@hag. School for Public Health and Primary Care (CAPHRI). Beyer M.43. were written by renowned international experts. EURACT and other WONCA Europe networks. Institute of General Practice. All authors are members of EGPRN and active in its committees. Wonca-Europe definition of Family Medicine. 2009. for example unexplained symptoms (57). Evidence gaps and research needs are pointed out to provide a basis for planning research for which there is a need and for action that may influence health and research policy. The European definitions of the key features of the discipline of general practice: the role of the GP and core competencies. Lanier D. Svab I.51:31–6. Gay B. SK. E-mail: hanny.nl References 1. Other review papers have a wider. N Engl J Med. Frankfurt (Oder). Research agenda for general practice/family medicine and primary health care in Europe. Germany.org/ (accessed 25 October 2009). mental health (59). EHP is member of the WONCA Europe Executive Board. ed. 3. 2001. the Executive Board of WONCA Europe. Mrs Hanny Prick. Leuven: EURACT. i. Eilat-Tsanani S. including the Kingston papers. some papers stated that using a wide range of methodologies. 248 E. egprn. applying or lobbying for research funds. and several university departments of GP/FM in Europe.52:526–7. EQuIP. is essential for GP/FM research. and is one of its strengths (26). http:// www. MD PhD. Chevallier P. Br J Gen Pract 2002. Germany. The Research Agenda enables WONCA Europe and its associated networks and special interest groups to reconsider the evidence base for the definition. European academy of teachers in general practice. Allen J. However. Institute for Transcultural Health Sciences. Maastricht: European General Practice Research Network EGPRN. Dovey SM.org Paper versions can be requested from the Coordinating Centre of EGPRN. Peremans L. . The ecology of medical care revisited. acknowledged that GP/FM needs to increase its research capacity and several papers focus on how to achieve this. Amsterdam. The Netherlands. Hannover Medical School.52. Several articles have attempted to draw up research agendas by suggesting themes that are perceived as particularly important. Yawn BP. primary care informatics (58). The Research Agenda was supported solely by EGPRN and grants from WONCA Europe. European University Viadrina. Maastricht and President of the Health Council of the Netherlands. and none linked methodologies to research themes. The authors should also like to thank the participants of the workshops where the research agenda drafts were presented for their contributions. Hannover. Hummers-Pradier et al. EURACT educational agenda.54).com by Universiteit Antwerpen Bibliotheek For personal use only. 4. Maastricht University. Declaration of interest: The authors report having on conflicts of interest. Lamberts H. Department of General Practice. Dr Johannes Hauswaldt. or with regard to the development of networks of research practices (25. Department of General Practice. mostly at a system level (38. Heyrman J. Fryer GE. Ram P. The following persons deserve special thanks for their detailed feedback: Professor André Knottnerus.e. many. the authors welcome further discussion. J Fam Pract 2002. 5. Associate Professor Harm van Marwijk. and review their positions and statements if necessary. The Hague. EMGO Institute for Health and Care Research of VU University Medical Centre. Heyrman J.50. The Netherlands. Dr Bettina Berger.51. 2005. or choice of GP/FM as a career (60). more general perspective. Nevertheless. The authors gratefully acknowledge the contributions and feedback from many institutions and individuals. The authors alone are responsible for the content and writing of the paper.56).344: 2021–5. Hummers-Pradier E. Acknowledgments The EGPRN and the authors of the research agenda should like to thank WONCA Europe for funding several meetings as well as the costs of layout and printing of this paper. none had a systematic approach or used a predefined thematic framework. including approaches initially developed by disciplines other than medicine. MD MPH.woncaeurope. and its meaning for researchers and policy makers. 2. some so-called research agendas are in fact limited to very specific topics or areas of research. WONCA Europe Special Interest groups. Additionally.Eur J Gen Pract Downloaded from informahealthcare. Full text versions of the research agenda Electronic versions (pdf) are available from: www. Lionis C. Green LA.

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25: 266–71. 58. Senf J. BMC Fam Pract 2008. et al. Teasdale S. Fam Med 2007. Lam C. Leaders.com by Universiteit Antwerpen Bibliotheek For personal use only. Family medicine specialty selection: a proposed research agenda. Int J Psychiatry Med 1998. American Informatics Association. 55. Hassink-Frank L. Greenhalgh T. van der Horst H.39:585–9. Ann Fam Med 2008.28: 361–74. Del Mar C. 6:459–62. Carter YH. Campos-Outcalt D. Kottke TE. Optimizing practice through research: a new perspective to solve an old problem. 60. Macfarlane F. Mullins HC.9:52. 22:298–304.11: 89–94. Zuckerman AE. Nelson AF. General practices as emergent research organizations: A qualitative study into organizational development. Furler J. Lasserson D. McGaha AL. 59. leadership and future primary care clinical research. Klinkman MS. Johnson KB. Hummers-Pradier et al. 56. Kadam U. Eur J Gen Pract Downloaded from informahealthcare. Shaw S. Fam Pract 2008. Dowrick C. Moving toward a United States strategic plan in primary care informatics: A white paper of primary care informatics working group.250 E. Fortes S. Little DR. Mental health problems in primary care: A research agenda. Caplan W Green LW. Zapp JA. Okkes I. Proceeding from WONCA 2007. . Solberg LI. Inform Prim Care 2003. Pungno PA. Medically unexplained symptoms in family medicine: Defining a research agenda. et al. Olde Hartman T. et al. 57. Belcher DW. 54. Hanratty B. Cleland J. Fam Pract 2005.

PATRICK CHEVALLIER3. there is a lack of research with a longitudinal perspective and/or relevant health or quality of life outcomes as well as research on patients’ preferences and education for organizational aspects of GP/FM. France. Institute of General Practice. E-mail: hummers-pradier. 15Department of Primary and Interdisciplinary Care. Hannover Medical School. Faculty of Health Sciences. Maastricht. Germany. and its implications for general practitioners/family doctors. Clalit Health Services. 2009: pp. Greece. providing advocacy of general practice/family medicine (GP/FM) in Europe. Most papers correspond poorly to the WONCA concept. researchers and policy makers.eva@mh-hannover. or the implications of electronic patient records. Many studies focus on care for specific diseases. IMRE RURIK10. Frankfurt. 9Department of Family Medicine.8. University of Ljubljana. The Netherlands. Malta.3109/13814780903563725 . 30625 Hannover.Vrije Universiteit of Brussels. Turkey. accepted 16 December 2009) ISSN 1381-4788 print/ISSN 1751-1402 online © 2009 Informa UK Ltd. community oriented health care. MARTIN BEYER2. objectives. DAVORINA PETEK9. University Debrecen. 14Middle East Technical University Medical Centre. In this second article. primary care management. Turkey. 7Department of Primary. Hungary. Belgium. SOPHIA EILAT-TSANANI4. 5Afula and the valleys. Northern District. JEAN KARL SOLER11. HUMMERS-PRADIER1. Antwerp. 13Department of Family Medicine. research agenda Background 1Based on: Hummers-Pradier E. 6Clinic of Social and Family Medicine. Part 2. 1. 12Department of General Practice. 11Mediterranean Institute of Primary Care. HENRI EJH STOFFERS12. Early Online: 1–9 BACKGROUND PAPER Eur J Gen Pract Downloaded from informahealthcare. Cost efficiency or process indicators of quality are current outcomes. Israel. and focuses on either care for specific diseases.European Journal of General Practice. The Research Agenda summarizes the evidence relating to the core competencies and characteristics of the WONCA Europe definition of GP/FM. Ankara. Maastricht: European General Practice Research Network. Attard. 13–15. In a first article. Current literature on community orientation is mainly descriptive. Belgium.5.de (Received 13 December 2009. Series: The research agenda for general practice/family medicine and primary health care in Europe. 4Department of Family Medicine. Slovenia. or specific patient populations. 3Department of General Practice. University of Antwerp. it represents a very scattered rather than a meta view. 2010. 27–28. LIEVE PEREMANS7. Germany. Saint-Quentin University Versailles. Germany. Belgium Abstract At the WONCA Europe conference 2009 the recently published ‘Research Agenda for General Practice/Family Medicine and Primary Health Care in Europe’ was presented. the primary/secondary care interface. It is a background paper and reference manual. CHRISTOS LIONIS6. Key words: General practice/family medicine. Medical School. (Informa Healthcare.com by Medizinischen Hochschule For personal use only. For both core competencies. 8Department of Youth Health. Hannover Medical School. Taylor & Francis AS) DOI: 10. Crete. Ben-Gurion University of the Negev. Research Agenda for General Practice/Family Medicine and Primary Health Care in Europe. Brussels. Maastricht University Medical Centre. Emek Medical Center. Interdisciplinary University of Antwerp. background. et al. PINAR TOPSEVER13. Though there is a large body of research on various aspects of ‘primary care management’. 10Department of Family Medicine. Acibadem University. Istanbul. and Department of Social Medicine. The ‘Research Agenda for General Practice/Family Medicine and Primary Healthcare in Europe’ was published in September 2009 by the European Correspondence: Eva Hummers-Pradier. Results: Primary care management and community orientation1 EVA. University of Crete. MEHMET UNGAN14 & PAUL VAN ROYEN15 1Institute of General Practice. University of Frankfurt. The European Journal of General Practice publishes a series of articles based on this document. School of Public Health and Primary Care (CAPHRI). Hannover. Carl-Neuberg-Str. the results for the core competencies ‘primary care management’ and ‘community orientation’ are presented. and methodology were discussed. or on the uptake of preventive services. 2Institute for General Practice.

‘primary care management’ and ‘community orientation’. 2 E. ฀ Master effective and appropriate care provision and health service utilisation. Background. covering health services research. Definition of the research domains According to the WONCA Europe definition of GP/FM (2). The core competency of community orientation includes the ability to reconcile the health needs of individual patients and the health needs of the community in balance with available resources (2). i. and ways of organizing care within a practice or primary health care team.e. ฀ Make available to the patient the appropriate services within the health care system. clinical research. ฀ Cover the full range of health conditions. In this and the following issues. Our research domain also includes the clinical effectiveness and health systems effects of models of managing particular health problems in primary care. objectives and methodology were presented and discussed in part 1.e. and received a more structured definition during the 1980s. It also includes the specific context-related decision making process. i. The European Journal of General Practice presents this document as a series of articles. It summarizes the evidence relating to the core competencies and characteristics of the WONCA Europe definition of General Practice/Family Medicine (GP/FM) (Figure 1) (2). using resources efficiently. Figure 1.e. . defined disease management programmes. testing and treatment. and cooperation with other professionals and agencies according to these health needs. According to this definition. as well as community health needs. Briefly. protecting them from harm which may ensue through unnecessary screening. educational research and methodology issues (3). ฀ Act as an advocate for the patient. i.com by Medizinischen Hochschule For personal use only. The WONCA tree: Core competencies and characteristics of general practice/family medicine. dealing with unselected problems. the results will be presented. Hummers-Pradier et al. and indicates evidence gaps and research needs. other specialists and secondary care. Educational research in this field comprises management skills at a health system and practice level. primary care management includes the ability to: ฀ Manage primary contact with patients. Presentation of the paradigm of community oriented medicine started with work of Kark in the 1950s and 1960s (4).Eur J Gen Pract Downloaded from informahealthcare. as well as education for collaborating medical professionals with a range of backgrounds and expertise. and providing open and unlimited access. This article reflects on the two core competencies which deal primarily with organizational aspects of GP/FM. ฀ Coordinate care with other professionals in primary care. the Research Agenda is based on international key informant surveys and expert consensus and a comprehensive literature review on research domains related to each of the six core competencies of the European definition. the following topics can be included in the research domain: health needs reflecting individual health needs in the context of a person’s environment. General Practice Research Network (EGPRN) (1). and possible conflicts between these two.

Series. it seems that there is little evidence in favour of any particular organizational.com by Medizinischen Hochschule For personal use only. Many of the retrieved papers were related to the management in primary care of patients with a specific disease (very often depression or other mental conditions. ‘organization and administration’ [MeSH Terms] combined with ‘primary health care’ [Majr MeSH] and/or ‘family practice’ [MeSH] ฀ ฀‘practice management’ combined with ‘primary health care’ [Majr MeSH] and/or ‘family practice’ [MeSH]. coordination (defined as the degree to which the primary care provider manages all the patient’s health care and possesses the necessary infrastructure to do so) and comprehensiveness (there defined as the provision of a range of services broad enough to meet all common needs in the population) (5–7). (‘community networks’[MeSH] OR ‘community health services’[MeSH] OR ‘community health planning’[MeSH] OR ‘community-institutional relations’[MeSH] OR ‘community health aides’[MeSH] OR ‘community health nursing’[MeSH] OR ‘community health centres’[MeSH] OR ‘community medicine’[MeSH] OR ‘consumer participation’[MeSH] OR ‘delivery of health care’[MeSH]) AND (‘primary health care’ [Majr MeSH] OR ‘family practice’ [MeSH] NOT ‘public health’[MeSH]) ฀ ฀(‘minority groups’[MeSH] AND ‘health services needs and demand’[MeSH] OR ‘community networks/utilization’) AND (‘primary health care’ [Majr MeSH] OR ‘family practice’ [MeSH]) ฀ ‘residence characteristics’[MeSH] AND (‘primary health care’ [Majr MeSH] OR ‘family practice’ [MeSH]) ฀ ‘community’ AND (‘family practice’[MeSH] OR ‘physicians. Methodology—overview of search strategies A general description of the methodology of our evaluation—key informant surveys. The retrieved literature gave very scattered results. often with a benchmarking approach. ‘specific problem solving skills’. Eur J Gen Pract Downloaded from informahealthcare. family’[MeSH]) AND ‘education’[Majr MeSH] . Literature on primary care management was sought using the MeSH terms and combinations shown in Table I. longitudinality or continuity. Results Primary care management The research field of primary care management is very large. geriatric care (20–24). as shown in Table II. Research Agenda for GP/FM. ‘health services’ [MeSH]. access and continuity and lower cost (8. quality of care provided by appropriately trained nurses is as high as care provided by Table II. ‘education. funding or workforce model. Additional searches using ‘seek related articles’ options. MeSH terms of relevant articles. such as outreach preventive visits or care by nurse practitioners. free text searches or search strings not limited to ‘family practice’ or ‘primary health care’ were used to extend the overview. in terms of better population health outcomes. and ‘comprehensive approach’. Search strategies: Primary care management. i. medical’ [Majr MeSH] ฀ ‘health services accessibility’[Majr MeSH] combined with ‘primary health care’ [Majr MeSH] and/or ‘family practice’ [MeSH] ฀ ฀‘medical records systems. will be considered with the core competency of ‘personcentred care’ in this research agenda.9).e. As there is no explicit MeSH term for community oriented primary care. and to some extent also with the competencies of ‘patient centred care’. or efficiency with regard to costs (10–19). Several studies suggest that for some well defined conditions. Common outcome measures in research on primary care management aspects included effectiveness with regard to quality aspects/quality indicators. a comprehensive literature review and expert consensus—was presented in the first part of this series (3). accessibility.e. or diabetes) or of a defined patient population. i. combinations of several terms were used. These research domains also reflect three of Starfield’s four central components of primary care. Her fourth component. Evidence shows advantages for health systems that rely relatively more on primary health care and general practice in comparison to those systems tending towards specialist care. rather than a meta-view. Although there have been few systematic comparisons. it seems obvious that the organization and workforce of general practice has to be developed further in order to meet current and future requirements of primary care management better. Part 2 3 Table I. However. Literature was reviewed and consented conclusions were drawn according to the procedure described in part 1 of this series (3). Outcomes which reliably reflect patients’ health or well-being or Starfield’s central components or indicators (5) were rarely used. computerized’ [MeSH] combined with ‘primary health care’ [Majr MeSH] and/or ‘family practice’ [MeSH] The research domains of primary care management and community orientation overlap with each other. was studied in different patient populations. The effect of various primary care management models or interventions. Search strategies: Community orientation. improved equity.

Hummers-Pradier et al. explanatory opinion papers. and prescribing. or by national legislation imposing use of ICD based coding.63–68). Belgium and the Netherlands (53–57). to decide on the effectiveness of this (45). There is a rapidly increasing body of literature both on methodological and quality issues of research on EMR/routine data.e. Often. for control or coordination of prescriptions) may possibly reduce medication-related adverse events. This is caused by either the lack of standard classifications. Research considering relevant. There has been quite a lot of research on the role and potential effects of electronic medical records (EMR) in primary care.26). and most lacked control groups or comparators. Further trials are needed focusing on health outcomes and cost effectiveness.e. The English language concept of ‘community’ includes both small entities such as a family. inter-professional collaboration. and on research projects using such records as a data source. prevention activities. and large communities such as a school. Most studies showed either small or insignificant effects. For research purposes. However. Local educational interventions actively involving GPs and secondary care specialists. Effectiveness with regard to health outcomes is rarely studied. A substantial proportion of research papers dealt with the potential of these databases to generate data for quality management (including audits) and of EMRs to represent a platform for implementing guidelines or recommendations. Much research has been conducted with regard to referral rates and it shows a wide variation between individual general practitioners. There were few research articles on community oriented primary care (COPC). A lot of research literature was related to nursing rather than GP/FM. Not unexpectedly. This renders the concept difficult to study and results in considerable overlap between public health and primary care research. doctors and health outcomes for patients are comparable. this results in incomplete records.Eur J Gen Pract Downloaded from informahealthcare. primary care by nurse practitioners is likely to cost as much as care provided by (salaried) GPs according to currently available data. for example eHID. Interventions on practice organization seem to influence service uptake. a city or a country. Many of the retrieved papers were disease related studies or nursing research papers. Access to primary care is differently organized across various countries both inside and outside Europe. but not overwhelmingly so. but the effect on health outcomes was rarely studied (25. detection of disease. Of the studies performed. must be adopted (51. However. but in general . and structured referral sheets are the only intervention shown to have an impact on referral rates based on current evidence. GP related outcomes was missing. Several articles from recent decades were descriptive. but until now the topic has mostly been studied from a local point of view rather than as a general characteristic or in a comparative way (27–32). the vast majority focuses on educational interventions aimed at doctors to implement specific service approaches. These show the usefulness. health insurance or billing data used for secondary analyses. this interface is organized very differently in various European countries. or to prompt drug warnings. Cooperation with pharmacists (i. An important focus of research was collaborative care and the interface between primary and secondary care. implying that studies have to be interpreted in their local context and cannot really be generalized to another setting. to identify patients eligible for treatment or preventive services. many narrative and descriptive reports were retrieved. QRESEARCH and other morbidity/EMR databases in the UK. The use of ICPC and coding of GPs’ daily practice activity based on patients’ reasons for encounter was a central concept of many papers (46). which may depend on the EMR system used. Results obtained were mostly positive. in many European countries medical record utilisation and quality are less than ideal from the perspectives of primary care epidemiology or data collection for national and international research databases. for example. 4 E. There has been a limited amount of educational research on primary care management aspects.52). sustainability of these effects has not been studied (58–62). More randomized controlled trials of primary care based pharmacist-led interventions are needed. There were some studies exploring health needs with a combination of qualitative and quantitative methods. i.com by Medizinischen Hochschule For personal use only. Improving access is a key policy issue in improving quality of (primary) care and in guaranteeing equity in health care. but without conclusive findings. The effects of an ‘in-house’ second opinion and other intermediate primary care based alternatives to outpatient referral appear promising in settings with otherwise strict gate-keeping by GPs (33–44). potential and possibilities for further development of primary care epidemiology based on the electronic medical records coded with ICPC and structured according to episodes of care (47–50). However. or care strategies for specific diseases. They attempted to define the concept of community oriented primary care and described its development (4. a pragmatic approach to ‘everyday’ EMR or other routine data. The impact of consultation length has been studied in observational studies. Community orientation Community orientation seems to be a rather new competence.

regarding outcomes with respect to both individual health and community needs (115). or patient/population groups (geriatric patients. Implications Research Given these results. on epidemiology of GP/FM. telephone consultations. and their convergence. minorities or deprived groups) or on preventive services (vaccinations. mothers and newborns. They were community or population based. many essential topics are not or not sufficiently well studied. perspectives and preferences on practice management issues (such as open access. Acknowledgments The authors acknowledge the support and contribution of many organizations and persons. or evaluated the implementation of a COPC model in local communities (105. or comparing innovative strategies with ‘care as usual’). It can be concluded that much of the current research focussed on specific diseases rather than a generalist perspective. research with regard to health outcomes is rare. ฀ Comparing different approaches/models of primary health care in the community. also on education. including specific aspects and outcomes of care. most of the current research did not really cover the concept of a community oriented approach as described in the European definition of GP/FM (92–97). Though there is a large body of scientific literature on organizational aspects of primary care. GPs’ referral to several community programmes. further research should focus on: ฀ Developing research instruments and outcome measures reflecting and measuring the different aspects of primary care management and community orientation. The majority of studies were not controlled. All authors are members of EGPRN and active in its committees. not only at the level of patient satisfaction and/or service uptake. EHP is member of the WONCA Europe Executive Board.e. ฀ Interventional research (controlled trials—comparing different primary care management strategies.com by Medizinischen Hochschule For personal use only. ฀ Longitudinal observational studies. ฀ Patient and doctor’s perceptions. ฀ Effective methods of inter-professional education and teaching management skills to (future) GPs. Most studies focused on very specific issues. dentistry) (69–91). or teaching experiences with students. data collection and data management in research. i. . there were several articles describing educational programmes on community related themes. and looking at both individuals and the community. ฀ Validity and utility of electronic patient records in a general practice. but were not community orientated from a primary care point of view. drug addiction programmes). 5 ฀ Community based care models for specific areas of clinical work (for example palliative care. Outcomes are usually process indicators or cost efficiency. The authors alone are responsible for the content and writing of the paper. appropriate denominators). including the evaluation of programmes with a clear methodology. Research methodology The following formulated: methodological needs can be ฀ Instrumental research to develop and validate measures for practice management issues and aspects of community orientation. ฀ Education for COPC. Series. ฀ Routine collection and the feasibility/validity of data from GPs’ electronic medical records. ฀ Mixed design studies. Additionally. common chronic diseases like diabetes or arthritis). telemedicine). screening. The full text can be read in the first article of this series (Eur J Gen Pract. either care for defined diseases (mental conditions. and as a means for recruitment. smoking cessation. or collaborative care (98–104). ฀ Comparing different models of care and evaluating effectiveness of different primary care management strategies or interventions. ฀ Observational cohort studies comparing different approaches and models. Part 2 there is a lack of qualitative research. 2009. and use of information technologies in COPC. Thus.Eur J Gen Pract Downloaded from informahealthcare. Research Agenda for GP/FM. Regarding educational research. The Research Agenda was supported solely by EGPRN and grants from WONCA Europe. but also on the health outcome level.e.15:243–50). Declaration of interest: The authors report having no conflicts of interest. Some articles described methods of disease management in COPC involving cooperation between primary care and institutions in the community. but very few evaluations (107–114). their use for studies of morbidity and GP care (incl. ฀ Implementation studies of effective strategies (observational).106). i.

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‘person centred care’. 9Department of Family Medicine. ‘comprehensive approach’ and ‘holistic approach’. Hannover Medical School. Turkey. Emek Medical Center. LIEVE PEREMANS7. Antwerp. and methodology were discussed.University of Ljubljana. Faculty of Health Sciences. 3Department of General Practice. Attard. Validated instruments to measure these competencies are lacking.8. holistic approach Background The ‘Research Agenda for General Practice/Family Medicine and Primary Healthcare in Europe’ was published in September 2009 by the European General Practice Research Network (EGPRN)(1). Germany Abstract The recently published ‘Research Agenda for General Practice/Family Medicine and Primary Health Care in Europe’ summarizes the evidence relating to the core competencies and characteristics of the Wonca Europe definition of GP/ FM. PATRICK CHEVALLIER3. 5Afula and the valleys. Hannover. Belgium. In a second article. 6Clinic of Social and Family Medicine. IMRE RURIK10. For all domains. The European Journal of General Practice publishes a series of articles based on this document. objectives. and its implications for general practitioners/family doctors. Universiteitsplein 1. Clalit Health Services. University of Antwerp—Faculty of Medicine. Early Online. background. Hungary. This article reflects on the three core competencies.vanroyen@ua. all person related aspects remain poorly defined and researched.5. 2610 Antwerp. PINAR TOPSEVER13.Vrije Universiteit of Brussels. Ankara. DAVORINA PETEK9. HENRI EJH STOFFERS12. 12Department of General Practice. 11Mediterranean Institute of Primary Care. Maastricht University Medical Centre. Belgium. and 15Institute of General Practice. Department of Primary and Interdisciplinary Care. 13Department of Family Medicine.e. University Debrecen. In a first article. (Informa Healthcare. Though there is an important body of opinion papers and (non-systematic) reviews. 2010. Northern District.481018 . researchers and policy makers. comprehensive and holistic approach PAUL VAN ROYEN1. 8Department of Youth Health.com by Medizinischen Hochschule on 05/08/10 For personal use only. Greece. E-mail: paul. Part 3. and Department of Social Medicine. Israel. The European Journal of General Practice presents this document as a series of articles.be (Received 15 March 2010. SOPHIA EILAT-TSANANI4. objectives and methodology were Correspondence: Paul Van Royen. Results: Person centred care. Key words: General practice/family medicine. 7Department of Primary. Taylor & Francis AS) DOI: 10. JEAN KARL SOLER11. Belgium. Brussels. School of Public Health and Primary Care (CAPHRI). Series: The research agenda for general practice/family medicine and primary health care in Europe. CHRISTOS LIONIS6. MARTIN BEYER2. Slovenia. Crete.2010.European Journal of General Practice. 2Institute for General Practice. which deal with person related aspects of GP/FM. the results for the two core competencies ‘primary care management’ and ‘community orientation’ were presented. Belgium. Saint-Quentin University Versailles. Medical School.Istanbul. most research examined patient and doctor preferences and experiences. 1-7 ORIGINAL ARTICLE Eur J Gen Pract Downloaded from informahealthcare. University of Frankfurt. It summarizes the evidence relating to the core competencies and characteristics of the WONCA Europe definition of General Practice/Family Medicine (GP/FM) (2). Background. Concerning patient-centredness. Acibadem University. and indicates evidence gaps and research needs. Malta. comprehensive approach. Studies on comprehensiveness mostly focus on prevention/care of specific diseases. there has been limited research conducted on its implications or outcomes. University of Crete. Ben-Gurion University of the Negev. Germany. i. Frankfurt.3109/13814788. person centred care. research agenda. 14Middle East Technical University Medical Centre. Turkey. 10Department of Family Medicine. The Netherlands. 4Department of Family Medicine. Interdisciplinary University of Antwerp. accepted 19 March 2010) ISSN 1381-4788 print/ISSN 1751-1402 online © 2010 Informa UK Ltd. France. Maastricht.ac. MEHMET UNGAN14 & EVA HUMMERS-PRADIER15 1Department of Primary and Interdisciplinary Care. University of Antwerp.

palliation and rehabilitation (2).8). culture and socio-ecological situation within the larger community. which deal with organizational aspects of GP/FM.2 P. The more directly involved the patient or the health care provider is in clinical or general practice interventional research. a ‘holistic approach’ includes the ability to use a biopsychosocial model that takes into account cultural and existential dimensions (7. ‘primary care management’ and ‘community orientation’ were presented and discussed in part 2 (4). This article reflects on the three core competencies that deal with person related aspects of GP/ FM. cure. care. as well as the effectiveness of a person.com by Medizinischen Hochschule on 05/08/10 For personal use only. treatment and followup of all diseases but also palliation. diagnosis. though there is an overlap with aspects of specific problem solving. The research domains of ‘person-centred care’ and ‘comprehensive approach’ reflect two of Starfield’s four central components of primary care. The holistic approach can be defined as ‘caring for the whole person in the context of his values. •฀ establish an effective doctor-patient relationship. with respect for the patient’s autonomy. the more sophisticated the design of the trial has to be to take account of the influence of the individual over the outcome (10).e. ‘comprehensive approach’ and ‘holistic approach’. According to the WONCA Europe definition. combined with ‘continuity of patient care’ (MeSH). It necessitates the simultaneous consideration of these different aspects of care. For retrieval of literature on ‘holistic approach’. According to the WONCA Europe definition of GP/ FM. i. ‘person centred care’. Definition of the research domains Eur J Gen Pract Downloaded from informahealthcare. prevention. Methodology A general description of the methodology of our evaluation—key informant surveys. social groups and society have characteristics of complex adaptive systems (9). ethical issues and cultural competency are considered an important part of a holistic approach to health and health care. The core competency and research domain ‘comprehensive approach’ thus includes two aspects: a focus on management of illness (managing simultaneously multiple complaints and pathologies encompassing acute as well as chronic health problems) and another on well-being and health promotion. family system. The research domain also includes studies on patients’ perspectives and preferences. Finally. presented in part 1(3).e. Patient-centredness has been accepted as an important. This means that the ‘comprehensive approach’ research domain includes studies on health promo- tion and prevention.or patient-centred approach and aspects of patient involvement and shared decision making. Van Royen et al. a ‘comprehensive approach’ includes the ability to •฀ manage multiple complaints and pathologies simultaneously. ‘longitudinality’ or ‘continuity’ (defined as personfocused care over time) and ‘comprehensiveness’ (defined as the extent to which the healthcare provider actually recognizes all the patient’s needs as they occur. •฀ manage and coordinate health promotion. General practitioners have to manage and coordinate all of these aspects in a specific long-term general practitioner-patient relationship. Results on the two core competencies. central value in medical care and it is nowadays universally advocated in medical education (5). As the MeSH term ‘comprehensive health care’ is a very large term also including primary health care and patient-centred care as subheadings. •฀ promote health and well being by applying disease prevention strategies appropriately.e. and offers a range of services broad enough to meet all common requirements) (6). ‘person centred care’ includes the ability to •฀ adopt a person-centred approach in dealing with patients and problems in the context of patient’s circumstances. set priorities and act in partnership. Individuals. different combinations on sub domains as health promotion. family beliefs. Literature on ‘comprehensive approach’ was sought using the MeSH terms and combinations shown in Table I. and considering a range of therapies based on the evidence of their benefits and cost’. and the specific aspects of complexity and cultural com- . prevention. organizations. •฀ communicate. but to patient groups or to health themes in all their aspects. palliative care and teaching were used. i. The complexity phenomenon is another aspect of a holistic approach. and requires research not linked to specific diseases. Literature on ‘patient centeredness’ was sought using the MeSH term’patient-centred care’. a comprehensive literature review and expert consensus—was presented in the first part of this series (3). referring to continuing and co-ordinated care management (2). ‘primary health care’ (Majr MeSH) and/or ‘family practice’ (MeSH). According to the WONCA Europe definition (2). •฀ provide longitudinal continuity of care as determined by the needs of the patient. i.

However. continuity is considered less important than good doctorpatient communication. Additional searches using ‘seek related articles’ options.e.฀medical’฀ [MeSH])฀AND฀‘primary฀health฀care’฀[Majr฀MeSH]฀ Complexity •฀ ‘complexity’฀[All฀Fields]฀AND฀(‘primary฀health฀care’฀[Majr฀ MeSH]฀OR฀‘family฀practice’฀[MeSH] Cultural competency •฀ (‘cultural฀competency’฀[MeSH]฀OR฀‘culture’฀[MeSH])฀AND฀ (‘primary฀health฀care’฀[Majr฀MeSH]฀OR฀‘family฀practice’฀ [MeSH]) 3 ing were not relevant to family practice. or shared decision making. the MeSH terms and combinations were used as shown in Table II. beliefs and preferences of a biomedical versus a patient-centred approach in communication. and participation. improved medical outcomes and decreased malpractice claims (12). videotapes) (11). Several papers studied patient and doctor experiences.฀family’฀[MeSH]) Teaching •฀ (‘teaching’฀[MeSH]฀OR฀‘education’฀[MeSH]฀OR฀‘education’฀ [Subheading]฀OR฀‘teaching฀materials’฀[MeSH])฀AND฀ ‘comprehensive฀health฀care’฀[MeSH]฀AND฀‘family฀practice’฀ [Majr฀MeSH] petency.฀social’฀[MeSH]฀OR฀‘sociology. on enablement. Continuous care performed by the same doctors seems to be beneficial for regular follow-up examinations in chronic disorders and to some extent for compliance with guidelines. •฀ ‘comprehensive฀health฀care’฀[MeSH]฀AND฀‘primary฀care’฀ [MeSH]฀OR฀‘family฀practice’฀(MeSH) •฀ ‘comprehensive฀health฀care’฀[Majr]฀AND฀((‘primary฀health฀ care’฀[TIAB]฀NOT฀Medline฀[SB])฀OR฀‘primary฀health฀care’฀ [MeSH฀Terms]฀OR฀primary฀care฀[Text฀Word])฀OR฀((‘family฀ practice’[TIAB]฀NOT฀Medline[SB])฀OR฀‘family฀practice’฀ [MeSH฀Terms]฀OR฀family฀medicine฀[Text฀Word])฀OR฀ ((‘family฀practice’[TIAB]฀NOT฀Medline฀[SB])฀OR฀‘family฀ practice’฀[MeSH฀Terms]฀OR฀general฀practice฀[Text฀Word])฀ AND฀Meta-Analysis฀[ptyp]฀NOT฀‘comprehensive฀dental฀ care’฀[MeSH] Health promotion •฀ (‘Comprehensive฀Health฀Care’฀[MeSH]฀OR฀‘Primary฀Health฀ Care’฀[MeSH]฀OR฀‘Family฀Practice’฀[MeSH])฀AND฀‘Health฀ Promotion’฀[Majr]฀NOT฀nursing฀Limits:฀meta-analysis Prevention •฀ (‘prevention฀and฀control’฀[Subheading]฀OR฀‘primary฀ prevention’฀[MeSH])฀AND฀(‘comprehensive฀health฀care’฀ [MeSH]฀OR฀‘primary฀health฀care’฀[MeSH]฀OR฀‘family฀ practice’฀[MeSH]) Palliative care •฀ ‘comprehensive฀health฀care’฀[MeSH]฀AND฀‘palliative฀care’฀ [MeSH])฀AND฀(‘primary฀health฀care’฀[MeSH]฀OR฀ ‘physicians. being able to achieve fast access to care is more important than interpersonal continuity for many otherwise healthy patients. some research has been done on selfmanagement education for patients with various chronic conditions. focus groups.com by Medizinischen Hochschule on 05/08/10 For personal use only. It appears that not every situation or each patient group in general practice cherishes a distinctly patientcentred communication style. Although some specific measures were developed. Other papers have explored the preferences and experiences of patients on (interpersonal) continuity of care. i. Recently. sometimes based on literature review (5). i.Series: Research Agenda for GP/FM. The concept remains however poorly defined. free text searches or search strings not limited to ‘family practice’ or ‘primary health care’ were used to extend the overview. health behaviour. patients and doctors valued continuity in addressing serious and psychosocial issues. small. Search strategies: Comprehensive approach. instruments to measure the complex concept as a whole are still lacking. A better understanding of the diversity of patient and doctor preferences in different situations may lead to more effective and individualized care. It appears that these programmes are more effective than information-only patient education. Literature was reviewed and consented conclusions were drawn according to the procedure described in part 1 of this series (3). mainly using qualitative research methods (interviews. The effects of a patient-centred approach or communication have been studied with regard to patient satisfaction and treatment adherence. Search strategies: Holistic approach.e. MeSH terms of relevant articles. satisfaction. As many retrieved articles focused on nursTable II. Part 3 Table I. these were excluded through use of the search string ‘NOT nursing’. and for routine checks of a chronic illness. Eur J Gen Pract Downloaded from informahealthcare. Most studies showed effects on patient satisfaction. short-term effects were recorded with regard to increased satisfaction. •฀ ‘holistic฀health’฀[Majr฀MeSH]฀AND฀(‘primary฀health฀care’฀ [Majr฀MeSH]฀OR฀‘family฀practice’฀[MeSH]) •฀ ‘holistic฀health’฀[Majr฀MeSH]฀AND฀(‘primary฀health฀care’฀ [Majr฀MeSH]฀OR฀‘family฀practice’฀[Majr฀MeSH]฀AND฀ ‘health฀services฀research’฀[Majr฀MeSH])฀ •฀ ‘holistic฀health’฀[Majr฀MeSH]฀AND฀(‘primary฀health฀care’฀ [Majr฀MeSH]฀AND฀‘education’฀(Subheading)฀AND฀ ‘research’฀[MeSH]฀OR฀‘research’฀[TextWord]) •฀ ‘holistic฀health’฀[Majr฀MeSH]฀AND฀(‘biomedical฀research’฀ [MeSH]฀OR฀‘clinical฀nursing฀research฀‘[MeSH]฀AND฀ ‘psychology. decreased symptoms and health care utilisation (13– . for diabetes. For acute disorders. Both. Results Person centred care Many of the retrieved articles dealing with the concept of patient-centredness were opinion papers.

Individual studies on lifestyle interventions often claim positive effects. which is. scientific evidence does not significantly support lifestyle interventions to modify health behaviour. Only some of these studies are really primary care based.4 P. The majority of the papers relate to nursing. Many studies related to practice management and organization were found under the heading comprehensive and primary care (32–36). Preventive primary care outreach interventions aimed at older people were associated with a reduction in mortality and increased likelihood of continuing to live in the community (27. whereas implications or outcomes of a patientcentred approach were hardly studied. This gives a very scattered view with multiple fragments of knowledge. apart from the Starfield indicator. There is almost no research on a generally comprehensive approach towards the patient irrespective of specific medical problems. Good communication. There is limited material on medical education for a comprehensive approach (37–40). With respect to quitting smoking. rarely used. Meta-analyses concluded that there is no evidence to support an effect of stages-of-change based interventions on levels of physical activity. becomes ever more important as populations present with more chronic diseases. However. another important issue within comprehensive care. many of the reviews and opinion papers agree that a holistic approach is important and valuable. a considerable number to complementary medicine. The concept of a comprehensive approach in general practice is not well defined in terms that are applicable for designing research. the concept of person-centredness remains poorly defined. meeting both the patient’s and the family’s needs. Van Royen et al. and whether patients share this view and recognize activities as comprehensive care. the setting of studies and their relevance for general practice are not clarified. Daily general practice and primary care often claim to adopt a holistic approach. Holistic approach Almost all of the retrieved papers are opinion papers or non-systematic reviews (41–45). or to specific activities such as disease screening or complex interventions (counselling (21–23). with aims to improve quality of life are important elements of good end of life care (29–31). highlighting very specific situations (often without defining the setting of care well). Almost all-existing research on a comprehensive approach is either cross-sectional or prospective with relatively short follow-up times. but usually the definition does not seem to follow the Wonca Europe concept. but these are usually small and often described by surrogate or disease-specific outcome measures and cover only very limited aspects of health. Comprehensive approach Most research on medical comprehensive care is either related to care or prevention of a specific disease. it is believed that the concept of patient self-activation or selfmotivation and establishing a pro-active team-patient relationship in GP/FM will gain in importance in the future. Despite this relatively weak evidence. there is very little evidence establishing this competency as understood in the Wonca definition. From a theoretical or consensus point of view. Few articles deal with ‘holistic care’ for various conditions. a theme that seems to be associated with a holistic approach. To aim for a broad concept of health and well-being. alcohol abuse) (19.17). interventions such as telephone counselling might positively affect behaviour (26). In conclusion. lifestyle modification (25)). In a review of educational interventions in primary care. very often mental health (depression. However. and that care providers and patients hold similar views on this issue. In conclusion. 15). Often. In conclusion. most fell into the domain of primary care management.and long-term follow-up. the authors concluded there were only two articles meeting the criteria for good research in this field. Eur J Gen Pract Downloaded from informahealthcare. discussed in the previous paper (4). however. There is virtually no investigative research. Some positive evidence was found regarding fat intake at short. and more often they were undertaken by specialists on more or less selected samples. implementation of a chronic care model (24). There is limited research on the effect of training programmes for practitioners in person-centred care on clinical and non-clinical outcomes (18). Most studies on palliative care. especially for chronic diseases (16. Most research examined patient and doctor preferences and experiences.com by Medizinischen Hochschule on 05/08/10 For personal use only.20) and cardiovascular disease.28). There is an important lack of methodologies and outcome measures as well as longitudinal studies. We do not know how well the concept is understood by primary care doctors. including the concept of complexity. Concerning prevention and comprehensive care. Sustainability and long-term impact on relevant health outcomes are rarely studied. but not resulting in a good picture on comprehensiveness as defined by Wonca. their care requires both . A considerable amount of research on lifestyle interventions for primary care patients is labelled with the term ‘comprehensive’. it seems that a holistic approach. there seems to be not much good research in family practice to date. focus on management and are performed by nurse researchers.

Simultaneous delivery of curative care (management and rehabilitation of illness) and preventive activities (health promotion and disease prevention) in the same patients. In conclusion. There is a limited number of papers studying the concept of cultural competency in depth. Implications Research Given these results. Frequently in lifestyle or preventive care intervention studies. ‘fullrange’ work of GPs. further research in the area of person centred care. measurement instruments. the concept of a holistic approach remains poorly defined. holistic approach and the sustainability of education effects. Effective methods of future GP training to practice a person-centred. In these studies. Concerning patient-centredness. •฀ Interventional studies. comprehensive and person centred view on the patient. the expected added value to the ‘usual’ comprehensive general practice care and its validity as a comparator should be considered carefully.com by Medizinischen Hochschule on 05/08/10 For personal use only. Part 3 a holistic. to develop measures for patient-centredness. Furthermore. should focus on: •฀ Better understanding and clearly defining the competencies person-centredness. comprehensive and holistic approach. most research examined patient and doctor preferences and expe- . looking at barriers and facilitators for change in healthcare as complex phenomena. involvement and shared decision making. taking into account their complexity and interactions. as well as the influencing factors. Series: Research Agenda for GP/FM. •฀ Longitudinal observational studies with retrospective and prospective designs. •฀ Developing research instruments and outcome measures for these competencies (or components thereof). and models of implementation (i.e. comprehensiveness and a holistic approach (or components thereof). obstacles in practice. cultural and environmental circumstances that may have an effect on different aspects of health. communication. Appreciation of the comprehensive. •฀ Patient and doctor perceptions. •฀ Evaluating effectiveness and efficiency of a person-centred approach. and is very rarely a topic for research. and a way to reflect this in electronic medical records and research databases. It has been postulated that a holistic approach improves patients’ satisfaction and coping. and quality of life. Research methodology For studies on the competencies person centred care. Validated instruments to measure these competencies are lacking. comprehensive or holistic approach. •฀ Understanding of the social. Both a clear definition in practical terms and validated instruments to measure it are still lacking. but research evidence supporting these assumptions is lacking (46). There is almost no research on its implications or outcomes. The observation and study of the ‘complex’ context and underlying social relations are proven to be more relevant (55). Such research also shows that the metaphor of ‘removing barriers to change’ is of limited use when studying the implementation of a certain policy or programme. comprehensive models of care and a holistic approach with regard to relevant clinical health outcomes and outcome •฀ •฀ •฀ •฀ 5 measures such as satisfaction. knowledge. and in demands for complementary medicine. to clarify the concepts of a comprehensive or holistic approach and to study patients’ and doctors’ concepts and expectations. comprehensive and holistic approach. some papers focus on complexity. the following methodological needs could be formulated: •฀ Qualitative research. Final comments It can be concluded that all person related aspects of family medicine are poorly defined. to assess the effectiveness and sustainability of (specific aspects of) a person-centred. •฀ Instrumental research. and probably their health. perspectives and preferences on person-centredness. and the effects of training these competencies. comprehensive and holistic approach. to assess effects of personcentred care or a holistic approach •฀ Mixed research designs. including social. ‘usual’ and ‘good’ general practice care are not well described. cultural and environmental circumstances affecting these preferences. programmes focussing on cultural competency) (47–54).Eur J Gen Pract Downloaded from informahealthcare. Some aspects of a holistic approach have been subject to research. Exploring what kind of need is expressed in the approval of holistic care.

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