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Introduction: Chronic breathlessness is a common and debilitating symptom, associated with high healthcare use and reduced quality of life. Challenges and delays in diagnosis for people with chronic breathlessness frequently occur, leading to delayed access to therapies. The overarching hypothesis is a symptom-based approach to diagnosis in primary care would lead to earlier diagnosis, and therefore earlier treatment and improved longer-term outcomes including health-related quality of life. This study aims to establish the feasibility of a multicentre cluster randomised controlled trial to assess the clinical and cost-effectiveness of a structured diagnostic pathway for breathlessness in primary care., Methods and Analysis: Ten general practitioner (GP) practices across Leicester and Leicestershire will be cluster randomised to either a structured diagnostic pathway (intervention) or usual care. The structured diagnostic pathway includes a panel of investigations within 1 month. Usual care will proceed with patient care as per normal practice. Eligibility criteria include patients presenting with chronic breathlessness for the first time, who are over 40 years old and without a pre-existing diagnosis for their symptoms. An electronic template triggered at the point of consultation with the GP will aid opportunistic recruitment in primary care. The primary outcome for this feasibility study is recruitment rate. Secondary outcome measures, including time to diagnosis, will be collected to help inform outcomes for the future trial and to assess the impact of an earlier diagnosis. These will include symptoms, health-related quality of life, exercise capacity, measures of frailty, physical activity and healthcare utilisation. The study will include nested qualitative interviews with patients and healthcare staff to understand the feasibility outcomes, explore what is 'usual care' and the study experience., Ethics and Dissemination: The Research Ethics Committee Nottingham 1 has provided ethical approval for this research study (REC Reference: 19/EM/0201). Results from the study will be disseminated by presentations at relevant meetings and conferences including British Thoracic Society and Primary Care Respiratory Society, as well as by peer-reviewed publications and through patient presentations and newsletters to patients, where available., Trial Registration Number: ISRCTN14483247., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY. Published by BMJ.)

There is a need for a paradigm shift across mental health in primary care to improve the lives of millions of Europeans. To contribute to this paradigm shift, the European Forum for Primary Care (EFPC-MH) working group for Mental Health, produced a Position Paper for Primary Care Mental Health outlining 14 themes that needed prioritizing. These themes were developed and discussed interactively during the EFPC conferences between 2012 and 2019. The Position Paper on Mental Health gives direction to the necessary improvements over the next ten years. The themes vary from preferable healthcare model to the social determinants highlighting issues such as inequalities. The Statement of Mental Health in Primary Care will be established in cooperation with fellow organizations.

Aim: The aim of this position paper is to assist primary health care (PHC) providers, policymakers, and researchers by discussing the current context in which palliative health care functions within PHC in Europe. The position paper gives examples for improvements to palliative care models from studies and international discussions at European Forum for Primary Care (EFPC) workshops and conferences., Background: Palliative care is a holistic approach that improves the quality of life of patients and their families facing problems associated with terminal illness, through the prevention and relief of suffering by means of early identification and diligent assessment and treatment of pain and other problems, whether physical, psychosocial, or spiritual. Unfortunately, some Europeans, unless they have cancer, still do not have access to generalist or specialist palliative care., Methods: A draft of this position paper was distributed electronically through the EFPC network in 2015, 2016, and 2017. Active collaboration with the representatives of the International Primary Palliative Care Network was established from the very beginning and more recently with the EAPC Primary Care Reference Group. Barriers, opportunities, and examples of good and bad practices were discussed at workshops focusing on palliative care at the international conferences of Southeastern European countries in Ljubljana (2015) and Budva (2017), at regular conferences in Amsterdam (2015) and Riga (2016), at the WONCA Europe conferences in Istanbul (2015), Copenhagen (2016), and Prague (2017), and at the EAPC conference in Madrid (2017)., Findings: There is great diversity in the extent and type of palliative care provided in primary care by European countries. Primary care teams (PCTs) are well placed to encourage timely palliative care. We collected examples from different countries. We found numerous barriers influencing PCTs in preparing care plans with patients. We identified many facilitators to improve the organization of palliative care.

Objective: To contrast how Brazil's and Canada's different jurisdictional and judicial realities have led to different types of telemedicine and how further scale and improvement can be achieved., Composition of the Committee: A subgroup of the Besrour Centre of the College of Family Physicians of Canada and Canadian telemedicine experts developed connections with colleagues in Porto Alegre, Brazil, and collaborated to undertake a between-country comparison of their respective telemedicine programs., Methods: Following a literature review, the authors collectively reflected on their experiences in an attempt to explore the past and current state of telemedicine in Canada and Brazil., Report: Both Brazil and Canada share expansive geographies, creating substantial barriers to health for rural patients. Telemedicine is an important part of a universal health system. Both countries have achieved telemedicine programs that have scaled up across large regions and are showing important effects on health care costs and outcomes. However, each system is unique in design and implementation and faces unique challenges for further scale and improvement. Addressing regional differences, the normalization of telemedicine, and potential alignment of telemedicine and artificial intelligence technologies for health care are seen as promising approaches to scaling up and improving telemedicine in both countries., (Copyright© the College of Family Physicians of Canada.)

Objective: To compare the national health systems of Canada and Brazil and how both countries have addressed similar challenges in their primary care sectors., Composition of the Committee: A subgroup of the Besrour Centre of the College of Family Physicians of Canada developed connections with colleagues in Brazil and collaborated to undertake a between-country comparison, comparing and contrasting various elements of both countries' efforts to strengthen primary care over the past few decades., Methods: Following a literature review, the authors collectively reflected on their experiences in an attempt to explore the past and current state of family medicine in Canada and Brazil., Report: The Brazilian and Canadian primary care systems are faced with similar challenges, including geography, demographic changes, population health inequities, and gaps in universal access to comprehensive primary care services. Although the approaches to addressing these challenges are different in both settings, they highlight the central importance of family physicians in both systems. Both countries continue to face considerable challenges in the context of mental health services in primary care. It remains important for Canada to draw lessons from the primary care systems and reforms of other countries, such as Brazil., (Copyright© the College of Family Physicians of Canada.)

Inter-professional education (IPE) can support professionals in developing their ability to work collaboratively. This position paper from the European Forum for Primary Care considers the design and implementation of IPE within primary care. This paper is based on workshops and is an evidence review of good practice. Enablers of IPE programmes are involving patients in the design and delivery, providing a holistic focus, focussing on practical actions, deploying multi-modal learning formats and activities, including more than two professions, evaluating formative and summative aspects, and encouraging team-based working. Guidance for the successful implementation of IPE is set out with examples from qualifying and continuing professional development programmes.

BackgroundPrimary care practices are responding to calls to incorporate patients' social risk factors, such as housing, food, and economic insecurity, into clinical care. Healthcare likely relies on the expertise and resources of community-based organizations to improve patients' social conditions, yet little is known about the referral process.ObjectiveTo characterize referrals to community-based organizations by primary care practices.DesignQualitative study using semi-structured interviews with healthcare administrators responsible for social care efforts in their organization.ParticipantsAdministrators at 50 diverse US healthcare organizations with efforts to address patients' social risks.Main measuresApproaches used in primary care to implement social needs referral to community-based organizations.ResultsInterviewed administrators reported that social needs referrals were an essential element in their social care activities. Administrators described the ideal referral programs as placing limited burden on care teams, providing patients with customized referrals, and facilitating closed-loop referrals. We identified three key challenges organizations experience when trying to implement the ideal referrals program: (1) developing and maintaining resources lists; (2) aligning referrals with patient needs; and (3) measuring the efficacy of referrals. Collectively, these challenges led to organizations relying on staff to manually develop and update resource lists and, in most cases, provide patients with generic referrals. Administrators not only hoped that referral platforms may help overcome some of these barriers, but also reported implementation challenges with platforms including inconsistent buy-in and use across staff; integration with electronic health records; management and prioritization of resources; and alignment with other organizations in their market.Conclusion and relevanceReferrals to community-based organizations were used in primary care to improve patients' social conditions, but despite strong motivations, interviewees reported challenges providing tailored and up-to-date information to patients.

Aim: This descriptive paper aims to describe the design and implementation of a community engaged primary healthcare strategy in rural Australia, the Primary Healthcare Registered Nurse: Schools-Based strategy. This strategy seeks to address the health, education and social inequities confronting children and adolescents through community engaged service provision and nursing practice., Background: There have been increasing calls for primary healthcare approaches to address rural health inequities, including contextualised healthcare, enhanced healthcare access, community engagement in needs and solutions identification and local-level collaborations. However, rural healthcare can be poorly aligned to community contexts and needs and be firmly entrenched in health systems, marginalising community participation., Methods: This strategy has been designed to enhance nursing service and practice responsiveness to the rural context, primary healthcare principles, and community experiences and expectations of healthcare. The strategy is underpinned by a cross-sector collaboration between a local health district, school education and a university department of rural health. A research framework is being developed to explore strategy impacts for service recipients, cross-sector systems, and the establishment and maintenance of a primary healthcare nursing workforce., Findings: Although in the early stages of implementation, key learnings have been acquired and strategic, relationship, resource and workforce gains achieved.

Clinical research relies on patients being willing to participate in research projects, and making this possible for patients with mental health problems can be a particular challenge. In the modern era, many countries have seen a movement to give a stronger voice to patients both in choices around their care and in how research is conducted. How to achieve effective patient and public involvement (PPI) and to make the patients real partners in this effort is itself a subject of research evaluation. This opinion piece-based on a keynote lecture given at the European General Practice Research Network 2017 autumn meeting in Dublin-describes both the reasons for expanding PPI, how it can usefully be achieved, and how this may relate to the particular context of mental health. There can be moral, methodological or policy reasons for PPI. The three commonest models of good practice in PPI are the 'one off,' the 'fully embedded' and the 'outreach' models. In research into common mental health problems in family practice, 'outreach' approaches that minimize commitment over time may work best. 'Expert patients' from mental health charities can sometimes play this role. PPI may be challenging and involve extra effort, but the gains for all may be considerable. Wonca Europe networks including EGPRN can extend this message and findings.

Objective: To compare primary care in Canada and Brazil and how both countries have embraced the Starfield principles in the design of their health care systems., Composition of the Committee: A subgroup of the Besrour Centre of the College of Family Physicians of Canada developed connections with colleagues in Brazil and collaborated to undertake a between-country comparison, comparing and contrasting various elements of both countries' efforts to strengthen primary care over the past few decades., Methods: Following a literature review, the authors collectively reflected on their experiences in an attempt to explore the past and current state of family medicine in Canada and Brazil., Report: The Brazilian and Canadian primary care systems have both adopted and advanced the Starfield principles in various ways, with both countries showing an increasing trend toward adopting interprofessional team-based care. Access to primary care remains a challenge in rural areas in both countries, and longitudinal relationships between providers and patients appear to be more common in Canada. With the advent of technology, increasing patient engagement and expectations, the decline of paternalistic medicine, and the sheer mass of readily available information (and misinformation), to be successful, primary care systems must also be constructed to engender trust at both the local and the system levels. Both countries face challenges to maintaining trust in the context of the increasing prevalence of team-based care, and a lack of trust at the system level can be seen in patients' perceptions about the difficulty of finding a family doctor and in high rates of emergency department and urgent care centre use in both countries. Primary care reform must be implemented with the public's trust in mind., Conclusion: Trust is a crucial ingredient to the success of primary care and must be protected at both local and system levels. If designed with trust in mind, primary care in Canada and Brazil has the potential to meet the challenges set out by the Starfield principles., (Copyright© the College of Family Physicians of Canada.)

Background: Referral letters sent from primary to secondary or tertiary care are a crucial element in the continuity of patient information transfer. Internationally, the need for improvement in this area has been recognised. This aim of this study is to review the current literature pertaining to interventions that are designed to improve referral letter quality., Methods: A search strategy designed following a Problem, Intervention, Comparator, Outcome model was used to explore the PubMed and EMBASE databases for relevant literature. Inclusion and exclusion criteria were established and bibliographies were screened for relevant resources., Results: A total of 18 publications were included in this study. Four types of interventions were described: electronic referrals were shown to have several advantages over paper referrals but were also found to impose new barriers; peer feedback increases letter quality and can decrease 'inappropriate referrals' by up to 50%; templates increase documentation and awareness of risk factors; mixed interventions combining different intervention types provide tangible improvements in content and appropriateness., Conclusion: Several methodological considerations were identified in the studies reviewed but our analysis demonstrates that a combination of interventions, introduced as part of a joint package and involving peer feedback can improve.

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Objective: To assess family medicine's role in developing strong, coordinated, community-based, integrated health care systems in low-resource settings globally., Composition of the Committee: A subgroup of the Besrour Centre of the College of Family Physicians of Canada developed connections with selected international colleagues with expertise in international family medicine practice, health systems and capacity building, and teaching to map family medicine globally and give a bird's eye view of family medicine internationally., Methods: Following a background literature review, the authors collectively reflected on their substantial international experience to attempt to describe best practices for various contexts., Report: With the failure of vertical, disease-oriented models to provide sustained improvements in health outcomes, the need to develop integrated primary care involving the most appropriate health professionals for differing contexts is becoming apparent worldwide. Health system planning is required to develop policies on health professional training to achieve this. Advocating and offering appropriate incentives for, and coordination of, local opportunities within the health system also becomes paramount. The adaptability and generalist nature of family medicine allows it to respond to the unique needs of a given population. Family physicians with adequate financial and physical resources can function most effectively as members of interdisciplinary teams, thus providing valuable, comprehensive health services in any area of the world., (Copyright© the College of Family Physicians of Canada.)

Three questionnaires are recommended in the management of chronic obstructive pulmonary disease by the global initiative for obstructive lung disease, of which two are the more comprehensive assessments: the chronic obstructive pulmonary disease assessment test and the clinical chronic obstructive pulmonary disease questionnaire. Both are carefully designed high-quality questionnaires, but information on the feasibility for routine use is scarce. The aim of this study was to compare the time to complete the chronic obstructive pulmonary disease assessment test and the clinical chronic obstructive pulmonary disease questionnaire and the acceptability of the questionnaires. Furthermore, the agreement between electronic and paper versions of the questionnaires was explored. The time to complete the electronic versions of the questionnaires was 99.6 [IQR 74; 157] vs. 97.5 [IQR 68; 136] seconds for clinical clinical chronic obstructive pulmonary disease questionnaire and chronic obstructive pulmonary disease assessment test, respectively. The difference in time to complete the questionnaire was not significant. The two questionnaires did not differ in "easiness to complete" or "importance of issues raised in questionnaires". Electronic vs. paper versions revealed high agreement (ICC CCQ = 0.815 [0.712; 0.883] and ICC CAT = 0.751 [0.608; 0.847]) between the administration methods. Based on this study it can be concluded that both questionnaires are equally suitable for use in routine clinical practice, because they are both quick to complete and have a good acceptability by the patient. Agreement between electronic and paper versions of the questionnaires was high, so use of electronic versions is justified.COPD: QUESTIONNAIRES EQUALLY SUITABLE FOR CLINICAL PRACTICE: Two questionnaires commonly used to manage chronic obstructive pulmonary diseases (COPD) are equally suitable for routine primary care. Researchers in The Netherlands, led by Janwillem Kocks from the University Medical Center Groningen, administered both the COPD assessment test (CAT) and the clinical COPD questionnaire (CCQ) to 95 patients with the lung disease. These two tests are the most comprehensive assessments recommended by the global initiative for obstructive lung disease for guiding treatment decisions. The researchers found that both tests took approximately 95-100 s on average. Both tests were also equally easy to complete and provided similar types of information. Most patients said they had no preference for either one, and they filled out both electronic and paper versions of the questionnaires in much the same way. The authors conclude that both tests seem fine for routine use.

Introduction: The overall aim of this project is to help develop knowledge about primary care delivery models likely to improve the accessibility, quality and efficiency of care. Operationally, this objective will be achieved through supporting and evaluating 8 primary care team pilot sites that rely on an expanded nursing role within a more intensive team-based, interdisciplinary setting., Methods and Analysis: The first research component is aimed at supporting the development and implementation of the pilot projects, and is divided into 2 parts. The first part is a logical analysis based on interpreting available scientific data to understand the causal processes by which the objectives of the intervention being studied may be achieved. The second part is a developmental evaluation to support teams in the field in a participatory manner and thereby learn from experience. Operationally, the developmental evaluation phase mainly involves semistructured interviews. The second component of the project design focuses on evaluating pilot project results and assessing their costs. This component is in turn made up of 2 parts. Part 1 is a pre-and-post survey of patients receiving the intervention care to analyse their care experience. In part 2, each patient enrolled in part 1 (around 4000 patients) will be matched with 2 patients followed within a traditional primary care model, so that a comparative analysis of the accessibility, quality and efficiency of the intervention can be performed. The cohorts formed in this way will be followed longitudinally for 4 years., Ethics and Dissemination: The project, as well as all consent forms and research tools, have been accepted by 2 health sciences research ethics committees. The procedures used will conform to best practices regarding the anonymity of patients., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Introduction: Stroke is a major health problem and transient ischaemic attack (TIA) is an important risk factor for stroke. Primary prevention of stroke and TIA will have the greatest impact on reducing the burden of these conditions. Evidence-based guidelines for stroke/TIA prevention identify individuals eligible for preventative interventions in primary care. This study will investigate: (1) the proportion of strokes/TIAs with prior missed opportunities for prevention in primary care; (2) the influence of patient characteristics on missed prevention opportunities and (3) how the proportion of missed prevention opportunities has changed over time., Methods and Analysis: A retrospective case review will identify first-ever stroke and patients with TIA between 2000 and 2013 using anonymised electronic medical records extracted from the health improvement network (THIN) database. Four categories of missed opportunities for stroke/TIA prevention will be sought: untreated high blood pressure in patients eligible for treatment (either blood pressure ≥160/100 or ≥140/90 mm Hg in patients at high cardiovascular disease (CVD) risk); patients with atrial fibrillation with high stroke risk and no anticoagulant therapy; no lipid modifying drug therapy prescribed in patients at high CVD risk or with familial hypercholesterolaemia. The proportion of patients with each missed opportunity and multiple missed opportunities will be calculated. Mixed effect logistic regression will model the relationship between demographic and patient characteristics and missed opportunities for care; practice will be included as a random effect., Ethics and Dissemination: THIN data collection was approved by the NHS South East Multi-centre Research Ethics Committee (MREC) in 2003. This study was approved by the independent scientific review committee in May 2013. Dissemination of findings has the potential to change practice, improve the quality of care provided to patients and ultimately reduce the incidence of strokes and TIAs. Findings will be published in a peer-reviewed journal and disseminated at national and international conferences., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Background With the deepening of health care reform in China, primary care and general practice researches have developed rapidly in recent years, and the number of papers published has increased rapidly. Objective Summarize and analyze the scientific research papers published in the field of primary care and general practice in China in 2021, explore the characteristics in the number of papers published, journals published, regions, institutions, research categories, research methods, and the number of authors. Methods Based on the disciplinary definition of the research concepts, themes and methods in this field, combining scoping review methods and bibliometric techniques, scientific research papers published by researchers in Chinese scientific research institutions in 2021 included in the CNKI, Wanfang, PubMed, and Web of Science database were retried, induced and analyzed. In this paper, combined with the scope review method and bibliometric technology, a systematic search and quantitative analysis were carried out on scientific research papers in the fields of primary care and general practice published by researchers in Chinese scientific research institutions in 2021 included in the CNKI, Wanfang, PubMed, and Web of Science databases. Results There are 3 122 original research papers published in the fields of primary care and general practice in China in 2021. The number of papers published by primary care institutions accounted for 57.69%, but most of the papers were completed by a single authoramong such institutions. Papers published by the eastern primary care institutions accounted for 80.12%. The research category is dominated by clinical research (58.23%) and health services researches (27.07%) , the co-occurrence analysis of keywords by VOSviewer shows that the research themes focus on "chronic disease management" and "contracted family doctor services", these papers mostly used randomized controlled trials (40.87%) and cross-sectional survey studies (36.71%) in research methods. The vast majority of papers in primary care and general practice field are published in non-core and non-SCI/SSCI journals (76.75%) , and only 6.98% of papers are published in SCI/SSCI journals. Conclusion The productivity level of primary care and general practice research in China has now reached the highest level in the world, of which the primary care institutions in the eastern region have made major contributions. The research topics in the primary care and general practice field are close to institutional practice and national health policy. However, there are still a series of problems and challenges in this field, such as the lack of cooperation among researchers in primary care institutions, the large number of studies using randomized controlled trial methods may have problems such as quality concerns and low recognition of research in this field in China by international SCI/SSCI journals.

This paper is a summary of the 2007 European Position Paper on Rhinosinusitis and Nasal Polyps (EP3OS)1 which was published in Rhinology in 2007. In order to widen dissemination of the EP3OS paper, the editors of Rhinology and the Primary Care Respiratory Journal (PCRJ) have agreed to publish this summary - which is focussed on the needs of general practitioners and community-based non-specialist clinicians - in the PCRJ. In the EP3OS process, an evidence-based methodology was used to identify evidence and to grade recommendations for clinical practice for the management of rhinosinusitis. The EP3OS Taskforce was commissioned by the European Academy of Allergology and Clinical Immunology (EAACI) with the aims of: * Presenting specialist and generalist clinicians with an updated summary of knowledge of rhinosinusitis and nasal polyposis * Providing clinicans with an evidence-based summary of diagnostic methods appropriate for specialist and generalist settings * Providing evidence-based recommendations for management in specialist and generalist settings * Proposing guidance for definitions and outcome measurements in clinical practice and in research in different settings. The current document aims to distil the information presented in the full EP3OS document1 into a shorter and more concise format suitable for use in primary care generalist settings. The summary recommendations for generalists are that clinicians should be aware that rhinitis and sinusitis usually co-exist, and that management strategies should encompass this. Acute rhinosinusitis is an inflammatory condition that may be diagnosed on the basis of acute symptoms of nasal blockage, obstruction, congestion with or without facial pain or reduced smell; many episodes are self-limiting, but where symptoms persist or increase after five days, topical nasal steroids may be considered, with addition of antibiotics in patients with more severe or increasing symptoms. Non-resolution in 14 days, or the presence of atypical symptoms, should prompt consideration of referral to specialist care. Chronic rhinosinusitis occurs when symptoms have been present for >12 weeks, and anterior rhinoscopy or more detailed endoscopy should be performed to identify polyps. Topical nasal corticosteroids, nasal douching, and use of antihistamines in allergic patients, may be used in patients without, or with less symptomatic, polyps; referral to specialist care is needed for patients whose symptoms do not respond or who have large polyps.

Objective: To understand the key challenges to adoption of advanced features of electronic medical records (EMRs) in office practice, and to better understand these challenges in a Canadian context., Design: Mixed-methods study., Setting: Manitoba., Participants: Health care providers and staff in 5 primary care offices., Methods: Level of EMR adoption was assessed, and field notes from interviews and discussion groups were qualitatively analyzed for common challenges and themes across all sites., Main Findings: Fifty-seven interviews and 4 discussion groups were conducted from November 2011 to January 2012. Electronic medical record adoption scores ranged from 2.3 to 3.0 (out of a theoretical maximum of 5). Practices often scored lower than expected on use of decision support, providing patients with access to their own data, and use of practice-reporting tools. Qualitative analysis showed there were ceiling effects to EMR adoption owing to how the EMR was implemented, the supporting eHealth infrastructure, lack of awareness or availability of EMR functionality, and poor EMR data quality., Conclusion: Many practitioners used their EMRs as "electronic paper records" and were not using advanced features of their EMRs that could further enhance practice. Data-quality issues within the EMRs could affect future attempts at using these features. Education and quality improvement activities to support data quality and EMR optimization are likely needed to support practices in maximizing their use of EMRs.

Background and Objectives: Reflective papers are increasingly recognized as potentially important contributors to clinical education and practice; however, few quality guidelines are available for potential authors or reviewers. We sought to identify key characteristics of effective reflective papers and to clarify factors that increased or reduced the probability of acceptance for publication., Methods: A 10-item survey addressing the definition, purpose, and quality characteristics of reflective papers was developed based on a literature review and analysis of the author instructions of 14 journals that regularly publish reflective papers and are likely to be read by primary care physicians. The survey was sent electronically to the editor or associate editor responsible for reflective papers at each journal., Results: Seven completed surveys were returned. The essential element defining a reflective paper was identified as narration of a specific professional experience that resonated with readers and conveyed deeper meaning. All respondents rated emotional engagement as very important, followed by stimulating reflection in the reader, providing a lesson applicable to patient care, and stimulating discussion with colleagues and/or learners. Reasons for acceptance or rejection of reflective submissions to journals were identified in issues related to writing style, topic selection, and reader reaction., Conclusions: Writing and reviewing reflective papers is strongly dependent on context, personal values, experience, and emotional reaction; nevertheless, core quality features can be identified to guide both writers and editors/reviewers without destroying the unique nature of these papers.

This paper aims to define the role of the primary care physician (PCP) in the management of Alzheimer's disease (AD) and to propose a model for a work plan. The proposals in this position paper stem from a collaborative work of experts involved in the care of AD patients. It combines evidence from a literature review and expert's opinions who met in Paris, France, on July 2009 during the International Association of Geriatrics and Gerontology (IAGG) World Congress. The PCP's intervention appears essential at many levels: detection of the onset of dementia, diagnostic management, treatment and follow-up. The key role of the PCP in the management of AD, as care providers and care planners, is consolidated by the family caregiver's confidence in their skills. In primary care practice the first step is to identify dementia. The group proposes a "case finding" strategy, in target situations in which dementia should be detected to allow, secondarily, a diagnosis of AD, in certain cases. We propose that the PCP identifies 'typical' cases. In typical cases, among older subjects, the diagnosis of "probable AD" can be done by the PCP and then confirm by the specialist. While under-diagnosis of AD exists, so does under-disclosure. Disclosure to patient and family should be done by both specialist and PCP. Then, the PCP has a central role in management of the disease with the general objectives to detect, prevent and treat, when possible, the complications of the disease (falls, malnutrition, behavioural and psychological symptoms of dementia). The PCP needs to give basic information to the caregiver on respite care and home support services in order to prevent crisis situations such as unplanned institutionalisation and "emergency" hospital admission. Finally, therapeutic research must be integrated in the daily practice of PCP. It is a matter of patients' right to benefit from access to innovation and clinical research whatever his age or diseases, while of course fully respecting the rules and protective measures that are in force.

Background: Recruiting to primary care studies is complex. With the current drive to increase numbers of patients involved in primary care studies, we need to know more about successful recruitment approaches. There is limited evidence on recruitment to focus group studies, particularly when no natural grouping exists and where participants do not regularly meet. The aim of this paper is to reflect on recruitment to a focus group study comparing the methods used with existing evidence using a resource for research recruitment, PROSPeR (Planning Recruitment Options: Strategies for Primary Care)., Methods: The focus group formed part of modelling a complex intervention in primary care in the Resources for Effective Sleep Treatment (REST) study. Despite a considered approach at the design stage, there were a number of difficulties with recruitment. The recruitment strategy and subsequent revisions are detailed., Results: The researchers' modifications to recruitment, justifications and evidence from the literature in support of them are presented. Contrary evidence is used to analyse why some aspects were unsuccessful and evidence is used to suggest improvements. Recruitment to focus group studies should be considered in two distinct phases; getting potential participants to contact the researcher, and converting those contacts into attendance. The difficulty of recruitment in primary care is underemphasised in the literature especially where people do not regularly come together, typified by this case study of patients with sleep problems., Conclusion: We recommend training GPs and nurses to recruit patients during consultations. Multiple recruitment methods should be employed from the outset and the need to build topic related non-financial incentives into the group meeting should be considered. Recruitment should be monitored regularly with barriers addressed iteratively as a study progresses.

Background: As the problem of patient non-adherence persists and a solution appears hard to be found, it continues to be important to look for new ways to further the issue. We recently conducted a meta-review of adherence intervention studies which yielded a preliminary agenda for future research, practice and theory development in patient adherence. The objective of the present project was to find out to what extent adherence experts consider this agenda relevant and feasible., Methods: The thirty-five corresponding authors of the review studies included in the meta-review were invited to join the International Expert Forum on Patient Adherence and to participate in a four-week web-based focus group discussion. The discussion was triggered by the points on the preliminary agenda presented as propositions to which forum members could react. Two researchers analysed the transcripts and selected relevant phrases., Results: Twenty adherence experts participated. Various ideas and viewpoints were raised. After the closure of the web-site, the expert forum was asked to authorize the synthesis of the discussion, to list the propositions in order of priority and to answer a few questions on the use of the web-based focus group as a tool to obtain expert opinions. Their ranking showed that the development of simple interventions is the most promising step to take in fostering patient adherence, preferably within a multidisciplinary setting of medical, pharmaceutical, social and technical science and, not in the least, by incorporating patients' perspectives., Conclusion: For enhancing adherence, the development of simple interventions originating from a multidisciplinary perspective including patients' input, appears most promising. Disclosing patients' perspectives requires open communication about patients' expectations, needs and experiences in taking medication and about what might help them to become and remain adherent.