Is it worth trying? A cross-sectional study on the implementation of point-of-care ultrasound in Hungarian primary care

Is it worth trying? 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A cross-sectional study on the implementation of point-of-care ultrasound in Hungarian primary care Róbert Kiss-Kovács, Blanka Morvai-Illés, Albert Varga, Gergely Ágoston This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4007075/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 05 Sep, 2024 Read the published version in BMC Primary Care → Version 1 posted 10 You are reading this latest preprint version Abstract Background Although the number of point-of-care ultrasound devices available in Hungarian primary care practices are increasing due to government funding, their use in day-to-day patient care is limited and unregulated. Our study aimed to evaluate the attitudes and needs of general practitioners (GPs) and patients in Hungary regarding the introduction of bedside ultrasonography in primary care practices. Methods As a part of a cross-sectional study, an anonymous, self-administered questionnaire was distributed to GPs and patients on a social media platform. Data collection was carried out from August 2023 to October 2023. Chi-square test was used to determine the associations between patient groups and categorical variables. Results The survey was completed by 415 GPs (mean age 53.8 ± 11.1 years, 54.9% female, mean 19.5 ± 11.9 years of practice) and 693 patients (mean age 45.5 ± 12.3 years, 95.2% female). There was a statistically significant increase in interest in PoCUS among young and middle-aged GPs (age 28–59; p = 0.02). In addition, this population of GPs was also more likely to undertake training in PoCUS than their older colleagues (p < 0.0001). A significant inverse correlation was found between the duration of practice and training willingness (p = 0.0011). Even with the government's financial support, only 8.2% of GPs currently use PoCUS in a daily basis, and 59.5% of GPs are unfamiliar with the indications and the ways of using it. Patients would even pay to have the examination done in a primary care setting, even though only 45.9% of patients would pay a GP who is not certified in PoCUS, but the willingness to pay increased to 99.4% for those with formal training (p = 0.024). Conclusion Our findings indicate a significant interest in adapting PoCUS in primary care from both GPs and patients. Based on the fact that a significant proportion of Hungarian GPs are unaware of PoCUS and its indications, it is particularly important to develop educational frameworks, and practical guidelines for the effective incorporation of PoCUS in Hungary. Primary care General practitioners Point-of-care ultrasound Survey Implementation Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Background Point-of-care ultrasound (PoCUS) is increasingly becoming the ‘stethoscope of modern medicine’ complement to physical examination [ 1 , 2 ]. Rapid technological advances in recent decades have also led to considerable changes to medical diagnostic tools [ 3 , 4 ]. Initially, bedside ultrasonography was widely used for the rapid assessment of trauma cases in the 1990s [ 5 ]. Since then, in many areas of inpatient care, mobile, hand-held, pocked-sized ultrasound devices, which are ideal for binary decision-making on clinical questions, have been gaining ground for many years. Their use is also important in time-sensitive urgent cases for rapid, accurate, noninvasive diagnosis and prompt initiation of definitive therapy, which facilitates improved clinical outcomes [ 6 , 7 , 8 ]. The last decade has seen an expansion of point-of-care ultrasonography in family medicine in several countries, but not at nearly the same pace as in inpatient care [ 9 ]. However, several known nations, including Hungary, have not yet spread this imaging technique in the family medicine community. For the United States, the goal is still to introduce uniform PoCUS training for family medicine residents, based on the point-of-care ultrasound training curriculum incorporated and published by the American Academy of Family Physicians in 2016 [ 10 ]. This has not yet occurred uniformly due to the lack of implementation of training standardisation, funding challenges and lack of resources [ 11 ]. As in the USA, there is considerable diversity in the use of PoCUS among European countries. The reasons for this are manifold and can be attributed to factors that have not yet been resolved [ 12 ]. In Hungary, one such factor that needs to be resolved is the lack of training and qualifications of family physicians and the absence of the implementation of detailed guidelines and a compatible and sustainable training programme in the curriculum for family medicine residents. In addition to training, financing, procurement, legal and quality assurance aspects still need to be clarified [ 13 , 14 , 15 ]. These shortcomings must be addressed so that PoCUS can become an integral part of everyday work in GP practices. To overcome these limitations, we considered it necessary to determine the current views of both GPs practising in Hungary and the adult population covered by social security in Hungary on implementing this diagnostic tool. To make it worthwhile to start making changes, it is pivotal to discover the impressions and attitudes of these two populations towards PoCUS. Methods Study design and participants As a part of a cross-sectional study, two online, self-administered, anonymous questionnaires were distributed via Facebook. The first nineteen questions, targeted actively on practicing, board certified GPs in a closed medical group with 3.909 members, and was approved by the group administrator. The second survey, consisting of eighteen questions, was directed at patients receiving public healthcare in a closed group specialising in giving medical advice for non-health professional people with 69.011 members, with permission from the group administrator. Both questionnaires featured a mix of open, closed, and semiclosed questions, ensuring a comprehensive and representative outcome. Despite being voluntary, participants’ responses were kept confidential through a cloud-based two-factor authentication security system, safeguarding against unauthorised access. Data collection was carried out from August 2023 to October 2023. During these period, the EUR/HUF exchange rate was 1 EUR to 379.88 HUF. Inclusion and exclusion criteria GPs could complete the questionnaire if they are board certified, and actively practising in a mixed or adult general practice in Hungary during the data collection. Patient eligibility required permanent residence in Hungary, with the entitlement to free, public healthcare benefits. Patients under 18 years of age were excluded. GPs practising outside Hungary and patients without a Hungarian address were also excluded. Questionnaires Before answering the questions, participants had to read a digital patient information leaflet and had to sign a consent form by clicking a button unlocking the questionnaire (can be found as a Supplementary Material). The GPs’ survey included demographic questions (age, sex) and fifteen questions about their practice, as well as their knowledge, training, and views on the use and regulation of PoCUS. Patients also answered demographic questions (age, sex, education, residence) and twelve questions on PoCUS in primary care, including questions about trust, training, availability, satisfaction, willingness to pay, and the importance of patient education and information. Both surveys included open questions on the advantages and disadvantages of using PoCUS. Data analysis Data analysis was performed with IBM® SPSS® software, version 29.0.1.0 (SPSS, Chicago, IL). Descriptive statistical analysis was presented as median with interquartile range (IQR) or mean with standard deviation (SD) for continuous variables. Categorical variables were summarised using frequency and percentage. Chi-square test was used to determine the associations between patient groups and categorical variables. Age and the duration of practice were treated as a categorical variable in the analysis. A p - value less than 0.05 was considered significant. Results A total of 415 GPs, and 693 patients completed the questionnaires. Results of the questions answered by GPs The mean age of the GPs was 53.8 ± 11.1 years, with 54.9% (n = 228) of patients being females and 45.1% (n = 187) males. Willingness to implement PoCUS (p = 0.02) and complete PoCUS training (p < 0.0001) correlated significantly with GP age. The mean duration of practice was 19.5 ± 11.9 years, strongly associated with willingness to participate in PoCUS training (p = 0.0011). A total of 23.9% (n = 99) of GPs were in mixed (adult and pediatric) care, while 76.1% (n = 316) were in adult care. Overall, 8.2% (n = 34) of the GPs used bedside ultrasonography. For these 34 participants, we asked additional questions about the use of PoCUS, as shown in Fig. 1 . Only 7.2% of GPs (n = 30) rated their knowledge of PoCUS as good, 33.3% limited (n = 138) and 59.5% none (n = 247). Assuming ideal conditions (training, qualification, clear legal and funding aspects, sufficient time to use), 95.4% of GPs (n = 396) believed that PoCUS would contribute to primary care in Hungary, while 4.6% (n = 19) thought the opposite. A total of 82.2% of GPs (n = 342) advocated PoCUS training for family medicine resident doctors. If available, 80.2% (n = 333) would complete PoCUS training, with 59.8% of GPs being confident in finding time for daily use, while 22,9% (n = 95) were uncertain about this question. A total of 88.9% of GPs (n = 369) stressed the need to develop and implement legislation and guidelines. A total of 88.7% (n = 368) of GPs anticipated a positive impact on patient satisfaction. If the ideal circumstances listed above were provided, 79.3% of GPs (n = 329) would incorporate PoCUS into daily practice. The last two questions about the advantages and disadvantages of PoCUS as expressed by GPs are illustrated in Fig. 2 and Fig. 3 , which were open questions with no response limit. The potential relationships between the demographic data of GPs and answers given are presented in Table 1 . Table 1 The potential relationships between the demographic data and answers given by GPs, with p-values. First variable Second variable p-value How familiar are you with Point-of-care ultrasound techniques? GPs age 0.51 How familiar are you with Point-of-care ultrasound techniques? Type of GPs practice* 0.09 Do you use an ultrasound machine in your daily work? Type of GPs practice 0.41 Could you make time for using PoCUS during your daily work? Type of GPs practice 0.33 Would you incorporate PoCUS in your daily practice under ideal circumstances (qualification, legal regulation, etc.)? Type of GPs practice 0.38 Would you incorporate PoCUS in your daily practice under ideal circumstances (qualification, legal regulation, etc.)? GPs age 0.02 If you had the opportunity, would you take a qualifying training course? GPs age < 0.0001 If you had the opportunity, would you take a qualifying training course? Type of GPs practice 0.98 How important would you consider it to develop and implement detailed legislation and professional guidelines (e.g. protocols, quality assurance standards) for PoCUS? GPs age 0.87 (with Fisher’s exact test) How important would you consider it to develop and implement detailed legislation and professional guidelines (e.g. protocols, quality assurance standards) for PoCUS? Type of GPs practice 0.17 (with Fisher’s exact test) How familiar are you with Point-of-care ultrasound techniques? Time of practice 0.22 Do you use an ultrasound machine in your daily work? Time of practice 0.67 Would you incorporate PoCUS in your daily practice under ideal circumstances (qualification, legal regulation, etc.)? Time of practice 0.11 If you had the opportunity, would you take a qualifying training course? Time of practice 0.0011 How important would you consider it to develop and implement detailed legislation and professional guidelines (e.g. protocols, quality assurance standards) for PoCUS? Time of practice 0.51 *Type of practice means it is either mixed (child and adult) or exclusively adult care. Results of the questions answered by patients The patients (n = 693) had a mean age of 45.5 ± 12.3 years, with 95.24% of them being females and 4.76% males. Regarding residence, 30.2% lived in Budapest, 25.3% in a large city (not including the capital), 25.4% in a small town, and 19.1% in smaller communities. A total of 55.3% of patients had a higher level of education, 44.0% had a secondary education. Patients with a higher level of education would be more willing to pay for a PoCUS examination (p = 0.024). Among those patients (n = 427), would pay an average of 5.000 HUF (± 4.623 HUF) for the service. 45.9% of patients would allow their GP to perform PoCUS without qualifications, but the proportion of patients accepting the examination increased to 99.4% if the GP has a formal training in ultrasonography. In the case of an untrained GP, 48.5% (n = 336) of patients would not completely believe the diagnosis. In contrast, 93.4% of patients (n = 647) would believe the result established by a certified GP. In this study, a total 93.8% of patients (n = 650) considered it essential to be trained in bedside ultrasound, and 94.6% found it important to receive detailed information about the examination. The potential relationships between the demographic data and answers given are presented in Table 2 . Table 2 The potential relationships between the demographic data and answers given by patients, with p-values. First variable Second variable p-value How important is it for you that your GP is qualified for PoCUS? Level of education 0.43 How important is it for you that your GP is qualified for PoCUS? Type of residence 0.22 Would you allow your GP to perform PoCUS on you without a qualification? Level of education 0.77 Would you allow your GP to perform PoCUS on you without a qualification? Type of residence 0.16 Would you believe your GP’s PoCUS report if he or she is not qualified? Level of education 0.72 Would you believe your GP’s PoCUS report if he or she is not qualified? Type of residence 0.35 Would you pay for a PoCUS examination performed by your GP? Level of education 0.024 Would you pay for a PoCUS examination performed by your GP? Type of residence 0.28 If you would pay, then how much? (n = 427) Level of education 0.26 If you would pay, then how much? (n = 427) Type of residence 0.58 In terms of patient satisfaction, 99.1% of patients would be satisfied if their GP were certified in PoCUS. The advantages and disadvantages of PoCUS, as expressed by patients, are illustrated in Fig. 4 and Fig. 5 , which were open questions with no response limit. Discussion Main findings Patients and GPs living and working in Hungary were surveyed on their attitudes and experiences toward PoCUS in primary care. Although the number of GPs using PoCUS on a daily basis is currently very low, practitioners and patients demonstrated a great interest and willingness to introduce bedside ultrasound. For GPs, the willingness to implement and learn PoCUS is significantly influenced by age, which suggests that younger GPs may be more open to adapting to modern technology. The responses showed higher trust and acceptance from patients, especially if their GPs are qualified to perform PoCUS. A significant correlation was found between patients’ willingness to pay for the examination and their level of education, suggesting that patients who may have a better financial background due to their higher level of education are more willing to pay the availability of high-quality healthcare. Comparison with the literature The process of adapting PoCUS to primary care is occurring at very different paces worldwide. In the USA, despite an increasing number of states including PoCUS in the training of family medicine residents, the rate of use by specialists remains low. The solution may lie in addressing the immaturity of the training infrastructure through targeted investments [ 16 ]. Furthermore, cooperation between family medicine departments to share best practices and continuity in procuring equipment and establishing a financing scheme are essential for further expansion [ 11 ]. Our study has shown that these are the main areas that Hungary needs to improve. A previous study revealed that family medicine residents and GPs showed high interest and importance to PoCUS [ 17 ]. According to the results of our research, these findings are in line with the views of Hungarian GPs. PoCUS began to gain ground in the primary care of more European countries but still not in sufficient quantities. In Denmark, an increasing number of GPs are using PoCUS despite the lack of evidence-based guidelines for its appropriate use. For this reason, Danish GPs who require PoCUS have developed guidelines for themselves, as reported in an article in 2019 [ 18 ]. In the same year, Danish, Norwegian, Swedish, and Finnish GPs experienced in PoCUS developed a list of ultrasound examinations that could be used as a guideline in primary care, which could form the basis for future training [ 19 ]. In Catalonia, Spain, based on the consensus of GPs experienced in PoCUS, a training curriculum was developed for the main indications of PoCUS in primary care, in which competence levels were also defined. [ 20 ]. The Danish and Spanish consensus-building methods could be good examples for the development of a detailed curriculum of PoCUS in Hungarian primary care, given our findings that there is a strong need to develop it. However, knowing the risks of using PoCUS without following existing professional guidelines is vital. In Norway, there was a fourfold increase in the number of GPs using PoCUS between 2009 and 2016, with 30% of them using the device by 2016 [ 21 ]. Similar to this study, in the future, we consider it useful to survey the number of PoCUS users among GPs in Hungary, where our current survey results would be the basis for comparison. In Slovenia, a small number of GPs included in a questionnaire used PoCUS for a wide range of indications, while at the same time, there was a significant number of disadvantages. The disadvantages mentioned by GPs were related to the organisation of examinations, the immature nature of training and the lack of funding [ 22 ]. The same problems currently exist in Hungary and need to be solved. A systematic review demonstrated that GPs are able to use PoCUS safely in a wide range of clinical settings, given a certain level of pretest probability [ 23 ]. One study revealed that using PoCUS in 3 out of 4 consultations influenced the diagnostic process and clinical decision-making of GPs [ 24 ]. The results of these studies and our current survey support the need to address the problems hindering the implementation of PoCUS in Hungary. From the patient’s perspective, a previous study has shown that a significant proportion of the patients involved had an overall positive experience of PoCUS in their GP practice [ 25 ]. This result correlates well with the direction of patients' attitudes in our research, but further in-depth studies are needed to explore patients’ views in more detail. Implications for research, clinical practice, education and policy Our study underlines the demand for targeted interventions in Hungary to address the limited use of PoCUS among GPs. Key implications include developing structured training programs, integrating residency training, and establishing standardised guidelines and regulations. Bridging the gap between willingness and utilisation requires educational efforts addressing technical and perception-related aspects. Lawmakers should focus on legislation and guidelines to support the implementation of PoCUS in Hungarian primary care settings. Strengths and limitations Our research’s strength is its comprehensive approach, gathering the views of providers and beneficiaries to understand PoCUS perspectives in Hungarian primary care. Anonymous online questionnaires on social media enable honest responses, with open-ended questions allowing unrestricted opinions from participants. However, our study has limitations as well, including the involvement of patients and GPs, that has been through closed social media platforms. Older patients and physicians are less represented on these online platforms, which may result in potential biases. The interpretation of our results is further limited by the fact that the sex of the patient population is almost entirely female. However, this observation may indicate that female patients are more involved in health-related issues. The cross-sectional design provides only a snapshot, limiting causal relationships and temporal monitoring. Conclusions Our findings indicate a a significant interest in adapting PoCUS in primary care from both GPs and patients. Based on the fact that a significant proportion of Hungarian GPs are unaware of PoCUS and its indications, it is particularly important to develop educational frameworks, and practical guidelines for the effective incorporation of PoCUS in Hungary. Abbreviations EUR Euro GP General practitioner HUF Hungarian forint PoCUS Point-of-care ultrasound SD Standard deviation USA United States of America Declarations Ethics approval and consent to participate Ethical approval was granted in a decision issued by the Medical Research Council in Hungary. The Institutional Research Ethics Committee approved the research on the basis of this decision. The registration number of the authorisation decision is BM/17953-1/2023. Informed consent was obtained from all subjects involved in this research. All the experiment protocol for involving human data was in accordance with the Declaration of Helsinki in the manuscript. Consent for publication Not applicable. Competing interests The authors declare that they have no competing interests. Funding The research required no financial resources. Author Contribution RK contributed to the study conception and design, development of questionnaires, data analysis, interpretation of the results and the first draft of the manuscript. BM contributed to the data analysis and data interpretation. AV contributed to the literature and data collection. GÁ contributed to the data and literature collection and critically revised the manuscript. All authors reviewed the manuscript. Acknowledgements Not applicable. Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. References Maw AM, Huebschmann AG, Mould-Millman NK, Dempsey AF, Soni NJ. 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Supplementary Files Questionnaires.docx Cite Share Download PDF Status: Published Journal Publication published 05 Sep, 2024 Read the published version in BMC Primary Care → Version 1 posted Editorial decision: Revision requested 28 May, 2024 Reviews received at journal 27 May, 2024 Reviews received at journal 21 May, 2024 Reviewers agreed at journal 21 May, 2024 Reviewers agreed at journal 17 May, 2024 Reviewers invited by journal 16 May, 2024 Editor invited by journal 14 Mar, 2024 Submission checks completed at journal 13 Mar, 2024 Editor assigned by journal 13 Mar, 2024 First submitted to journal 02 Mar, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Ágoston","email":"data:image/png;base64,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","orcid":"","institution":"University of Szeged","correspondingAuthor":true,"prefix":"","firstName":"Gergely","middleName":"","lastName":"Ágoston","suffix":""}],"badges":[],"createdAt":"2024-03-02 22:34:05","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4007075/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4007075/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12875-024-02578-z","type":"published","date":"2024-09-05T16:05:50+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":52917581,"identity":"020a8e5d-4a7c-4d00-8587-45681320d9db","added_by":"auto","created_at":"2024-03-18 17:02:33","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":36663,"visible":true,"origin":"","legend":"\u003cp\u003eAnswers to questions to GPs using PoCUS.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-4007075/v1/a8945c754fe2985e4215cce4.png"},{"id":52918736,"identity":"41be1753-f2ec-4b18-8392-085250e1906d","added_by":"auto","created_at":"2024-03-18 17:10:33","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":24265,"visible":true,"origin":"","legend":"\u003cp\u003eThe advantages of point-of-care ultrasonography as expressed by GPs.\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-4007075/v1/7284d049883e02505cedb924.png"},{"id":52917584,"identity":"98636512-a9df-4114-8176-a9d4d88b651b","added_by":"auto","created_at":"2024-03-18 17:02:33","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":26707,"visible":true,"origin":"","legend":"\u003cp\u003eThe disadvantages of point-of-care ultrasonography as expressed by GPs.\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-4007075/v1/e350a32a91ed2c9adcca6489.png"},{"id":52917585,"identity":"63cd031e-9580-4241-83eb-62676edafe57","added_by":"auto","created_at":"2024-03-18 17:02:33","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":22895,"visible":true,"origin":"","legend":"\u003cp\u003eThe advantages of point-of-care ultrasonography as expressed by patients.\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-4007075/v1/9194083c04843816427950d8.png"},{"id":52917586,"identity":"f225e8a9-0303-42a9-8e1f-0d9950fc3da5","added_by":"auto","created_at":"2024-03-18 17:02:33","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":23012,"visible":true,"origin":"","legend":"\u003cp\u003eThe disadvantages of point-of-care ultrasonography as expressed by patients.\u003c/p\u003e","description":"","filename":"floatimage5.png","url":"https://assets-eu.researchsquare.com/files/rs-4007075/v1/7e06afb2d6b0736f9ce4590f.png"},{"id":64185976,"identity":"64626fb4-8ad5-4cd4-89a1-dbe60e7b4b50","added_by":"auto","created_at":"2024-09-09 16:23:20","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1300589,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4007075/v1/be3d7f50-7807-4951-a85c-a81de4ed691c.pdf"},{"id":52917582,"identity":"ae0e11e1-e615-4d1a-8f7c-0252d27c0e6d","added_by":"auto","created_at":"2024-03-18 17:02:33","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":23070,"visible":true,"origin":"","legend":"","description":"","filename":"Questionnaires.docx","url":"https://assets-eu.researchsquare.com/files/rs-4007075/v1/01dde04492d63ad0d7636865.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Is it worth trying? A cross-sectional study on the implementation of point-of-care ultrasound in Hungarian primary care","fulltext":[{"header":"Background","content":"\u003cp\u003ePoint-of-care ultrasound (PoCUS) is increasingly becoming the \u0026lsquo;stethoscope of modern medicine\u0026rsquo; complement to physical examination [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Rapid technological advances in recent decades have also led to considerable changes to medical diagnostic tools [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Initially, bedside ultrasonography was widely used for the rapid assessment of trauma cases in the 1990s [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Since then, in many areas of inpatient care, mobile, hand-held, pocked-sized ultrasound devices, which are ideal for binary decision-making on clinical questions, have been gaining ground for many years. Their use is also important in time-sensitive urgent cases for rapid, accurate, noninvasive diagnosis and prompt initiation of definitive therapy, which facilitates improved clinical outcomes [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. The last decade has seen an expansion of point-of-care ultrasonography in family medicine in several countries, but not at nearly the same pace as in inpatient care [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. However, several known nations, including Hungary, have not yet spread this imaging technique in the family medicine community. For the United States, the goal is still to introduce uniform PoCUS training for family medicine residents, based on the point-of-care ultrasound training curriculum incorporated and published by the American Academy of Family Physicians in 2016 [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. This has not yet occurred uniformly due to the lack of implementation of training standardisation, funding challenges and lack of resources [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. As in the USA, there is considerable diversity in the use of PoCUS among European countries. The reasons for this are manifold and can be attributed to factors that have not yet been resolved [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. In Hungary, one such factor that needs to be resolved is the lack of training and qualifications of family physicians and the absence of the implementation of detailed guidelines and a compatible and sustainable training programme in the curriculum for family medicine residents. In addition to training, financing, procurement, legal and quality assurance aspects still need to be clarified [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. These shortcomings must be addressed so that PoCUS can become an integral part of everyday work in GP practices. To overcome these limitations, we considered it necessary to determine the current views of both GPs practising in Hungary and the adult population covered by social security in Hungary on implementing this diagnostic tool. To make it worthwhile to start making changes, it is pivotal to discover the impressions and attitudes of these two populations towards PoCUS.\u003c/p\u003e "},{"header":"Methods","content":"\u003ch2\u003eStudy design and participants\u003ch2\u003e\u003cp\u003eAs a part of a cross-sectional study, two online, self-administered, anonymous questionnaires were distributed via Facebook. The first nineteen questions, targeted actively on practicing, board certified GPs in a closed medical group with 3.909 members, and was approved by the group administrator. The second survey, consisting of eighteen questions, was directed at patients receiving public healthcare in a closed group specialising in giving medical advice for non-health professional people with 69.011 members, with permission from the group administrator. Both questionnaires featured a mix of open, closed, and semiclosed questions, ensuring a comprehensive and representative outcome. Despite being voluntary, participants\u0026rsquo; responses were kept confidential through a cloud-based two-factor authentication security system, safeguarding against unauthorised access. Data collection was carried out from August 2023 to October 2023. During these period, the EUR/HUF exchange rate was 1 EUR to 379.88 HUF.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eInclusion and exclusion criteria\u003c/h2\u003e \u003cp\u003eGPs could complete the questionnaire if they are board certified, and actively practising in a mixed or adult general practice in Hungary during the data collection. Patient eligibility required permanent residence in Hungary, with the entitlement to free, public healthcare benefits. Patients under 18 years of age were excluded. GPs practising outside Hungary and patients without a Hungarian address were also excluded.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eQuestionnaires\u003c/h2\u003e \u003cp\u003eBefore answering the questions, participants had to read a digital patient information leaflet and had to sign a consent form by clicking a button unlocking the questionnaire (can be found as a Supplementary Material). The GPs\u0026rsquo; survey included demographic questions (age, sex) and fifteen questions about their practice, as well as their knowledge, training, and views on the use and regulation of PoCUS. Patients also answered demographic questions (age, sex, education, residence) and twelve questions on PoCUS in primary care, including questions about trust, training, availability, satisfaction, willingness to pay, and the importance of patient education and information. Both surveys included open questions on the advantages and disadvantages of using PoCUS.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eData analysis was performed with IBM\u0026reg; SPSS\u0026reg; software, version 29.0.1.0 (SPSS, Chicago, IL). Descriptive statistical analysis was presented as median with interquartile range (IQR) or mean with standard deviation (SD) for continuous variables. Categorical variables were summarised using frequency and percentage. Chi-square test was used to determine the associations between patient groups and categorical variables. Age and the duration of practice were treated as a categorical variable in the analysis. A p\u003cem\u003e-\u003c/em\u003evalue less than 0.05 was considered significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 415 GPs, and 693 patients completed the questionnaires.\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eResults of the questions answered by GPs\u003c/h2\u003e \u003cp\u003eThe mean age of the GPs was 53.8\u0026thinsp;\u0026plusmn;\u0026thinsp;11.1 years, with 54.9% (n\u0026thinsp;=\u0026thinsp;228) of patients being females and 45.1% (n\u0026thinsp;=\u0026thinsp;187) males. Willingness to implement PoCUS (p\u0026thinsp;=\u0026thinsp;0.02) and complete PoCUS training (p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001) correlated significantly with GP age. The mean duration of practice was 19.5\u0026thinsp;\u0026plusmn;\u0026thinsp;11.9 years, strongly associated with willingness to participate in PoCUS training (p\u0026thinsp;=\u0026thinsp;0.0011). A total of 23.9% (n\u0026thinsp;=\u0026thinsp;99) of GPs were in mixed (adult and pediatric) care, while 76.1% (n\u0026thinsp;=\u0026thinsp;316) were in adult care. Overall, 8.2% (n\u0026thinsp;=\u0026thinsp;34) of the GPs used bedside ultrasonography. For these 34 participants, we asked additional questions about the use of PoCUS, as shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eOnly 7.2% of GPs (n\u0026thinsp;=\u0026thinsp;30) rated their knowledge of PoCUS as good, 33.3% limited (n\u0026thinsp;=\u0026thinsp;138) and 59.5% none (n\u0026thinsp;=\u0026thinsp;247). Assuming ideal conditions (training, qualification, clear legal and funding aspects, sufficient time to use), 95.4% of GPs (n\u0026thinsp;=\u0026thinsp;396) believed that PoCUS would contribute to primary care in Hungary, while 4.6% (n\u0026thinsp;=\u0026thinsp;19) thought the opposite. A total of 82.2% of GPs (n\u0026thinsp;=\u0026thinsp;342) advocated PoCUS training for family medicine resident doctors. If available, 80.2% (n\u0026thinsp;=\u0026thinsp;333) would complete PoCUS training, with 59.8% of GPs being confident in finding time for daily use, while 22,9% (n\u0026thinsp;=\u0026thinsp;95) were uncertain about this question. A total of 88.9% of GPs (n\u0026thinsp;=\u0026thinsp;369) stressed the need to develop and implement legislation and guidelines. A total of 88.7% (n\u0026thinsp;=\u0026thinsp;368) of GPs anticipated a positive impact on patient satisfaction. If the ideal circumstances listed above were provided, 79.3% of GPs (n\u0026thinsp;=\u0026thinsp;329) would incorporate PoCUS into daily practice. The last two questions about the advantages and disadvantages of PoCUS as expressed by GPs are illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, which were open questions with no response limit. The potential relationships between the demographic data of GPs and answers given are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe potential relationships between the demographic data and answers given by GPs, with p-values.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFirst variable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSecond variable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHow familiar are you with Point-of-care ultrasound techniques?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGPs age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.51\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHow familiar are you with Point-of-care ultrasound techniques?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eType of GPs practice*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.09\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDo you use an ultrasound machine in your daily work?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eType of GPs practice\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.41\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCould you make time for using PoCUS during your daily work?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eType of GPs practice\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.33\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWould you incorporate PoCUS in your daily practice under ideal circumstances (qualification, legal regulation, etc.)?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eType of GPs practice\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.38\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWould you incorporate PoCUS in your daily practice under ideal circumstances (qualification, legal regulation, etc.)?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGPs age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.02\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIf you had the opportunity, would you take a qualifying training course?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGPs age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIf you had the opportunity, would you take a qualifying training course?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eType of GPs practice\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.98\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHow important would you consider it to develop and implement detailed legislation and professional guidelines (e.g. protocols, quality assurance standards) for PoCUS?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGPs age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.87 (with Fisher\u0026rsquo;s exact test)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHow important would you consider it to develop and implement detailed legislation and professional guidelines (e.g. protocols, quality assurance standards) for PoCUS?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eType of GPs practice\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.17 (with Fisher\u0026rsquo;s exact test)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHow familiar are you with Point-of-care ultrasound techniques?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTime of practice\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.22\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDo you use an ultrasound machine in your daily work?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTime of practice\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.67\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWould you incorporate PoCUS in your daily practice under ideal circumstances (qualification, legal regulation, etc.)?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTime of practice\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIf you had the opportunity, would you take a qualifying training course?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTime of practice\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.0011\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHow important would you consider it to develop and implement detailed legislation and professional guidelines (e.g. protocols, quality assurance standards) for PoCUS?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTime of practice\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.51\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e*Type of practice means it is either mixed (child and adult) or exclusively adult care.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eResults of the questions answered by patients\u003c/h2\u003e \u003cp\u003eThe patients (n\u0026thinsp;=\u0026thinsp;693) had a mean age of 45.5\u0026thinsp;\u0026plusmn;\u0026thinsp;12.3 years, with 95.24% of them being females and 4.76% males. Regarding residence, 30.2% lived in Budapest, 25.3% in a large city (not including the capital), 25.4% in a small town, and 19.1% in smaller communities. A total of 55.3% of patients had a higher level of education, 44.0% had a secondary education. Patients with a higher level of education would be more willing to pay for a PoCUS examination (p\u0026thinsp;=\u0026thinsp;0.024). Among those patients (n\u0026thinsp;=\u0026thinsp;427), would pay an average of 5.000 HUF (\u0026plusmn;\u0026thinsp;4.623 HUF) for the service. 45.9% of patients would allow their GP to perform PoCUS without qualifications, but the proportion of patients accepting the examination increased to 99.4% if the GP has a formal training in ultrasonography. In the case of an untrained GP, 48.5% (n\u0026thinsp;=\u0026thinsp;336) of patients would not completely believe the diagnosis. In contrast, 93.4% of patients (n\u0026thinsp;=\u0026thinsp;647) would believe the result established by a certified GP. In this study, a total 93.8% of patients (n\u0026thinsp;=\u0026thinsp;650) considered it essential to be trained in bedside ultrasound, and 94.6% found it important to receive detailed information about the examination. The potential relationships between the demographic data and answers given are presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe potential relationships between the demographic data and answers given by patients, with p-values.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFirst variable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSecond variable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHow important is it for you that your GP is qualified for PoCUS?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLevel of education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.43\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHow important is it for you that your GP is qualified for PoCUS?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eType of residence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.22\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWould you allow your GP to perform PoCUS on you without a qualification?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLevel of education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.77\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWould you allow your GP to perform PoCUS on you without a qualification?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eType of residence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWould you believe your GP\u0026rsquo;s PoCUS report if he or she is not qualified?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLevel of education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.72\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWould you believe your GP\u0026rsquo;s PoCUS report if he or she is not qualified?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eType of residence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.35\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWould you pay for a PoCUS examination performed by your GP?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLevel of education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.024\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWould you pay for a PoCUS examination performed by your GP?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eType of residence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.28\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIf you would pay, then how much? (n\u0026thinsp;=\u0026thinsp;427)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLevel of education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.26\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIf you would pay, then how much? (n\u0026thinsp;=\u0026thinsp;427)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eType of residence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.58\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIn terms of patient satisfaction, 99.1% of patients would be satisfied if their GP were certified in PoCUS. The advantages and disadvantages of PoCUS, as expressed by patients, are illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e and Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e, which were open questions with no response limit.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eMain findings\u003c/h2\u003e \u003cp\u003ePatients and GPs living and working in Hungary were surveyed on their attitudes and experiences toward PoCUS in primary care. Although the number of GPs using PoCUS on a daily basis is currently very low, practitioners and patients demonstrated a great interest and willingness to introduce bedside ultrasound. For GPs, the willingness to implement and learn PoCUS is significantly influenced by age, which suggests that younger GPs may be more open to adapting to modern technology. The responses showed higher trust and acceptance from patients, especially if their GPs are qualified to perform PoCUS. A significant correlation was found between patients\u0026rsquo; willingness to pay for the examination and their level of education, suggesting that patients who may have a better financial background due to their higher level of education are more willing to pay the availability of high-quality healthcare.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eComparison with the literature\u003c/h2\u003e \u003cp\u003eThe process of adapting PoCUS to primary care is occurring at very different paces worldwide. In the USA, despite an increasing number of states including PoCUS in the training of family medicine residents, the rate of use by specialists remains low. The solution may lie in addressing the immaturity of the training infrastructure through targeted investments [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Furthermore, cooperation between family medicine departments to share best practices and continuity in procuring equipment and establishing a financing scheme are essential for further expansion [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Our study has shown that these are the main areas that Hungary needs to improve. A previous study revealed that family medicine residents and GPs showed high interest and importance to PoCUS [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. According to the results of our research, these findings are in line with the views of Hungarian GPs. PoCUS began to gain ground in the primary care of more European countries but still not in sufficient quantities. In Denmark, an increasing number of GPs are using PoCUS despite the lack of evidence-based guidelines for its appropriate use. For this reason, Danish GPs who require PoCUS have developed guidelines for themselves, as reported in an article in 2019 [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. In the same year, Danish, Norwegian, Swedish, and Finnish GPs experienced in PoCUS developed a list of ultrasound examinations that could be used as a guideline in primary care, which could form the basis for future training [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. In Catalonia, Spain, based on the consensus of GPs experienced in PoCUS, a training curriculum was developed for the main indications of PoCUS in primary care, in which competence levels were also defined. [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. The Danish and Spanish consensus-building methods could be good examples for the development of a detailed curriculum of PoCUS in Hungarian primary care, given our findings that there is a strong need to develop it. However, knowing the risks of using PoCUS without following existing professional guidelines is vital. In Norway, there was a fourfold increase in the number of GPs using PoCUS between 2009 and 2016, with 30% of them using the device by 2016 [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Similar to this study, in the future, we consider it useful to survey the number of PoCUS users among GPs in Hungary, where our current survey results would be the basis for comparison. In Slovenia, a small number of GPs included in a questionnaire used PoCUS for a wide range of indications, while at the same time, there was a significant number of disadvantages. The disadvantages mentioned by GPs were related to the organisation of examinations, the immature nature of training and the lack of funding [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The same problems currently exist in Hungary and need to be solved. A systematic review demonstrated that GPs are able to use PoCUS safely in a wide range of clinical settings, given a certain level of pretest probability [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. One study revealed that using PoCUS in 3 out of 4 consultations influenced the diagnostic process and clinical decision-making of GPs [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. The results of these studies and our current survey support the need to address the problems hindering the implementation of PoCUS in Hungary. From the patient\u0026rsquo;s perspective, a previous study has shown that a significant proportion of the patients involved had an overall positive experience of PoCUS in their GP practice [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. This result correlates well with the direction of patients' attitudes in our research, but further in-depth studies are needed to explore patients\u0026rsquo; views in more detail.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eImplications for research, clinical practice, education and policy\u003c/h2\u003e \u003cp\u003eOur study underlines the demand for targeted interventions in Hungary to address the limited use of PoCUS among GPs. Key implications include developing structured training programs, integrating residency training, and establishing standardised guidelines and regulations. Bridging the gap between willingness and utilisation requires educational efforts addressing technical and perception-related aspects. Lawmakers should focus on legislation and guidelines to support the implementation of PoCUS in Hungarian primary care settings.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and limitations\u003c/h2\u003e \u003cp\u003eOur research\u0026rsquo;s strength is its comprehensive approach, gathering the views of providers and beneficiaries to understand PoCUS perspectives in Hungarian primary care. Anonymous online questionnaires on social media enable honest responses, with open-ended questions allowing unrestricted opinions from participants. However, our study has limitations as well, including the involvement of patients and GPs, that has been through closed social media platforms. Older patients and physicians are less represented on these online platforms, which may result in potential biases. The interpretation of our results is further limited by the fact that the sex of the patient population is almost entirely female. However, this observation may indicate that female patients are more involved in health-related issues. The cross-sectional design provides only a snapshot, limiting causal relationships and temporal monitoring.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eOur findings indicate a a significant interest in adapting PoCUS in primary care from both GPs and patients. Based on the fact that a significant proportion of Hungarian GPs are unaware of PoCUS and its indications, it is particularly important to develop educational frameworks, and practical guidelines for the effective incorporation of PoCUS in Hungary.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eEUR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEuro\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eGP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eGeneral practitioner\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHUF\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHungarian forint\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePoCUS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePoint-of-care ultrasound\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eStandard deviation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eUSA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eUnited States of America\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":" \u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e \u003cp\u003e Ethical approval was granted in a decision issued by the Medical Research Council in Hungary. The Institutional Research Ethics Committee approved the research on the basis of this decision. The registration number of the authorisation decision is BM/17953-1/2023. Informed consent was obtained from all subjects involved in this research. All the experiment protocol for involving human data was in accordance with the Declaration of Helsinki in the manuscript.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication\u003c/strong\u003e \u003cp\u003eNot applicable.\u003c/p\u003e \u003ch2\u003eCompeting interests\u003c/h2\u003e \u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThe research required no financial resources.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eRK contributed to the study conception and design, development of questionnaires, data analysis, interpretation of the results and the first draft of the manuscript. BM contributed to the data analysis and data interpretation. AV contributed to the literature and data collection. G\u0026Aacute; contributed to the data and literature collection and critically revised the manuscript. All authors reviewed the manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e \u003cp\u003eNot applicable.\u003c/p\u003e\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e \u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMaw AM, Huebschmann AG, Mould-Millman NK, Dempsey AF, Soni NJ. Point-of- Care Ultrasound and Modernization of the Bedside Assessment. J Grad Med Educ. 2020;12(6):661\u0026ndash;5. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.4300/JGME-D-20-00216.1\u003c/span\u003e\u003cspan address=\"10.4300/JGME-D-20-00216.1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKimura BJ. 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Point- of-care ultrasound for general practitioners: a systematic needs assessment. Scand J Prim Health Care. 2020;38(1):3\u0026ndash;11. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1080/02813432.2020.1711572\u003c/span\u003e\u003cspan address=\"10.1080/02813432.2020.1711572\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eConangla-Ferrin L, Guirado-Vila P, Solanes-Cab\u0026uacute;s M, et al. Ultrasound in primary care: Consensus recommendations on its applications and training. Results of a 3-round Delphi study. 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Patients' experiences of the use of point-of-care ultrasound in general practice - a cross-sectional study. BMC Fam Pract. 2021;22(1):116. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12875-021-01459-z\u003c/span\u003e\u003cspan address=\"10.1186/s12875-021-01459-z\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-primary-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"famp","sideBox":"Learn more about [BMC Primary Care](https://bmcprimcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12875","title":"BMC Primary Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Primary care, General practitioners, Point-of-care ultrasound, Survey, Implementation","lastPublishedDoi":"10.21203/rs.3.rs-4007075/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4007075/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eAlthough the number of point-of-care ultrasound devices available in Hungarian primary care practices are increasing due to government funding, their use in day-to-day patient care is limited and unregulated. Our study aimed to evaluate the attitudes and needs of general practitioners (GPs) and patients in Hungary regarding the introduction of bedside ultrasonography in primary care practices.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eAs a part of a cross-sectional study, an anonymous, self-administered questionnaire was distributed to GPs and patients on a social media platform. Data collection was carried out from August 2023 to October 2023. Chi-square test was used to determine the associations between patient groups and categorical variables.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe survey was completed by 415 GPs (mean age 53.8\u0026thinsp;\u0026plusmn;\u0026thinsp;11.1 years, 54.9% female, mean 19.5\u0026thinsp;\u0026plusmn;\u0026thinsp;11.9 years of practice) and 693 patients (mean age 45.5\u0026thinsp;\u0026plusmn;\u0026thinsp;12.3 years, 95.2% female). There was a statistically significant increase in interest in PoCUS among young and middle-aged GPs (age 28\u0026ndash;59; p\u0026thinsp;=\u0026thinsp;0.02). In addition, this population of GPs was also more likely to undertake training in PoCUS than their older colleagues (p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). A significant inverse correlation was found between the duration of practice and training willingness (p\u0026thinsp;=\u0026thinsp;0.0011). Even with the government's financial support, only 8.2% of GPs currently use PoCUS in a daily basis, and 59.5% of GPs are unfamiliar with the indications and the ways of using it. Patients would even pay to have the examination done in a primary care setting, even though only 45.9% of patients would pay a GP who is not certified in PoCUS, but the willingness to pay increased to 99.4% for those with formal training (p\u0026thinsp;=\u0026thinsp;0.024).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eOur findings indicate a significant interest in adapting PoCUS in primary care from both GPs and patients. Based on the fact that a significant proportion of Hungarian GPs are unaware of PoCUS and its indications, it is particularly important to develop educational frameworks, and practical guidelines for the effective incorporation of PoCUS in Hungary.\u003c/p\u003e","manuscriptTitle":"Is it worth trying? A cross-sectional study on the implementation of point-of-care ultrasound in Hungarian primary care","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-03-18 17:02:28","doi":"10.21203/rs.3.rs-4007075/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-05-28T05:42:39+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-05-27T07:21:43+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-05-21T16:30:07+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"111523168386908235467583089034809921923","date":"2024-05-21T12:56:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"131402819512155247410704599555193099127","date":"2024-05-17T23:26:27+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-05-16T09:40:40+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-03-14T12:29:29+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-03-13T08:55:45+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-03-13T08:55:45+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Primary Care","date":"2024-03-02T22:24:34+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-primary-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"famp","sideBox":"Learn more about [BMC Primary Care](https://bmcprimcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12875","title":"BMC Primary Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c1b08b6c-92af-4dec-94aa-8bd8a9d94005","owner":[],"postedDate":"March 18th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-09-09T16:14:47+00:00","versionOfRecord":{"articleIdentity":"rs-4007075","link":"https://doi.org/10.1186/s12875-024-02578-z","journal":{"identity":"bmc-primary-care","isVorOnly":false,"title":"BMC Primary Care"},"publishedOn":"2024-09-05 16:05:50","publishedOnDateReadable":"September 5th, 2024"},"versionCreatedAt":"2024-03-18 17:02:28","video":"","vorDoi":"10.1186/s12875-024-02578-z","vorDoiUrl":"https://doi.org/10.1186/s12875-024-02578-z","workflowStages":[]},"version":"v1","identity":"rs-4007075","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4007075","identity":"rs-4007075","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}