Showing papers in "British Journal of General Practice in 2016"
TL;DR: Although resources are important, many barriers to improving care are amenable to behaviour change strategies, and improvement strategies need to account for differences between clinical targets and consider tailored rather than 'one size fits all' approaches.
Abstract: Background Despite the availability of evidence-based guidance, many patients with type 2 diabetes do not achieve treatment goals. Aim To guide quality improvement strategies for type 2 diabetes by synthesising qualitative evidence on primary care physicians’ and nurses’ perceived influences on care. Design and setting Systematic review of qualitative studies with findings organised using the Theoretical Domains Framework. Method Databases searched were MEDLINE, Embase, CINAHL, PsycInfo, and ASSIA from 1980 until March 2014. Studies included were English-language qualitative studies in primary care of physicians’ or nurses’ perceived influences on treatment goals for type 2 diabetes. Results A total of 32 studies were included: 17 address general diabetes care, 11 glycaemic control, three blood pressure, and one cholesterol control. Clinicians struggle to meet evolving treatment targets within limited time and resources, and are frustrated with resulting compromises. They lack confidence in knowledge of guidelines and skills, notably initiating insulin and facilitating patient behaviour change. Changing professional boundaries have resulted in uncertainty about where clinical responsibility resides. Accounts are often couched in emotional terms, especially frustrations over patient compliance and anxieties about treatment intensification. Conclusion Although resources are important, many barriers to improving care are amenable to behaviour change strategies. Improvement strategies need to account for differences between clinical targets and consider tailored rather than ‘one size fits all’ approaches. Training targeting knowledge is necessary but insufficient to bring about major change; approaches to improve diabetes care need to delineate roles and responsibilities, and address clinicians’ skills and emotions around treatment intensification and facilitation of patient behaviour change.
168 citations
TL;DR: Although some people make a spontaneous recovery after mTBI, nearly half continue to experience persistent symptoms linked to their injury, and Demographic factors and medical history should be taken into account in treatment planning.
Abstract: Background Mild traumatic brain injury (mTBI) is a common problem in general practice settings, yet previous research does not take into account those who do not attend hospital after injury. This is important as there is evidence that effects may be far from mild. Aim To determine whether people sustain any persistent effects 1 year after mTBI, and to identify the predictors of health outcomes. Design and setting A community-based, longitudinal population study of an mTBI incidence cohort ( n = 341) from a mixed urban and rural region (Hamilton and Waikato Districts) of the North Island of New Zealand (NZ). Method Adults (>16 years) completed assessments of cognitive functioning, global functioning, post-concussion symptoms, mood, and quality of life over the year after injury. Results Nearly half of participants (47.9%) reported experiencing four or more post-concussion symptoms 1 year post-injury. Additionally, 10.9% of participants revealed very low cognitive functioning. Levels of anxiety, depression, or reduced quality of life were comparable with the general population. Having at least one comorbidity, history of brain injury, living alone, non-white ethnic group, alcohol and medication use, and being female were significant predictors of poorer outcomes at 12 months. Conclusion Although some people make a spontaneous recovery after mTBI, nearly half continue to experience persistent symptoms linked to their injury. Monitoring of recovery from mTBI may be needed and interventions provided for those experiencing persistent difficulties. Demographic factors and medical history should be taken into account in treatment planning.
164 citations
TL;DR: Stigma and negative perceptions surrounding mental health and help-seeking may explain why young people are reluctant to approach others for help, and improving public awareness of the services and resources available may be necessary to improve mental wellbeing among young adults.
Abstract: Background Despite the high prevalence and burden of mental health problems among young people, studies have suggested that they infrequently seek professional help. Understanding the barriers to help-seeking is an important step towards facilitating early access to mental health services and improving psychological wellbeing.
Aim To investigate why young adults may choose not to seek any support for an emotional or mental health difficulty.
Design and setting A cross-sectional online survey of young adults aged 18–25 from the general UK population.
Method The survey consisted of an anonymous questionnaire that measured psychological distress, help-seeking preferences, and barriers to accessing help, which included the Barriers to Access to Care Evaluation (BACE) scale and an open-ended question to explore reasons for not seeking help in the past. Qualitative feedback was analysed using thematic analysis.
Results Overall, 35% of participants ( n = 45) who reported having an emotional or mental health difficulty did not seek any formal or informal help. The thematic analysis revealed that stigmatising beliefs, difficulty identifying or expressing concerns, a preference for self-reliance, and difficulty accessing help were prominent barrier themes among responders.
Conclusion Young adults experiencing psychological distress may struggle to access help from others. Stigma and negative perceptions surrounding mental health and help-seeking may explain why young people are reluctant to approach others for help. Improving public awareness of the services and resources that are available, as well as screening for psychological distress in primary care services, may be necessary to improve mental wellbeing among young adults.
148 citations
TL;DR: The identification of a broad range of significant barriers highlights the need for tools and training to aid accurate identification and management, and for more efficient access to specialist services in primary care.
Abstract: Background Mental health problems are common and typically have an early onset. Effective treatments for mental health problems in childhood and adolescence are available, yet only a minority of children who are affected access them. This is of serious concern, considering the far-reaching and long-term negative consequences of such problems. Primary care is usually the first port of call for concerned parents so it is important to understand how primary care practitioners manage child and adolescent mental health problems and the barriers they face.
Aim To ascertain primary care practitioners’ perceptions of the barriers that prevent effective management of child and adolescent mental health problems.
Design and setting A systematic review of qualitative and quantitative literature in a primary care setting.
Method A database search of peer-reviewed articles using PsycINFO, MEDLINE®, Embase, and Web of Science, from inception (earliest 1806) until October 2014, was conducted. Additional studies were identified through hand searches and forward-citation searches. Studies needed to have at least one search term in four categories: primary care, childhood/adolescence, mental health, and barriers.
Results A total of 4151 articles were identified, of which 43 were included (30 quantitative studies and 13 qualitative studies). The majority of the barriers related to identification, management, and/or referral. Considerable barriers included a lack of providers and resources, extensive waiting lists, and financial restrictions.
Conclusion The identification of a broad range of significant barriers highlights the need to strengthen the ability to deal with these common difficulties in primary care. There is a particular need for tools and training to aid accurate identification and management, and for more efficient access to specialist services.
136 citations
TL;DR: Overdiagnosis of childhood asthma is common in primary care, leading to unnecessary treatment, disease burden, and impact on quality of life, however, only in a small percentage of children is a diagnosis of asthma confirmed by lung function tests.
Abstract: Background Asthma is one of the most common chronic diseases in childhood. According to guidelines, a diagnosis of asthma should be confirmed using lung function testing in children aged >6 years. Previous studies indicate that asthma in children is probably overdiagnosed. However, the extent has not previously been assessed. Aim To assess the extent and characteristics of confirmed and unconfirmed diagnoses of asthma in children who were diagnosed by their GP as having asthma or who were treated as having asthma. Design and setting Retrospective analysis in four academic primary healthcare centres in Utrecht, the Netherlands. Method Routine care registration data of children aged 6–18 years who received a diagnosis of asthma or were treated as having asthma were analysed. Results In only 16.1% ( n = 105) of the children diagnosed with asthma was the diagnosis confirmed with spirometry, whereas in 23.2% ( n = 151) the signs and symptoms did give rise to suspected asthma but the children should have undergone further lung function tests. In more one-half (53.5%, n = 349) of the children the signs and symptoms made asthma unlikely and thus they were most likely overdiagnosed. The remaining 7.2% ( n = 47) were probably correctly classified as not having asthma. The main reasons for classifying asthma without children undergoing further lung function tests were dyspnoea (31.9%, n = 174), cough (26.0%, n = 142), and wheezing (10.4%, n = 57). Conclusion Overdiagnosis of childhood asthma is common in primary care, leading to unnecessary treatment, disease burden, and impact on quality of life. However, only in a small percentage of children is a diagnosis of asthma confirmed by lung function tests.
126 citations
TL;DR: Health professional resilience is multifaceted, combining discrete personal traits alongside personal, social, and workplace features, and a measure for health professional resilience should be developed and validated that may be used to measure the effect of an intervention to promote it.
Abstract: Background Modern demands and challenges among healthcare professionals can be particularly stressful and resilience is increasingly necessary to maintain an effective, adaptable, and sustainable workforce. However, definitions of, and associations with, resilience have not been examined within the primary care context. Aim To examine definitions and measures of resilience, identify characteristics and components, and synthesise current evidence about resilience in primary healthcare professionals. Design and setting A systematic review was undertaken to identify studies relating to the primary care setting. Method Ovid ® , Embase ® , CINAHL, PsycINFO, and Scopus databases were searched in December 2014. Text selections and data extraction were conducted by paired reviewers working independently. Data were extracted on health professional resilience definitions and associated factors. Results Thirteen studies met the inclusion criteria: eight were quantitative, four qualitative, and one was an intervention study. Resilience, although multifaceted, was commonly defined as involving positive adaptation to adversity. Interactions were identified between personal growth and accomplishment in resilient physicians. Resilience, high persistence, high self-directedness, and low avoidance of challenges were strongly correlated; resilience had significant associations with traits supporting high function levels associated with demanding health professional roles. Current resilience measures do not allow for these different aspects in the primary care context. Conclusion Health professional resilience is multifaceted, combining discrete personal traits alongside personal, social, and workplace features. A measure for health professional resilience should be developed and validated that may be used in future quantitative research to measure the effect of an intervention to promote it.
123 citations
TL;DR: GPs should be aware of their major influence on patients and regularly discuss appropriateness of current medication use with older adults and their carers and address reasons for deprescribing.
Abstract: Background Deprescribing describes the complex process that is required for the safe and effective cessation of medications that are likely to cause more harm than benefit. Knowledgeof older adults’ and carers’ attitudes towards deprescribing will enhance shared decision making in medication optimisation. Aim To explore the views, beliefs, and attitudes of older adults and carers on deprescribing. Design and setting Qualitative focus group study in New South Wales, Australia. Method Four focus groups with 14 older adults and 14 carers were conducted. Results were analysed using a previously developed framework (directed content analysis) with additional conventional content analysis. Results The willingness of both older adults and carers to have one or more medications deprescribed was influenced by the following main themes: their perception of the appropriateness of that medication; fear of outcomes of withdrawal; dislike of taking medications; and the availability of a process for withdrawal (including a discussion with a healthcare professional and knowing that the medication could be restarted if necessary). A patient’s regular GP was identified as a strong influence both for and against medication withdrawal. The identified themes supported the previously developed framework. An additional theme unique to the carers was the complexity involved in making decisions about medications for their care recipients. Conclusion This study highlights that discussions between the healthcare professional and the olderadult or carer about withdrawing medications should address reasons for deprescribing. GPs should be aware of their major influence on patients and regularly discuss appropriateness of current medication use with older adults and their carers.
113 citations
TL;DR: To improve retention of young GPs, the pace of administrative change needs to be minimised and the time spent by GPs on work that is not face-to-face patient care reduced.
Abstract: Background The loss of GPs in the early stages of their careers is contributing to the GP workforce crisis. Recruitment in the UK remains below the numbers needed to support the demand for GP care. Aim To explore the reasons why GPs leave general practice early. Design and setting A mixed methods study using online survey data triangulated with qualitative interviews. Method Participants were GPs aged Results Reasons for leaving were cumulative and multifactorial. Organisational changes to the NHS have led to an increase in administrative tasks and overall workload that is perceived by GP participants to have fundamentally changed the doctor–patient relationship. Lack of time with patients has compromised the ability to practise more patient-centred care, and, with it, GPs’ sense of professional autonomy and values, resulting in diminished job satisfaction. In this context, the additional pressures of increased patient demand and the negative media portrayal left many feeling unsupported and vulnerable to burnout and ill health, and, ultimately, to the decision to leave general practice. Conclusion To improve retention of young GPs, the pace of administrative change needs to be minimised and the time spent by GPs on work that is not face-to-face patient care reduced.
106 citations
TL;DR: Patients were less satisfied in practices with frugal antibiotic prescribing, and a cautious approach to antibiotic prescribing may require a trade-off in terms of patient satisfaction.
Abstract: Background Concerns about adverse effects on patient satisfaction may be an important obstacle to attempts to curtail antibiotic prescribing. Aim To determine the relationship between antibiotic prescribing in general practice and reported patient satisfaction. Design and setting Retrospective cross-sectional study of general practices in England. Method Data were obtained from the General Practice Patient Survey (GPPS) in 2012 (2.7 million questionnaires in England; 982 999 responses; response rate 36%); the national Quality and Outcomes Framework dataset for England, 2011–2012 (8164 general practices); and general practice and demographic characteristics. Standardised measures of antibiotic prescribing volumes were obtained for each practice in England during 2012–2013, together with 12 other nationally available prescribing variables. The role of antibiotic prescribing volume was identified as a determinant of GPPS scores and adjusted for demographic and practice factors using multiple linear regression. Results The final dataset consisted of 7800 (95.5%) practices. A total of 33.7 million antibiotic prescriptions were issued to a registered population of 53.8 million patients. Antibiotic prescribing volume was a significant positive predictor of all ‘doctor satisfaction’ and ‘practice satisfaction’ scores in the GPPS, and was the strongest predictor of overall satisfaction out of 13 prescribing variables. A theoretical 25% reduction in antibiotic prescribing volume would be associated with 0.5–1.0% lower patient satisfaction scores, a drop of 3–6 centile points in national satisfaction ranking. Conclusion Patients were less satisfied in practices with frugal antibiotic prescribing. A cautious approach to antibiotic prescribing may require a trade-off in terms of patient satisfaction.
99 citations
TL;DR: Experience and training in recognising severe RTIs, together with more evidence to help HCPs identify the children at risk of future illness deterioration, may support HCP’s’ identification of the children most and least likely to benefit from antibiotics.
Abstract: Consultations for RTIs are more complex than most guidelines assume, requiring primary care doctors and nurses (from here on ‘healthcare professionals’, HCPs) to manage clinical uncertainty regarding diagnosis, prognosis, and treatment. 3
96 citations
TL;DR: There is a general reluctance among GPs to implement alternatives to face-to-face consultations, and a substantial gap between rhetoric and reality in terms of the likelihood of certain alternatives changing practice in the near future.
Abstract: © 2016 British Journal of General Practice. Background : The ubiquitous use of communication technologies has led to an expectation that a similar approach should extend to health care. Despite considerable rhetoric about the need for general practices to offer alternatives to faceto- face consultations, such as telephone, email, and internet video consultations, the extent to which such technologies are actually used at present is unclear. Aim: The aim of the survey was to identify the frequency and range of ways in which general practices are providing (or planning) alternatives to face-to-face consultations. Design and setting : A postal survey of practices around Bristol, Oxford, Lothian, the Highlands, and the Western Isles of Scotland. Method : A postal questionnaire survey was sent to each of the GPs and practice managers of 421 practices between January and May 2015. Results: A response was received from 319/421 practices (76%). Although the majority of the practices reported that they were conducting telephone consultations frequently (n = 211/318, 66%), fewer were implementing email consultations (n = 18/318, 6%), and most (n = 169/318, 53%) had no plans to introduce this. None were currently using internet video, and 86% (n = 273/318) had no plans to introduce internet video consultations. These findings were repeated in the reported use of alternatives to face-to-face consultations at an individual GP level. Optional free text responses were completed by 28% of responders, and offered an explanation for the (often perceived) barriers and incentives for implementation. Conclusion: Despite policy pressure to introduce consultations by email and internet video, there is a general reluctance among GPs to implement alternatives to face-to-face consultations. This identifies a substantial gap between rhetoric and reality in terms of the likelihood of certain alternatives (email, video) changing practice in the near future.
TL;DR: A model of health professional resilience is proposed that concurs with existing literature but adds the concept of personal traits being synergistic with workplace features and social networks to facilitate adaptability and enable individual health professionals to cope with adversity.
Abstract: Background The modern primary healthcare workforce needs to be resilient Early research framed professional resilience as avoiding ‘burnout’; however, more recent literature has introduced the concept of positive adaptation to professional challenges, which results in individuals thriving in their role Aim To explore what primary health professionals working in challenging environments consider to be characteristics of resilience and what promotes or challenges professional resilience Design and setting A qualitative focus group in north east Scotland Method Five focus groups were held with 20 health professionals (six GPs, nine nurses, four pharmacists, and a practice manager) based in rural or deprived city areas in the north east of Scotland Inductive thematic analysis identified emerging themes Results Personal resilience characteristics identified were optimism, flexibility and adaptability, initiative, tolerance, organisational skills, being a team worker, keeping within professional boundaries, assertiveness, humour, and a sense of self-worth Workplace challenges were workload, information overload, time pressures, poor communication, challenging patients, and environmental factors (rural location) Promoters of professional resilience were strong management support, teamwork, workplace buffers, and social factors such as friends, family, and leisure activities Conclusion A model of health professional resilience is proposed that concurs with existing literature but adds the concept of personal traits being synergistic with workplace features and social networks These facilitate adaptability and enable individual health professionals to cope with adversity that is inevitably part of the everyday experience of those working in challenging healthcare environments
TL;DR: This study demonstrates that low continuity of care in general practice is associated with a higher risk of mortality, strengthening the case for encouragement ofContinuity of care.
Abstract: Background Although continuity of care is a widely accepted core principle of primary care, the evidence about its benefits is still weak.
Aim To investigate whether continuity of care in general practice is associated with better survival in older people.
Design and setting Data were derived from the Longitudinal Aging Study Amsterdam, an ongoing cohort study in older people in the Netherlands. The study sample consisted of 1712 older adults aged ≥60 years, with 3-year follow-up cycles up to 17 years (1992–2009), and mortality follow-up until 2013.
Method Continuity of care was defined as the duration of the ongoing therapeutic relationship between patient and GP. The Herfindahl–Hirschman Index was used to calculate the continuity of care (COC). A COC index value of 1 represented maximum continuity. COC index values <1 were divided into tertiles, with a fourth category for participants with maximum COC. Cox regression analysis was used to investigate the association between COC and survival time.
Results Seven hundred and forty-two participants (43.3%) reported a maximum COC. Among the 759 participants surviving 17 years, 251 (33.1%) still had the same GP. The lowest COC category (index >0–0.500) showed significantly greater mortality than those in the maximum COC category (hazard ratio (HR) = 1.20, 95% CI = 1.01 to 1.42). There were no confounders that affected this HR.
Conclusion This study demonstrates that low continuity of care in general practice is associated with a higher risk of mortality, strengthening the case for encouragement of continuity of care.
TL;DR: Despite contraindications and guidance for the use of NSAIDs, their use in high-risk groups remains substantial and there has been no overall reduction in volume of NSAID prescribing.
Abstract: Preventable adverse drug reactions (ADRs) are responsible for 10% of hospital admissions in older people at a cost of around £800 million annually. Non-steroidal anti-inflammatory drugs (NSAIDs) are responsible for 30% of hospital admissions for ADRs, mainly due to bleeding, heart attack, stroke, and renal damage.1 In primary care 6% of patients prescribed NSAIDs reconsulted their GP with a potential ADR over the next 2 months. Most of these ADRs are avoidable because vulnerable groups and drug interactions can be predicted. Given that over 15 million NSAID prescriptions were dispensed in England in 2014, even a low rate of ADRs translates into a major cumulation of harm. Despite contraindications and guidance for the use of NSAIDs, their use in high-risk groups remains substantial and there has been no overall reduction in volume of NSAID prescribing. Safety is a system-wide attribute; what more should be done?
Non-steroidal anti-inflammatory drugs (NSAIDs) in a blister pack. The active ingredient is diclofenac diethylammonium. Collection: Medical Photographic Library. Credit: Julie Reza, Wellcome Images, 2007.
From the first day of use, all NSAIDs increase the risk of gastrointestinal (GI) bleeding, myocardial infarction, and stroke. NSAIDs reduce prostaglandin synthesis, with differences in the extent of inhibition of the enzymes COX-1 and COX-2. All NSAIDs increase both bleeding and cardiovascular disease (CVD) risk but selective COX-2 inhibitors are more likely to cause cardiovascular events, whereas less selective NSAIDs are more likely to cause GI bleeds. The risk of bleeding and of cardiovascular events is …
TL;DR: The findings reveal enduring priorities for policy, commissioning, practice development, and research in future primary palliative care.
Abstract: Background With increasing numbers of people living with complex life-limiting multimorbidity in the community, consideration must be given to improving the organisation and delivery of high-quality palliative and end-of-life care (EOLC). Aim To provide insight into the experience of GPs providing EOLC in the community, particularly the facilitators and barriers to good-quality care. Design and setting A web-based national UK questionnaire survey circulated via the Royal College of General Practitioners, NHS, Marie Curie, and Macmillan networks to GPs. Method Responses were analysed using descriptive statistics and an inductive thematic analysis. Results Responses were received from 516 GPs, who were widely distributed in terms of practice location. Of these, 97% felt that general practice plays a key role in the delivery of care to people approaching the end of life and their families. Four interdependent themes emerged from the data: continuity of care — which can be difficult to achieve because of resource concerns including time, staff numbers, increasing primary care workload, and lack of funding; patient and family factors — with challenges including early identification of palliative care needs and recognition of the end of life, opportunity for care planning discussions, and provision of support for families; medical management — including effective symptom-control and access to specialist palliative care services; and expertise and training — the need for training and professional development was recognised to enhance knowledge, skills, and attitudes towards EOLC. Conclusion The findings reveal enduring priorities for policy, commissioning, practice development, and research in future primary palliative care.
TL;DR: Whereas approximately half of smokers in England visiting their GP in the past year report having received advice on cessation, <10% of those who drink excessively report havingreceived advice on their alcohol consumption.
Abstract: BACKGROUND: Brief interventions have a modest but meaningful effect on promoting smoking cessation and reducing excessive alcohol consumption. Guidelines recommend offering such advice opportunistically and regularly but incentives vary between the two behaviours. AIM: To use representative data from the perspective of patients to compare the prevalence and characteristics of people who smoke or drink excessively and who receive a brief intervention. DESIGN AND SETTING: Data was from a representative sample of 15 252 adults from household surveys in England. METHOD: Recall of brief interventions on smoking and alcohol use, sociodemographic information, and smoking and alcohol consumption patterns were assessed among smokers and those who drink excessively (AUDIT score of â?¥8), who visited their GP surgery in the previous year. RESULTS: Of 1775 smokers, 50.4% recalled receiving brief advice on smoking in the previous year. Smokers receiving advice compared with those who did not were more likely to be older, female, have a disability, have made more quit attempts in the previous year (compared with no attempts: one attempt), and have greater nicotine dependence but were less likely to have no post-16 qualifications. Of 1110 people drinking excessively, 6.5% recalled receiving advice in their GP surgery on their alcohol consumption in the previous year. Those receiving advice compared with those who did not had higher AUDIT scores and were less likely to be female. CONCLUSION: Whereas approximately half of smokers in England visiting their GP in the past year report having received advice on cessation, <10% of those who drink excessively report having received advice on their alcohol consumption.
TL;DR: There was no association between patient experience measures of communication and consultation length, and patients may sometimes report good experiences from very short consultations, but longer consultations may be required to achieve clinical effectiveness and patient safety.
Abstract: This work was funded by the National Institute for Health Research Programme Grants for Applied Research (NIHR PGfAR) Programme (RP-PG-0608-10050). The views expressed are those of the authors and not necessarily those of the NHS, the NIHR, or the Department of Health.
TL;DR: Compared with the general population, people with ID have generally higher overall levels of chronic disease and greater primary care use and ensuring access to high-quality chronic disease management, especially for epilepsy and mental illness will help address these greater healthcare needs.
Abstract: Background People with intellectual disability (ID) are a group with high levels of healthcare needs; however, comprehensive information on these needs and service use is very limited. Aim To describe chronic disease, comorbidity, disability, and general practice use among people with ID compared with the general population. Design and setting This study is a cross-sectional analysis of a primary care database including 408 English general practices in 2012. Method A total of 14 751 adults with ID, aged 18–84 years, were compared with 86 221 age-, sex- and practice-matched controls. Depending on the outcome, prevalence (PR), risk (RR), or odds (OR) ratios comparing patients with ID with matched controls are shown. Results Patients with ID had a markedly higher prevalence of recorded epilepsy (18.5%, PR 25.33, 95% confidence interval [CI] = 23.29 to 27.57), severe mental illness (8.6%, PR 9.10, 95% CI = 8.34 to 9.92), and dementia (1.1%, PR 7.52, 95% CI = 5.95 to 9.49), as well as moderately increased rates of hypothyroidism and heart failure (PR>2.0). However, recorded prevalence of ischaemic heart disease and cancer was approximately 30% lower than the general population. The average annual number of primary care consultations was 6.29 for patients with ID, compared with 3.89 for matched controls. Patients with ID were less likely to have longer doctor consultations (OR 0.73, 95% CI = 0.69 to 0.77), and had lower continuity of care with the same doctor (OR 0.77, 95% CI = 0.73 to 0.82). Conclusion Compared with the general population, people with ID have generally higher overall levels of chronic disease and greater primary care use. Ensuring access to high-quality chronic disease management, especially for epilepsy and mental illness, will help address these greater healthcare needs. Continuity of care and longer appointment times are important potential improvements in primary care.
TL;DR: Observing what actually happens when practitioners develop and use their clinical knowledge reveals the complexities of their everyday practice, observing and analysing exactly how they put their knowledge into practice.
Abstract: Coffee-room chat may impact on evidence-based practice at least as much as all those guidelines that deluge GPs. If so, we need to understand better how and why that is, so that our informal conversations help rather than impede the spread of best practice.
The pressure to comply with guidelines and evidence-based patient pathways has been rising inexorably, but so too has the feeling that the evidence-based medicine movement often misses the point.1 Its champions, who include many policymakers and managers as well as researchers, lament clinicians’ apparent slowness in implementing research evidence, while clinicians grumble that their hard-learned clinical judgement is undervalued by an overemphasis on conforming to guidelines. The struggle is not just about practice, but also professional autonomy and identity. Yet both sides of the argument recognise that best practice must be grounded in best evidence and that guidelines have their place. So what exactly is that place and how do we get from the linear rationalism of guidelines to the complex wisdom of good practice?
Fifteen years ago we decided to examine such questions afresh by observing what actually happens when practitioners develop and use their clinical knowledge. We used the ethnographic methods of anthropologists, who while retaining some analytical distance immerse themselves among their chosen subjects to try to get an inside understanding of their beliefs and actions. Our subjects were deliberately selected as highly respected primary care teams, and our aim was to comprehend the complexities of their everyday practice, observing and analysing exactly how they put their knowledge into practice. We published our preliminary findings in 2004,2 but continued to gather data from our principal study site over the next 5 years3 while supplementing and exploring our …
TL;DR: Differences in baseline characteristics, including body mass index (BMI), symptom severity, and pain coping strategies between the different trajectories can help differentiate those patients who require more specific monitoring in the management of early symptomatic knee OA from those for whom a 'wait-and-see' policy seems justifiable.
Abstract: Background GPs have high consultation rates for symptoms related to knee osteoarthritis (OA). Many risk factors for symptomatic knee OA progression remain unknown. Aim To define distinct knee pain trajectories in individuals with early symptomatic knee OA and determine the risk factors for these pain trajectories. Design and setting Data were obtained from the multicentre prospective Cohort Hip and Cohort Knee study in the Netherlands. Participants with knee OA, according to the clinical criteria of the American College of Rheumatology, and a completed 5-year follow-up were included. Method Baseline demographic, anamnestic, and physical examination characteristics were assessed. Outcome was annually assessed by the Numeric Rating Scale for pain. Pain trajectories were retrieved by latent class growth analysis. Multinomial logistic regression was used to calculate relative risk ratios. Results In total, 705 participants were included. Six distinct pain trajectories were identified with favourable and unfavourable courses. Statistically significant differences were found in baseline characteristics, including body mass index (BMI), symptom severity, and pain coping strategies between the different trajectories. Higher BMI, lower level of education, greater comorbidity, higher activity limitation scores, and joint space tenderness were more often associated with trajectories characterised by more pain at first presentation and pain progression — compared with the reference group with a mild pain trajectory. No association was found for baseline radiographic features. Conclusion These results can help differentiate those patients who require more specific monitoring in the management of early symptomatic knee OA from those for whom a ‘wait-and-see’ policy seems justifiable. Radiography provided no additional benefit over clinical diagnosis of early symptomatic knee OA in general practice.
TL;DR: The study shows that MBSR for GPs is feasible and might result in fewer burnout symptoms and increased work engagement and wellbeing, however, an adequately powered randomised controlled trial is needed to confirm the study's findings.
Abstract: Background Burnout is highly prevalent in GPs and can have a negative influence on their wellbeing, performance, and patient care. Mindfulness-based stress reduction (MBSR) may be an effective intervention to decrease burnout symptoms and increase wellbeing. Aim To gain insight into the feasibility and effectiveness of MBSR on burnout, empathy, and (work-related) wellbeing in GPs. Design and setting A mixed methods pilot study, including a waiting list-controlled pre-/post-study and a qualitative study of the experiences of participating GPs in the Netherlands. Method Participants were sent questionnaires assessing burnout, work engagement, empathy, and mindfulness skills, before and at the end of the MBSR training/waiting period. Qualitative data on how GPs experienced the training were collected during a plenary session and with evaluation forms at the end of the course. Results Fifty Dutch GPs participated in this study. The MBSR group reported a greater decrease in depersonalisation than the control group (adjusted difference −1.42, 95% confidence interval [CI] = −2.72 to −0.21, P = 0.03). Dedication increased more significantly in the MBSR group than in the control group (adjusted difference 2.17, 95% CI = 0.51 to 3.83, P = 0.01). Mindfulness skills increased significantly in the MBSR group compared with the control group (adjusted difference 6.90, 95% CI = 1.42 to 12.37, P = 0.01). There was no significant change in empathy. The qualitative data indicated that the MBSR course increased their wellbeing and compassion towards themselves and others, including their patients. Conclusion The study shows that MBSR for GPs is feasible and might result in fewer burnout symptoms and increased work engagement and wellbeing. However, an adequately powered randomised controlled trial is needed to confirm the study’s findings.
TL;DR: Attracting rather than coercing students to general practice is likely to be more effective at changing their career choices, and increasing opportunities to help students understand what it means to be a 'good GP' and how this can be achieved are created.
Abstract: Background Despite concerns about recruitment to UK general practice, there has been no concerted educational intervention to address them. Aim To better understand how medical students’ perceptions of their experiences of their undergraduate curriculum may affect choosing general practice as a career. Design and setting Qualitative study comprising focus groups of a total of 58 students from a range of medical schools across the UK. Method A range of UK medical schools students were invited by email to participate in focus groups and return a questionnaire detailing their current career choice to facilitate sampling students with varied career preferences. Students late in their studies were sampled as they were likely to be considering future careers. Focus group discussions were audiotaped, transcribed, and anonymised for both school and participant, then thematically analysed. Perceived differences in medical school culture, curriculum philosophy, design, and intent were explored. Results Six focus groups (58 students) were convened. Some student participants’ career aspirations were strongly shaped by family and home, but clinical placements remained important in confirming or refuting these choices. High-quality general practice attachments are a powerful attractor to general practice and, when they reflect authentic clinical practice, promote general practice careers. GP tutors can be powerful, positive role models. Students’ comments revealed conflicting understandings about general practice. Conclusion Attracting rather than coercing students to general practice is likely to be more effective at changing their career choices. Early, high-quality, ongoing and, authentic clinical exposure promotes general practice and combats negative stereotyping. It is recommended that increasing opportunities to help students understand what it means to be a ‘good GP’ and how this can be achieved are created.
TL;DR: Current UK guidelines provide a pragmatic clinical approach to classification reflecting long-term endogenous insulin production; caution is needed in older patients commencing insulin from diagnosis, where misclassification rates are increased.
Abstract: Background Differentiating between type 1 and type 2 diabetes is fundamental to ensuring appropriate management of patients, but can be challenging, especially when treating with insulin. The 2010 UK Practical Classification Guidelines for Diabetes were developed to help make the differentiation. Aim To assess diagnostic accuracy of the UK guidelines against ‘gold standard’ definitions of type 1 and type 2 diabetes based on measured C-peptide levels. Design and setting In total, 601 adults with insulin-treated diabetes and diabetes duration ≥5 years were recruited in Devon, Northamptonshire, and Leicestershire. Method Baseline information and home urine sample were collected. Urinary C-peptide creatinine ratio (UCPCR) measures endogenous insulin production. Gold standard type 1 diabetes was defined as continuous insulin treatment within 3 years of diagnosis and absolute insulin deficiency (UCPCR Results UK guidelines correctly classified 86% of participants. Most misclassifications occurred in patients classed as having type 1 diabetes who had significant endogenous insulin levels (57 out of 601; 9%); most in those diagnosed ≥35 years and treated with insulin from diagnosis, where 37 out of 66 (56%) were misclassified. Time to insulin and age at diagnosis performed best in predicting long-term endogenous insulin production (ROC AUC = 0.904 and 0.871); BMI was a less strong predictor of diabetes type (AUC = 0.824). Conclusion Current UK guidelines provide a pragmatic clinical approach to classification reflecting long-term endogenous insulin production; caution is needed in older patients commencing insulin from diagnosis, where misclassification rates are increased.
TL;DR: FC has a high NPV for colorectal cancer and significant polyps in patients with suspected cancer and the addition of FC testing into the current symptom-based assessment has the potential to increase coloreCTal cancer detection rate yet be clinically and cost effective.
Abstract: Background NICE guidance exists for the use of faecal calprotectin (FC) when irritable bowel syndrome or inflammatory bowel disease are suspected. Often, however, colorectal cancer is considered within the differential. Should FC have a high diagnostic accuracy for colorectal cancer, it may be applicable as a primary care screening test for all patients with lower gastrointestinal symptoms. Aim To determine the negative and positive predictive value (NPV/PPV) of FC in patients referred from primary care with suspected colorectal cancer. Design and setting A diagnostic accuracy study conducted at a single secondary care site Method Consenting patients referred with suspected colorectal cancer within the ‘2-week wait’ pathway provided a stool sample for FC prior to investigation. FC levels were reconciled with end diagnoses: cancer, adenomatous polyps ≥10 mm, and all enteric organic disease. Results A total of 654 patients completed the evaluation; median age 69 years, female 56%. The NPV for colorectal cancer was 98.6% and 97.2% when including polyps ≥10 mm. The PPV for all organic enteric disease was 32.7%. The diagnostic yield for cancer based on clinical suspicion was 6.3%. By altering the FC cut-off to fix the NPV at 97.0%, the PPV for cancer increased from 8.7% to 13.3%. Conclusion FC has a high NPV for colorectal cancer and significant polyps in patients with suspected cancer. In total, 27.8% of patients had a normal FC and could safely have been spared a ‘2-week wait’ referral. The addition of FC testing into the current symptom-based assessment has the potential to increase colorectal cancer detection rate yet be clinically and cost effective.
TL;DR: Despite an overall decline in drug misuse in recent years, the use of so-called ‘legal highs’ or novel psychoactive substances (NPS) has seen exponential growth, with new brands, chemicals, and products proliferating rapidly in a new and evolving market.
Abstract: In a somewhat prophetic statement, Henderson wrote in 1988: ‘ It is likely that the future drugs of abuse will be synthetics rather than plant products. They will be synthesised from readily available chemicals, may be derivatives of pharmaceuticals, will be very potent, and often very selective in their action. In addition, they will be marketed very cleverly .’1
Indeed, despite an overall decline in drug misuse in recent years, the use of so-called ‘legal highs’ or novel psychoactive substances (NPS) has seen exponential growth, with new brands, chemicals, and products proliferating rapidly in a new and evolving market. The United Nations Office on Drugs and Crime recently reported more than twice the number of new substances now available as compared with 2 years ago.2 In addition, the European Monitoring Centre for Drugs and Drug Addiction report that in Europe two new NPS are available on the market almost every week.3 In the face of such a rapidly growing market, it is difficult to keep pace with what these products contain, what psychoactive effects they have, and how best to manage patients who are taking them.
Although we may feel fairly confident in managing a patient who has injected heroin, with Toxbase guidelines at the ready, managing a patient who has smoked ‘Blast Off’, snorted ‘Charly Sheen’, or injected ‘Magic Dragon’ may not be quite as straightforward. Toxbase guidelines for synthetic stimulants, hallucinogens, and empathogens are sparse, if present at all,4 and the fact that there is no way of knowing what chemicals these products contain compounds the issue because treating clinicians cannot know which chemicals to reference on Toxbase. Further, data show that products …
TL;DR: Children with food allergy and, in particular, infants with suspected adverse reactions to cow’s milk, commonly present to primary care and GPs’ knowledge of these guidelines is poor.
Abstract: Children with food allergy and, in particular, infants with suspected adverse reactions to cow’s milk, commonly present to primary care. It is thought that 6–8% of children aged <3 years have a food allergy1 and up to 4.9% have a cow’s milk allergy.2
Inconsistencies in the management of food allergy prompted the commissioning of projects such as the National Institute for Health and Care Excellence (NICE) clinical guideline on the diagnosis and assessment of food allergy in the community1 and in 2014 the NICE Clinical Knowledge Summary looking specifically at the management of milk allergy.3
It has been shown that GPs’ knowledge of these guidelines is poor. Inconsistencies remain in the management of milk allergy, with a particularly lengthy time period and multiple consultations before diagnosis.4
There is anecdotal evidence of confusion between lactose intolerance and milk allergy among both patients and physicians, which could result in unnecessary dietary restriction or avoidable reactions. Terminology such as suspected ‘milk allergy’, ‘milk intolerance’, and also ‘lactose intolerance’ are often used without a clear sense of the different meanings, understanding of the different mechanisms that underlie them, or the dietary implications of the diagnosis. The management of these conditions is distinctly different, and inappropriate recognition or management may have significant implications for the patient. In the last 15 years, there have been many discussions on the nomenclature of reactions to foods, including milk. The currently accepted nomenclature is …
TL;DR: Social support and goal setting were frequently used BCTs in home-based CR programmes, with the BCTS related to monitoring, instruction on how to perform the behaviour, and credible source being included in effective programmes.
Abstract: Background Cardiac rehabilitation (CR) programmes offering secondary prevention for cardiovascular disease (CVD) advise healthy lifestyle behaviours, with the behaviour change techniques (BCTs) of goals and planning, feedback and monitoring, and social support recommended. More information is needed about BCT use in home-based CR to support these programmes in practice. Aim To identify and describe the use of BCTs in home-based CR programmes. Design and setting Randomised controlled trials of home-based CR between 2005 and 2015 were identified by searching MEDLINE ® , Embase, PsycINFO, Web of Science, and Cochrane Database. Method Reviewers independently screened titles and abstracts for eligibility. Relevant data, including BCTs, were extracted from included studies. A meta-analysis studied risk factor change in home-based and comparator programmes. Results From 2448 studies identified, 11 of good methodological quality (10 on post-myocardial infarction, one on heart failure, 1907 patients) were included. These reported the use of 20 different BCTs. Social support (unspecified) was used in all studies and goal setting (behaviour) in 10. Of the 11 studies, 10 reported effectiveness in reducing CVD risk factors, but one study showed no improvement compared to usual care. This study differed from effective programmes in that it didn’t include BCTs that had instructions on how to perform the behaviour and monitoring, or a credible source. Conclusion Social support and goal setting were frequently used BCTs in home-based CR programmes, with the BCTs related to monitoring, instruction on how to perform the behaviour, and credible source being included in effective programmes. Further robust trials are needed to determine the relative value of different BCTs within CR programmes.
TL;DR: Worrying about wasting GP time is a complex barrier to help-seeking, and friendly GP relationships, economic reasoning, and a focus on the GP's responsibilities as a medical professional reduce this worry.
Abstract: Background Worrying about wasting GP time is frequently cited as a barrier to help-seeking for cancer symptoms. Aim To explore the circumstances under which individuals feel that they are wasting GP time. Design and setting Community-based, qualitative interview studies that took place in London, the South East and the North West of England. Method Interviewees ( n = 62) were recruited from a sample ( n = 2042) of adults aged ≥50 years, who completed a ‘health survey’ that included a list of cancer ‘alarm’ symptoms. Individuals who reported symptoms at baseline that were still present at the 3-month follow-up ( n = 271), and who had also consented to be contacted ( n = 215), constituted the pool of people invited for interview. Analyses focused on accounts of worrying about wasting GP time. Results Participants were worried about wasting GP time when time constraints were visible, while dismissive interactions with their GP induced a worry of unnecessary help-seeking. Many felt that symptoms that were not persistent, worsening, or life-threatening did not warrant GP attention. Additionally, patients considered it time-wasting when they perceived attention from nurses or pharmacists to be sufficient, or when appointment structures (for example, ‘one issue per visit’) were not adhered to. Close relationships with GPs eased worries about time-wasting, while some patients saw GPs as fulfilling a service financed by taxpayers. Conclusion Worrying about wasting GP time is a complex barrier to help-seeking. GP time and resource scarcity, symptom gravity, appointment etiquette, and previous GP interactions contribute to increasing worries. Friendly GP relationships, economic reasoning, and a focus on the GP’s responsibilities as a medical professional reduce this worry.
TL;DR: Prevalences of IADs rise in relation to underlying cardiovascular comorbidities of the population studied, and are overestimated threefold when sequential measurement is used.
Abstract: Background Various prevalence figures have been reported for inter-arm differences in blood pressure (IAD); variation may be explained by differing population vascular risk and by measurement method.
Aim To review the literature to derive robust estimates of IAD prevalence relevant to community populations.
Design and setting Systematic review and meta-analysis.
Method MEDLINE, Embase, and CINAHL were searched for cross-sectional studies likely to represent general or primary care populations, reporting prevalence of IAD and employing a simultaneous method of measurement. Using study-level data, pooled estimates of mean prevalence of systolic IADs were calculated and compared using a random effects model.
Results Eighty IAD studies were identified. Sixteen met inclusion criteria: pooled estimates of prevalence for systolic IAD ≥10 mmHg were 11.2% (95% confidence interval [CI] = 9.1 to 13.6) in hypertension, 7.4% (95% CI = 5.8 to 9.2) in diabetes, and 3.6% (95% CI = 2.3 to 5.0) for a general adult population ( P <0.001 for subgroup differences). Differences persisted for higher cut-off values. Prevalences were lower for East Asian than for Western populations and were overestimated by sequential measurement where this could be compared with simultaneous measurement within studies (relative risk for IAD: 2.9 [95% CI = 2.1 to 4.1]). Studies with higher mean absolute systolic pressures had higher prevalences for a systolic IAD ≥10 mmHg ( P = 0.04).
Conclusion Prevalences of IADs rise in relation to underlying cardiovascular comorbidities of the population studied, and are overestimated threefold when sequential measurement is used. Population-specific variation in prevalences of IAD should be taken into account in delivering clinical care and in planning future studies.
TL;DR: Although motives and barriers to antidepressant continuation or discontinuation were related to the same themes for patients and GPs, dyads indicated discrepancies between them.
Abstract: Background Antidepressant use is often prolonged in patients with anxiety and/or depressive disorder(s) compared with recommendations in treatment guidelines to discontinue after sustained remission.
Aim To unravel the motivations of patients and GPs causing long-term antidepressant use and to gain insight into possibilities to prevent unnecessary long-term use.
Design and setting Qualitative study using semi-structured, in-depth interviews with patients and GPs in the Netherlands.
Method Patients with anxiety and/or depressive disorder(s) ( n = 38) and GPs ( n = 26) were interviewed. Innovatively, the interplay between patients and their GPs was also investigated by means of patient–GP dyads ( n = 20).
Results The motives and barriers of patients and GPs to continue or discontinue antidepressants were related to the availability of supportive guidance during discontinuation, the personal circumstances of the patient, and considerations of the patient or GP. Importantly, dyads indicated a large variation in policies of general practices around long-term use and continuation or discontinuation of antidepressants. Dyads further indicated that patients and GPs seemed unaware of each other’s (mismatching) expectations regarding responsibility to initiate discussing continuation or discontinuation.
Conclusion Although motives and barriers to antidepressant continuation or discontinuation were related to the same themes for patients and GPs, dyads indicated discrepancies between them. Discussion between patients and GPs about antidepressant use and continuation or discontinuation may help clarify mutual expectations and opinions. Agreements between a patient and their GP can be included in a patient-tailored treatment plan.