Family practice最新文献

Background: Continuity of care is a defining feature of general practice, with strong evidence for improved patient outcomes. Variability in practices' rates of continuity could markedly influence general practitioner (GP) registrars' learning experience. Previous research found "upstream" (registrar previously seen patient) continuity of 43% and "downstream" (follow-up appointment arranged between registrar and patient) continuity of 49% in Australian GP registrars.

Objectives: This study aimed to assess inter-practice variability in registrar experience of continuity of care.

Methods: Cross-sectional analysis (2010-23) from the Registrar Clinical Encounters in Training study of GP registrars' in-consultation clinical experiences. Outcome factors were "upstream" and "downstream" continuity. Inter-practice variability was assessed using median odds ratios (MORs). Outcome variance attributable to practice was estimated within the Bayesian modeling framework using a mixed-effects logistic regression with cross-classified random effects for registrar and practice.

Results: The analysis included 4643 registrars (response rate 93.3%) across 978 practices. 42.5% (289 426) of registrar consults involved "upstream" continuity and 45.5% (313 295) of registrar consults involved "downstream" continuity. The MOR values were 1.47 [credible interval [CrI] (1.44, 1.50)] and 1.40 [CrI (1.38, 1.43)], for "upstream" and "downstream" continuity, respectively, in a model with random effects for practice and registrar; and 1.35 [CrI (1.32, 1.37)] and 1.38 [CrI (1.36, 1.41)], respectively, in the model adjusted for time/registrar/patient/consultation/consultation outcome/practice variables.

Conclusions: Considerable variability exists in continuity of care measures between GP training practices. This has implications for registrars' learning opportunities, particularly in chronic disease management-essential in the context of an aging population. Strategies to improve registrars' continuity of care in practices with lower rates of continuity should be considered.

Background: The Tanner staging system is recommended to assess pubertal development and to screen for pubertal development disorders. General practitioners (GPs) play a central role in monitoring pubertal development, yet the practical application of the Tanner stages in general practice remains underexplored.

Objectives: To explore the perceptions of GPs regarding Tanner stages and their experiences in performing these assessments in children and adolescents.

Methods: Two studies were conducted using an inductive qualitative approach. Study 1 examined the views and practices of GPs during puberty assessments. We then asked the doctors to assess the Tanner stages before exploring their personal feelings and the challenges they faced in Study 2. Semi-structured interviews were conducted from November 2022 to November 2023.

Results: GPs report that they rarely perform systematic puberty assessments using Tanner stages. Key barriers included insufficient training, lack of confidence in grading, and the sensitive nature of the examination. Participants questioned the clinical utility of Tanner staging, preferring general observation of pubertal onset over precise quantification. GPs remained sceptical about the routine use of Tanner stages in general practice and emphasized the need for additional support, training, and practical tools to enhance implementation.

Conclusion: While GPs focus on how to screen for pubertal disorders, the underlying purpose and potential benefits remain less clear to them. Raising GPs' awareness of the importance of identifying pubertal disorders and providing practical strategies is essential for adolescent care. We recommend that GPs systematically check that puberty begins at the expected age in their young patients.

Background: Dyslipidemia is a major risk factor for cardiovascular disease, with statins widely prescribed to manage lipid levels. However, statin-associated muscle symptoms and the interplay with physical activity (PA) may impact patients' quality of life (QoL). This study aimed to explore the relationship between PA levels and QoL in statin users.

Methods: A cross-sectional study was conducted among 384 adult statin users attending Dokuz Eylül University Family Health Centers. PA was assessed using the International Physical Activity Questionnaire, and QoL was evaluated with the Short Form-36 Health Survey. Due to the non-normal data distribution, nonparametric statistical tests were applied.

Results: Of the participants, 18.2% were inactive, 65.1% minimally active, and 16.7% very active. Higher PA levels were associated with significantly better scores in physical functioning, role limitations due to physical health, energy/fatigue, social functioning, pain, and general health (P < 0.001). Sitting duration was negatively correlated with most Short Form-36 domains. No significant association was found between PA and role limitations due to emotional problems.

Conclusion: Higher physical activity levels are positively associated with better quality of life among statin users, despite potential concerns regarding muscle symptoms. Regular, moderate physical activity may enhance this population's physical and mental health outcomes.

Objective: To explore the effects of comfort care and family participatory care during the perioperative period of cesarean section in obstetrics and gynecology.

Methods: This single-center, randomized controlled trial assigned 90 cesarean women to two groups: control (conventional perioperative care) and observation (comfort and family participatory care). The primary outcome measures included maternal pain [Visual Analog Scale (VAS)], anxiety [Self-Rating Anxiety Scale (SAS)], and depression [Self-Rating Depression Scale (SDS)]. Secondary outcomes included mean arterial pressure and heart rate, adrenaline and cortisol levels, lactation onset time, 24-h postpartum lactation volume, off-bed activity time, anal defecation time, and hospital stay, as well as evaluating maternal self-care ability [Exercise of Self-Care Agency Scale (ESCA)], maternal complications, and maternal satisfaction with nursing assessed using a satisfaction questionnaire at discharge.

Results: The observation group possessed lower VAS at 24, 48, and 72 h postoperatively, and SAS and SDS scores postoperatively, lower mean arterial pressure, heart rate, and adrenaline and cortisol levels, higher scores of self-care skills, self-care responsibility, self-concept, and self-care health knowledge, shorter times to lactation onset, off-bed activity, anal defecation, and hospital stay, greater 24-h postpartum lactation volume, lower incidence rate of complications (4.44% vs 24.44%), and higher nursing satisfaction (97.78% vs 84.22%) compared with the control group (all P < 0.05).

Conclusion: During the perioperative period of cesarean section, comfort care and family participatory care can effectively alleviate postoperative pain, reduce anxiety and depression, improve stress responses, enhance maternal self-care ability and nursing satisfaction, and decrease the incidence of complications.

Introduction: Human papillomaviruses (HPVs) cause several vaccine-preventable cancers, including cervical cancer. In France, HPV vaccination coverage remains low. Decision aids (DAs) can help individuals make informed health choices. This study assessed the impact of an online DA (SOSHPV) on decisional conflict and vaccination intention, and explored user perceptions in real-life contexts.

Methods: A convergent mixed-methods design was used (November 2023-June 2024). The quantitative component included a pre-post questionnaire assessing knowledge, vaccination intention, and decisional conflict. The qualitative component involved semistructured interviews with a subsample of users, analyzed using grounded theory.

Results: Among 943 website visitors, 187 participants (54 males, 12 adolescents) completed the presurvey, and 44 (12 males, 6 adolescents) completed both assessments. Over half (54%) were young parents using the tool to support HPV vaccination decisions for their child. Post-intervention, knowledge improved (P < 0.001), and decisional conflict decreased (P < 0.001). Vaccination intention shifted: 55%-75% in favor and 32%-18% undecided (P < 0.001). Qualitative analysis (n = 12) revealed three themes: social ambivalence around vaccination, the DA as a support for informed choices, and its role in enhancing communication with healthcare providers.

Discussion: This study showed a reduction in decisional conflict and increased vaccination intention. These findings suggest that DAs may play an important role in addressing vaccine hesitancy and supporting value-aligned choices in real-world settings.

Conclusion: This study highlights the potential of an online DA to improve vaccine acceptance by reducing decisional conflict and enhancing dialog. Further research is needed to assess its large-scale impact on vaccine uptake.

Background: The trends in sedative use have varied in recent years. Benzodiazepines and z-drugs are indicated for anxiety and/or sleep disorders but should be limited to short-term use. The aim of this study is to examine trends and patterns in sedative prescribing in Ireland between 2014 and 2022, as well as comparing trends between Ireland and England within the same period.

Methods: Monthly data on medicines prescribed and dispensed in primary care on the means-tested General Medical Services (GMS) scheme in Ireland were used. Volumes of prescribed benzodiazepine and z-drug use and patterns of prescribing, including initiations, discontinuations, chronic use, and high-risk prescribing were summarized per year. Other sedating agents (sedating antihistamines, antidepressants, and antipsychotics) were also analysed. Volume of use outcomes were compared with NHS data from England for the same period.

Results: The rate of benzodiazepine and z-drug dispensings per 1000 GMS population decreased by 5%, from 1531 in 2014 to 1474 in 2022. By comparison in England, there was a steeper decrease of 27% in the dispensing rate and the level of use was substantially lower, falling from 288 dispensings per 1000 population in 2014 to 210 in 2022. In Ireland, dispensing rates were highest amongst women and older age groups. High-risk dispensings of benzodiazepines and z-drugs decreased over the study period.

Discussion: Despite decreases in benzodiazepine and z-drug dispensings, rates remain high in Ireland and may suggest a need for enhanced availability of non-pharmacological interventions, and improved education and deprescribing support for healthcare professionals.

Background: Effective and timely referral to specialist care is a fundamental responsibility of primary care providers, including family physicians, general practitioners, and community health workers. However, challenges in triage can lead to delays, unnecessary referrals, and increased strain on healthcare systems. Advances in artificial intelligence (AI) now offer new opportunities to support referral decision-making at the primary care level.

Objective: This study evaluates the performance and reliability of two AI models as referral decision support tools, using simulated scenarios commonly encountered in primary care settings involving ear, nose, and throat conditions.

Methods: Sixteen clinical vignettes representing common or high-stakes primary care presentations requiring specialist input were presented to each model in both structured clinical and informal patient-language formats. Responses were independently assessed by five otolaryngologists and 10 lay reviewers using a standardized rubric focused on appropriateness, clarity, safety, and usefulness. Quantitative analysis included comparisons of model performance, reviewer agreement, and the impact of prompt structure on output quality.

Results: Both AI models generated safe and clinically appropriate referral recommendations when provided with structured clinical input. No statistically significant differences were observed between the two models across the evaluated domains. Performance declined for one model when prompts were presented in informal language, underscoring the importance of clear input structure. Reviewer agreement was high, confirming the reliability of findings.

Conclusion: AI decision support tools show potential to assist specialist referral triage in primary care. Clear, structured input is essential to maximize safety and reliability.

Background: Chronic kidney disease (CKD) is increasing in prevalence and is associated with substantial morbidity and mortality. Early initiation of cardiorenal protective medications is recommended to improve outcomes. Barriers to implementation include renal function monitoring and resources to initiate and titrate treatment. We aimed to evaluate the feasibility and acceptability of a protocolled point-of-care testing (POCT) pathway to optimise people living with proteinuric CKD in primary care.

Method: A pilot quality improvement study conducted across three general practices in Greater London, United Kingdom. Inclusion criteria were adults (18-80 years) with hypertension and/or type 2 diabetes mellitus, proteinuria, and reduced kidney function (eGFR 30-75 ml/min/1.73m2), who were identified using electronic health records. POCT for creatinine and potassium enabled real-time decision-making using a traffic light clinical decision support system. The primary outcome was recruitment rate and patient acceptability. Secondary efficacy outcomes included medication optimisation and renal function changes.

Results: Twenty-five (52%) of 48 patients agreed to participate. Overall, 23/25 (92%) completed the pathway and 20/25 (80%) achieved pharmacological optimisation. There were no significant adverse events. POCT was successful in 44/57 (77%) of cases and well tolerated by most participants (10/13; 77%). Patient satisfaction was high (12/13; 92%), with most preferring advanced nurse practitioners or pharmacists in future clinics.

Conclusion: A POCT-led CKD optimisation pathway is feasible and well-accepted in primary care. While high medication optimisation rates were achieved, barriers to recruitment and engagement remain. Future studies should evaluate scalability, long-term clinical impact, and cost-effectiveness to inform wider implementation.

Background: Multimorbidity-the co-existence of two or more chronic health conditions in the same individual, without reference to an index condition-has become a global health issue and creates enormous pressure on the healthcare system. This review aimed to summarize evidence on the effectiveness of interventions used to manage people with multimorbidity.

Methods: MEDLINE, EMBASE, CINAHL, Cochrane Library, two trials registers, and grey literature were searched for studies of adults with multimorbidity receiving care in primary or community care settings up to 30 September 2024. Two reviewers independently screened studies for eligibility, extracted data, and assessed risk of bias and study certainty. Interventions were categorized as medicines management (MM), support for self-management (SSM), or care coordination plus support for self-management (CC + SSM). Meta-analyses for primary outcomes (health-related quality of life, healthcare utilization, and healthcare costs) were conducted.

Results: From 10 272 titles screened, 33 eligible studies (this review: 18, previous review: 15; MM: 6, SSM: 9, CC + SSM: 18) were identified, of which 26 studies with 9449 participants were included in meta-analysis. Overall, there was little significant evidence of benefit of the interventions compared with usual care for most outcomes. SSM was associated with lower hospitalization risk and medication costs, but slightly more emergency department (ED) visits; and CC + SSM with better SF-12 PCS score, lower hospitalization risk and fewer ED visits, but more outpatient and general practitioner visits.

Conclusion: This review found some suggestions of improved outcomes and reduced healthcare utilization (especially hospitalization) for these interventions. There is a paucity of evidence reporting on health outcomes, especially healthcare costs, in the management of multimorbidity.

Introduction: Family physicians spend approximately half their professional time on indirect patient care activities (IPCA). Essential to patient care, inbox IPCA includes renewing prescriptions, checking lab results, and reviewing messages. However, IPCA detracts time from direct patient care and has been linked to burnout, potentially contributing to the family medicine crisis in Canada. Our objective was to understand the range of family physicians' experiences and perspectives regarding electronic inbox management.

Methods: We conducted a systematic review of peer-reviewed articles, published in English between 1 January 2012, and 22 April 2024, that addressed family physicians' perspectives on tasks related to the electronic inbox and used any method of primary data collection and analysis. Data analysis used a constant comparative method.

Results: Fifty-four articles were included. The combination of fragmented technical systems and an overwhelming volume of complex tasks has created a system where family physicians struggle to manage the administrative work of patient care. Selected impacts include excessive time spent on duplicated or unnecessary tasks, inadvertently making uninformed clinical decisions, and perceived tension between patient accessibility and workload. Strategies for management were described, including the re-design of electronic medical record systems, task delegation, and synchronizing prescription renewals with patient visits.

Conclusions: The intersection of inefficient systems and high workloads makes inbox management labour-intensive and frustrating, lowering job satisfaction and efficacy. Downloading administrative tasks to family physicians, combined with the growing complexity of patient management, has generated a tremendous burden. Solutions are needed to improve the sustainability and appeal of family medicine.