Family practice最新文献

Background: The primary cause of antimicrobial resistance is excessive and non-indicated antibiotic use.

Aim: To evaluate the impact of a multifaceted intervention aimed at various healthcare professionals (HCPs) on antibiotic prescribing and dispensing for common infections.

Design and setting: Before-and-after study set in general practice, out-of-hours services, nursing homes, and community pharmacies in France, Greece, Lithuania, Poland, and Spain.

Methods: Following the Audit Project Odense method, HCPs from these four settings self-registered encounters with patients related to antibiotic prescribing and dispensing before and after an intervention (February-April 2022 and February-April 2023). Prior to the second registration, the HCPs undertook a multifaceted intervention, which included reviewing and discussing feedback on the first registration's results, enhancing communication skills, and providing communication tools. Indicators to identify potentially unnecessary prescriptions and non-first-line antibiotic choices were developed, and the results of the two registrations were compared.

Results: A total of 345 HCPs registered 10 744 infections in the first registration period and 10 207 infections in the second period. In general practice, participants showed a significant 9.8% reduction in unnecessary antibiotic prescriptions in the second period, whereas limited or no effect was observed in out-of-hours services and nursing homes (0.8% reduction and 4.5% increase, respectively). Pharmacies demonstrated an 18% increase in safety checks, and correct advice in pharmacies rose by 17%.

Conclusion: External factors like COVID-19, antibiotic shortages, and a streptococcal epidemic impacted the intervention's benefits. Despite this, the intervention successfully improved antibiotic use in both settings.

Background: Cannabinoid hyperemesis syndrome (CHS) is an increasingly recognized condition linked to chronic cannabis use, yet it remains frequently overlooked in clinical practice. The syndrome is characterized by cyclic episodes of severe nausea, vomiting, and abdominal pain, often relieved temporarily by hot showers or baths. With the rising prevalence of cannabis use following its legalization, the incidence of CHS has surged, presenting a significant challenge in both diagnosis and management within primary healthcare settings. Understanding the epidemiology, risk factors, and potential long-term sequelae of CHS is crucial for timely identification and intervention. This case report highlights the challenge of diagnosis and management of CHS in primary healthcare.

Objective(s): To emphasize the importance of proper counseling and the use of Rome IV criteria in diagnosing CHS. To illustrate how this may reduce patient suffering and unnecessary investigation.

Case: A 22-year-old female with chronic, daily cannabis use presented with recurrent episodes of intense nausea, vomiting, and abdominal pain over a 2-year period. Extensive diagnostic evaluations were inconclusive. A tentative diagnosis of CHS was made by a medical student and family doctor based on published criteria. The Rome IV criteria were then applied for confirmation of diagnosis and management. In so doing, the patient was advised to cease cannabis use for a minimum of 3 months. Initially, symptom improvement was reported with cannabis cessation. However, symptoms recurred following a relapse in cannabis use.

Conclusion: To confirm the diagnosis of CHS, counseling should specify the need for a minimum of 3 months of cannabis cessation to achieve symptom relief. Increased physician and patient awareness of this minimal time period for drug cessation can help to avoid unnecessary investigations, and prolonged patient suffering. This case emphasizes the need for vigilance in recognizing CHS and consideration of cannabis as a potential cause of cyclic vomiting.

Background: A national policy in Norway demanding certificates for medical absences in upper secondary school was implemented in 2016, leading to an increase in general practitioner (GP) visits in this age group.

Objectives: To assess the policy's effect on the use of primary and specialist healthcare.

Methods: A cohort study following all Norwegian youth aged 14-21 in the years 2010-2019 using a difference-in-differences approach comparing exposed cohorts expected to attend upper secondary school after the policy change in 2016 with previous unexposed cohorts. Data were collected from national registries.

Results: The absence policy led to the increased number of contacts with GPs for exposed cohorts during all exposed years, with estimated incidence rate ratios (IRRs) in the range from 1.14 (95% confidence intervals [CI] 1.11-1.18) to 1.25 (95% CI 1.21-1.30). Consultations for respiratory tract infections increased during exposed years. However, there was no conclusive policy-related difference in mental health consultations with GPs. In specialist healthcare we did not find conclusive evidence of an effect of absence policy on the risk of any contact per school year, but there was a slightly increased risk of contacts with ear-nose-throat specialist services.

Conclusions: We found an increase in general practice contacts attributable to the school absence policy. Apart from a possible increase in ear-nose-throat contacts, increased GP attention did not increase specialized healthcare.

Background: Antenatal depression and anxiety are associated with preterm labour, low birth weight, and postpartum depression, and can impact the emotional and mental development of the child. Both adverse childhood experiences and recent stressful events are linked to negative health outcomes. However, certain events may be more impactful than others.

Objective: This study aims to investigate the most important types of adverse childhood events and recent stressors that may help in identifying pregnant women in most need of psychological support.

Methods: This observational study examines data from the FamilieTrivsel trial, in which women between 6 and 10 weeks gestation were recruited by general practitioners. All participants were asked to complete questionnaires. Mental health was assessed with the Hospital Anxiety and Depression Score (HADS). Potential contributory risk factors were identified using the Recent Life Events Questionnaire and the Adverse Childhood Experiences questionnaire. The relative importance of the various types of events was analysed in a dominance analysis, and the direction of their association was determined by a multivariable linear regression analysis.

Results: Of specific recent life events, serious problems with a friend, divorce, racial harassment, unemployment, financial difficulties, and moving house had the strongest associations with poor mental health, along with childhood experience of mental illness in the household. Growing up with an experience of physical neglect and parental divorce were, paradoxically, associated with lower HADS scores.

Conclusions: Recent stressful life events have a stronger association with postnatal mental health than adverse childhood events, implying that it might be useful for clinicians providing routine antenatal care to gather information on recent stressors.

Background: Relational continuity is a fundamental component of primary care. The 'Quality in General Practice Trial' (EQuIP-GP), was a 12-month cluster randomized trial, designed to investigate whether financial incentives can improve relational continuity in primary care.

Aim: To examine (i) how financial incentives are perceived and experienced by primary care patients, providers, and practice staff, and (ii) how clinical and organizational routines related to relational continuity are influenced by the introduction of a financial model designed to incentivize relational continuity.

Design and setting: We used a mixed methods case study approach with six of the intervention arm practices participating in the EQuIP-GP trial.

Method: Semi-structured interviews were conducted with patients, providers, practice staff, and intervention facilitators. Intervention facilitators kept structured diaries to capture reflective notes. To contextualize results, practices completed a modified practice attributes survey and patients completed the Primary Care Assessment Tool at baseline and 12 months.

Results: Patient-perceived relational continuity was not impacted by the intervention. Financial incentives were preferred for rewarding, as opposed to incentivizing, quality care; however, they were perceived as a blunt and inflexible instrument. The introduction of the incentive model increased attention to pre-existing organizational routines rather than creating new ones.

Conclusion: Incentive models should be suitably flexible to accommodate diversity in patient and practice needs. Small changes can be made to existing practice routines that will improve awareness and conscientiousness of relational continuity. Further research should examine how feasible these routine changes would be in practices that do not already focus on continuity.

Background: One role of primary care is to support people living with and beyond cancer, the number of whom is increasing worldwide. This study aimed to identify factors affecting cancer care provision within English primary care after the start of the coronavirus pandemic, during high healthcare service demand, and a depleted workforce.

Methods: An exploratory qualitative descriptive approach was used to collect data via remote semi-structured interviews with primary care staff after gaining informed consent. Interview transcripts were analysed using reflexive thematic analysis.

Results: Fifteen primary care staff were interviewed (11 general practitioners, 3 practice nurses, and 1 physician associate). Factors affecting cancer care delivery in primary care were: (i) patient level: acceptance of healthcare and understanding of cancer; (ii) clinician level: personal experience with cancer and knowledge; (iii) general practice level: care coordinators and cancer registers, and (iv) system level: lack of healthcare resourcing and political inaction.

Conclusions: The ability of primary care to deliver cancer care is affected by multiple factors at various levels. Future studies should identify the implementation strategies of local and national policies to better understand how to improve cancer care education, practice-level infrastructure, evidence-based workforce planning, and healthcare resourcing.

Background: Healthcare providers often lack awareness, knowledge, and confidence in managing vulvodynia, which can lead to difficulties with diagnosis and treatment for individuals with the condition.

Objective: To develop and test an educational online toolkit tailored to supporting community-based primary care providers with diagnosis, treatment, and patient support for vulvodynia.

Methods: A sample of 19 community-based family physicians completed online surveys before and after testing the Vulvodynia Primary Care Toolkit (the toolkit hereafter) in their practice for 6 months. Nine physicians also completed a semi-structured interview to describe their experiences using the toolkit.

Results: The toolkit was adopted into clinical care, being used an average of 4.1 times per physician (SD = 2.7) during the test period. The toolkit demonstrated high acceptability, as evidenced by a high level of reported satisfaction with the toolkit and the amount of information it contained. The toolkit increased self-reported knowledge and confidence in diagnosing (P = .003), treating (P < .001), and supporting (P < .001) patients with vulvodynia. Through reflexive thematic analysis, we generated five themes from interview data that represented physicians' experiences: (i) There are facilitators and barriers to toolkit use in practice, (ii) the toolkit is valued by family physicians, (iii) the toolkit is educational, (iv) the toolkit is empowering, and (v) the toolkit improves vulvodynia management and referrals.

Conclusion: An online educational toolkit tailored to community-based primary care settings supports the management of patients with vulvodynia by family physicians. Our findings lay the foundation for the upscaling of this tool.

Background: Despite the increasing presence of women in US medical schools over the past 25 years, gender equity in medical leadership remains elusive. This qualitative study delves deeper into definitions of institutional leadership roles, who they are designed for, and how women currently contribute in unrecognized and uncompensated leadership positions.

Methods: We recruited family physicians who responded to the American Board of Family Medicine 2022 or 2023 graduate survey. We developed a semistructured interview guide following a modified life history approach to uncover women's experiences through the stages from residency to workforce. A qualitative researcher used Zoom to interview 25 geographically and racially diverse early career women physicians. Interviews were transcribed verbatim and analyzed utilizing NVivo software following an Inductive Content Analysis approach.

Results: Three themes emerged from the data. First, the nature of institutionally recognized leadership positions was largely perceived as bureaucratic and disciplinary, which did not appeal to most participants. Second, women engaged in leadership roles that increased practice efficiency, improved working conditions, and added to their emotional labor-without remuneration. Third, women experienced a tension between work and family, but this did not impact their long-term career goals-which remained focused on patient care or lower-level leadership positions.

Conclusion: Increasing the number of women in leadership positions can be achieved through innovative leadership models that prioritize collaboration, flexibility, and work-life balance. Organizations must revise definitions of leadership to expand it to include the valuable, unrewarded work women undertake that advance their goals and overall patient health.

Background: Iron deficiency during pregnancy poses a significant risk to both maternal and foetal health. Current international guidelines provide discrepant advice on antenatal iron supplementation for non-anaemic women.

Objective: We aimed to quantify the benefits and harms of routine antenatal supplementation in non-anaemic women.

Methods: The Cochrane Library, MEDLINE, Embase, and clinical trial registries were searched for randomized controlled trials and observational studies comparing oral iron supplementation with placebo or no supplement in non-anaemic pregnant women. Risk of bias was assessed for each study and the results were synthesized via meta-analysis.

Results: Twenty-three eligible studies were identified with 4492 non-anaemic pregnant women. Supplemented groups had higher haemoglobin [mean difference = 6.95 g/l, 95% confidence interval (CI): 4.81-9.09, P < .001, moderate certainty, I2 = 91%] and ferritin (mean difference = 12.22 ng/ml, 95% CI: 6.92-17.52, P < .001, moderate certainty, I2 = 87%) and were at lower risk of anaemia (relative risk = 0.50, 95% CI: 0.34-0.74, P < .001, high certainty, I2 = 42%, number needed to treat (NNT) = 10). There was no difference in birth weight, preterm birth, and rate of caesarean section. Reporting on harms was inconsistent and there was insufficient evidence to determine an association between iron supplements and any negative outcome.

Discussion: Prophylactic iron supplementation likely results in a large reduction in maternal anaemia during pregnancy. Future research should qualify the impact of this benefit on women's quality of life and determine which subpopulations benefit most. Evidence surrounding the harms of iron supplementation in the non-anaemic population is poor quality and inconsistent. Randomized controlled trials quantifying the risk of gastrointestinal (GI) disturbance and iron overload are essential to inform iron supplement use and reduce unwarranted variations in international guidelines.

Background: During coronavirus disease 2019 (COVID-19), people managing multiple chronic conditions (MCCs) experienced barriers to obtaining needed medications. The purposes of this paper are to (i) determine risk factors for difficulty obtaining medications during COVID-19, (ii) document reasons for the difficulty, and (iii) evaluate the impact on later physical and mental health outcomes.

Method: In a randomized controlled trial conducted in 2016-2021, 1969 adult primary care patients were surveyed about physical and mental health both before and during COVID-19. They reported their needs for medication during COVID-19 and any difficulty obtaining them. Reasons for difficulty accessing medications were tabulated descriptively. Logistic regression identified predictors of medication access difficulty. Multivariable linear regression modeled the relationship between access to medications and health outcomes, accounting for pre-COVID health.

Results: In total 13% of participants experienced difficulty accessing needed medications. Compared to the larger sample, those participants were younger, had more MCCs, and had lower income. They were more often female, unmarried, and were facing insecurities in housing, food, or finances (all P < 0.004). Younger age and the presence of socioeconomic insecurity at baseline increased the odds of later difficulty accessing medications. Barriers to access included concerns about contracting COVID-19 (52%), physician or pharmacy inaccessibility (38%), and cost (26%). Adjusting for baseline health, difficulty accessing medications was associated with poorer health at follow up (P = 0.001).

Conclusion: People with socioeconomic disadvantages experienced a disproportionate impact of difficulty obtaining medications and poorer health outcomes due to COVID-19. They may be at greater risk in the event of future pandemics and other societal disruptions.