Family practice最新文献

Background: China is currently making efforts to transform the current hospital-centric service delivery system to people-centred primary health care (PHC)-based delivery system, with service delivery organized around the health needs and expectations of people. To help direct China's PHC reform efforts, a profile of high-quality PHC from the public's perspective is required.

Objectives: To profile high-quality PHC from the perspective of the Chinese public.

Methods: Semistructured interviews were conducted in 6 provinces (Henan, Shandong, Zhejiang, Shaanxi, Shanxi, and Heilongjiang) in China. In total, 58 interviewees completed the recorded interview. For transcription, trained research assistant listened to the recording of the interviews, summarizing each 30-s segment in English. Next, thematic analysis was performed on the narrative summaries to identify thematic families.

Results: Seven themes and 16 subthemes were generated from the analysis of our interview data. In order of their frequency, the interviewees expressed a high expectation for interpersonal communication and technical quality; followed by access, comprehensive care, cost, continuity, and coordination.

Conclusions: Using qualitative data from 6 provinces in China, knowledge was generated to reveal the public's views and expectations for high-quality PHC. Our results confirm the urgent need for quality improvement efforts to improve patient experience and technical quality. The government also needs to further improve the delivery system and medical training programme to better meet public expectation in these areas, especially in establishing an innovative integrated primary care model, and strengthening interpersonal and clinical competency training for family doctors.

Background: Parkinson's disease (PD) is a common neurodegenerative disorder in older adults that is associated with neuroinflammation, oxidative stress, and characterized by loss of dopaminergic cells. Illicit stimulants increase oxidative stress and are associated with increased risk of PD. Prescription stimulants are similar in mechanism to illicit stimulants, yet their influence on PD is not well described. This study aims to determine if prescription stimulants influence risk of PD among older adults with attention-deficit and hyperactivity disorder (ADHD).

Methods: We implemented a retrospective observational cohort design utilizing the TriNetX database which sources from the electronic health records of 57 healthcare organizations. Inclusion criteria were ADHD diagnosis and age ≥50. Those exposed to stimulants and the unexposed controls were matched based on demographics and known risk factors for PD. The outcome of interest was the incidence of PD over a 30-year follow-up period. We utilized TriNetX software for hazard ratio (HR) analysis.

Results: Among the 59,471 individuals treated with prescription stimulants 131 of them developed PD, and there were 272 individuals who developed PD that were not prescribed stimulants. This analysis yielded a HR of 0.419 (HR = 0.419 [95% CI 0.34, 0.516], P = 0.0013).

Conclusion: Illicit stimulants are associated with increased risk of PD, but this study suggests prescribed stimulants may not impart that same risk. The reduced risk in this cohort may be due to protection from illicit substance use and oxidative stress, however additional study exploring the relationship between prescription stimulants and PD is warranted.

Background: Interruptions can impact consultation duration, doctors and patients' satisfaction, and quality of care provided. Although most of them seem to have a negative impact, affecting doctor-patient relationship and interfering with clinical reasoning, which increases the risk of error, there is still no evidence on their global impact on consultations.

Objectives: To evaluate the number and duration of interruptions during general practice consultations. To compare physicians and patients' perceptions of their urgency and impact, as well as the overall satisfaction with the consultation.

Methods: Cross-sectional study of a representative sample of annual face-to-face general practice consultations at a Health Centre. Between January and March 2022, anonymous questionnaires were given to physicians and patients after consultation. We performed a descriptive and inferential statistical analysis.

Results: A total of 403 consultations were included. Physicians reported more interruptions than patients (108 vs. 87, P < 0.001). From patients' perspective those interruptions were more urgent (34.5%) compared with physicians' perspective (20.6%; P = 0.029). Patients undervalued their impact on consultations (7.1% of interruptions with a negative impact among patients vs. 24.7% among doctors; P < 0.001). Interruptions did not interfere with patients' satisfaction with consultation (P = 0.135) but were associated with lower physicians' satisfaction with consultation (P = 0.003).

Conclusion: Physicians are more critical regarding consultations interruptions, being more aware of their incidence and reporting more often a negative impact, which translates into lower satisfaction with interrupted consultations. Patients devalue the occurrence of interruptions, showing no concern about their impact on security or privacy, and their satisfaction is not affected by them.

Background: Rainbow young people (RYP; people of diverse genders, sexualities, and variations in sex characteristics) face barriers accessing primary care, often report negative experiences and the need to educate clinicians on rainbow-specific issues. This study explores general practice staff views and experiences of providing care to RYP.

Methods: Three focus groups were held with staff from 5 general practices in an urban area of Aotearoa New Zealand (25 participants in total). Practices were purposively selected to include some known to be more "rainbow-friendly" seeing larger numbers of RYP and some with no particular focus on RYP. All members of each practice were invited to participate, including administration and reception staff. Focus groups were audio-recorded, transcribed, and analysed in NVivo using inductive thematic analysis.

Results: Four main themes were identified: (i) Practice experience, (ii) Feeling awkward, (iii) Knowledge and training, and (iv) Structural barriers. Differences were apparent in health provider knowledge, comfort, and experience in providing care to RYP. Participants identified a lack of knowledge and training and wanted more resources and education. Systems limitations were common (e.g. with IT systems for recording gender) and often contributed to awkward clinical encounters.

Conclusions: Participants recognized shortcomings in their training, knowledge, and level of confidence providing care to RYP and expressed a desire to improve their competency. Further work is needed to identify and trial practical strategies that help improve communication skills, knowledge, and the delivery of more equitable healthcare to RYP.

Background: Asthma is one of the most frequent reasons children visit a general practitioner (GP). The diagnosis of childhood asthma is challenging, and a variety of diagnostic tests for asthma exist. GPs may refer to clinical practice guidelines when deciding which tests, if any, are appropriate, but the quality of these guidelines is unknown.

Objectives: To determine (i) the methodological quality and reporting of paediatric guidelines for the diagnosis of childhood asthma in primary care, and (ii) the strength of evidence supporting diagnostic test recommendations.

Design: Meta-epidemiological study of English-language guidelines from the United Kingdom and other high-income countries with comparable primary care systems including diagnostic testing recommendations for childhood asthma in primary care. The AGREE-II tool was used to assess the quality and reporting of the guidelines. The quality of the evidence was assessed using GRADE.

Results: Eleven guidelines met the eligibility criteria. The methodology and reporting quality varied across the AGREE II domains (median score 4.5 out of 7, range 2-6). The quality of evidence supporting diagnostic recommendations was generally of very low quality. All guidelines recommended the use of spirometry and reversibility testing for children aged ≥5 years, however, the recommended spirometry thresholds for diagnosis differed across guidelines. There were disagreements in testing recommendations for 3 of the 7 included tests.

Conclusions: The variable quality of guidelines, lack of good quality evidence, and inconsistent recommendations for diagnostic tests may contribute to poor clinician adherence to guidelines and variation in testing for diagnosing childhood asthma.

Objective: To explore consultation patterns, management practices, and costs of foot, ankle, and leg problems in Australian primary care.

Study design: We analyzed data from the Bettering the Evaluation and Care of Health program, April 2000 to March 2016. Foot, ankle, and leg problems were identified using the International Classification of Primary Care, Version 2 PLUS terminology. Data were summarized using descriptive statistics examining general practitioner (GP) and patient characteristics associated with a foot, ankle, or leg problem being managed. Cost to government was estimated by extracting fees for GP consultations, diagnostic imaging, and pathology services from the Medicare Benefits Schedule (MBS) database. Costs for prescription-only medicines were extracted from the Pharmaceutical Benefits Schedule and for nonprescribed medications, large banner discount pharmacy prices were used.

Results: GPs recorded 1,568,100 patient encounters, at which 50,877 foot, ankle, or leg problems were managed at a rate of 3.24 (95% confidence intervals [CIs] 3.21-3.28) per 100 encounters. The management rate of foot, ankle, or leg problems was higher for certain patient characteristics (older, having a health care card, socioeconomically disadvantaged, non-Indigenous, and being English speaking) and GP characteristics (male sex, older age, and Australian graduate). The most frequently used management practice was the use of medications. The average cost (Australian dollars) per encounter was A$52, with the total annual cost estimated at A$256m.

Conclusions: Foot, ankle, and leg problems are frequently managed by GPs, and the costs associated with their management represent a substantial economic impact in Australian primary care.

Objective: To examine changes in life satisfaction and physical and mental health associated with opioid and potentially inappropriate opioid prescribing (PIOP) among older adults.

Methods: Secondary data analysis from the Étude sur la Santé des Aînés (ESA)-Services study. The sample consisted of 945 older adults recruited in primary care with available health survey information linked to administrative medical record data. The exposure of interest was categorized as no prescription, opioid prescription, and PIOP, defined using the Beers criteria. Outcomes were self-rated physical health, mental health, and life satisfaction measured at baseline and at a 3-year follow-up. Generalized estimating equations were used to examine 3-year changes in outcomes as a function of opioid prescribing. Analyses were adjusted for covariates relating to health, psychosocial, and sociodemographic factors as well as duration/frequency of opioid prescribing. Analyses were conducted in the overall sample and in non-cancer patients.

Results: The sample had an average age of 73.1 years; the majority was Canadian-born (96.3%) while females made up over half (55.4%) the sample. Compared to not receiving an opioid prescription, PIOP was associated with a deterioration in physical health (ORadjusted = 0.65; 95%CI = 0.49, 0.86), but not mental health and life satisfaction. In non-cancer patients, PIOP was associated with poorer physical health (ORadjusted = 0.59; 95%CI = 0.40, 0.87) and opioid prescribing was marginally associated with improved life satisfaction (ORadjusted = 1.58; 95%CI = 0.96, 2.60).

Conclusion: PIOP was associated with a deterioration in physical health. Patient-centred chronic pain management and the effect on health and well-being require further study in older adults.

Background: Headache disorders are globally prevalent and insufficient treatment contribute to low quality of life, increased disability, and socioeconomic costs. However, headache can to a large extent be treated appropriately by general practitioners.

Objective: To explore general practitioners' (GPs') management of patients with headache lasting ≥6 months.

Methods: In this retrospective descriptive cross-sectional study based on medical audit, all GPs practicing in Vejle municipality (population 116,992), Denmark, were invited to review their latest 20 patients with headache. Outcome measures were headache diagnostics, treatment, and referrals. Factors associated with referral to neurological treatment were examined by logistic regression.

Results: Of 26 invited practices, 19 participated reporting on 367 patients with lasting headache (71.4% women; mean-age 48.5 years). One hundred and sixty-one patients had migraine (44%; IQR: 28-60%), 140 (38%; IQR: 25-44%) had tension-type headache; 243 (66%; IQR: 50-79%) used simple analgesics, 147 (40%; IQR: 29-59%) triptans, 37 (10%; IQR: 0-14%) opioids, 93 (25%; IQR: 20-35%) were prescribed preventive medication; 176 (48%; IQR: 48-59%) were referred to neurologist, and 92 (25%; IQR: 10-37%) were referred to CT or MRI scan. Associated factors for referral were >1 headache diagnosis (aOR 1.75 [95% CI: 1.05-2.95]; P = 0.03), post-traumatic headache (aOR 2.53 [95% CI: 1.25-5.38]; P = 0.01), unspecific headache (aOR 2.04 [95% CI: 1.08-3.93]; P = 0.03), and using preventive treatment (aOR 2.75 [95% CI: 1.68-4.57]; P < 0.001).

Conclusion: This study provides insights to how GPs manage patients with long-lasting headache. Focus should be on reducing opioids, increasing preventive treatment, and keeping more patients in primary care.