Family practice最新文献

Background: Hypnotherapy is an effective treatment for children with functional abdominal pain in secondary care. However, children usually present first to general practitioners (GPs) in Dutch primary care, and it is unknown how children, parents, and GPs perceive hypnotherapy in this setting.

Objective: To explore the perceptions of children, parents, and GPs about hypnotherapy in primary care for children with functional abdominal pain.

Methods: This is a qualitative study among Dutch children with functional abdominal pain, the parents of other children with functional abdominal pain, and GPs. Semi-structured interviews were conducted online. Interviews were recorded and transcribed verbatim. Data were analysed iteratively by thematic content analysis.

Results: In total, 7 children, 8 parents, and 12 GPs participated. We identified three main themes: attitude to abdominal pain, therapeutic context, and societal constraints and considerations. The attitudes of children and parents to abdominal pain, including acceptance of pain as functional and coping behaviour, affected their expectations of hypnotherapy. Therapeutic context (e.g. the GP-patient relationship and expectations of an effect) and societal constraints and considerations (e.g. stigma and cost) regarding hypnotherapy affected the willingness of children, parents, and GPs to use hypnotherapy.

Conclusions: Despite controversy about its use, hypnotherapy for functional abdominal pain is considered as a treatment option in primary care. Attitudes of children and parents influenced their willingness to use hypnotherapy. Effective implementation requires good information about hypnotherapy, a good GP-patient relationship, and clear and reliable referral options for hypnotherapy.

Background: The demand for care is increasing in volume and complexity. Digital interdisciplinary consultation (DIDC) has the potential to support general practitioners (GPs) with specialist knowledge and prevent unnecessary referrals. Successful DIDC requires collaboration between stakeholders with potentially different goals, barriers and motivations. Little is known about this broader context of DIDC.

Aim: To identify stakeholders' perceptions about DIDC including barriers and facilitators to its use.

Design and setting: Semistructured interviews with seven stakeholder groups in the Netherlands.

Method: We used purposive sampling to attain various stakeholders. The semistructured online or telephone interviews were transcribed verbatim and analyzed thematically.

Results: We interviewed 46 stakeholders (12 GPs, 10 medical specialists, 11 patients, 3 health insurance representatives, 6 platform developers, 3 primary-secondary care coordinators (PSCCs), and 1 chief medical information officer). We identified six themes: effectiveness, implementation requirements, evaluation of DIDC use, impact on networked care, acceptance by patients and future use of DIDC. Overall, stakeholders were positive about DIDC. The expected impact of DIDC on the accessibility and affordability of healthcare varied from modest to high. Agreements on collaboration and funding, and the need for user-friendly digital platforms were identified as the most important requirements for successful implementation. Physicians particularly appreciated the asynchronous nature of DIDC and the time saved. Patients appreciated receiving timely care, free from a deductible excess and avoiding unnecessary hospital visits.

Conclusion: This study shows that all stakeholders were overall positive about DIDC. Agreements on organization, collaboration, financing, and platform design are essential.

Background: Family physicians (FPs) endorse the value of spiritual care (SC) as part of comprehensive, patient-centered care. However, a mismatch exists between patients' desire to have spiritual needs addressed and physicians' SC provision. Studies explore physician barriers, but few examine workplace barriers/facilitators. Qualitative and longitudinal studies are rare. The objective is to gain an in-depth understanding of how workplace factors affect FPs' SC provision.

Methods: This was a longitudinal, qualitative, and individual interview study; a secondary analysis of a dataset collected over 20 years. All 38 residents in a USA FM residency were invited to participate; the longitudinal study-group (PGY-1 subset) was interviewed four times over 20 years. The data were collected through semi-structured interviews, audio-recorded, and transcribed. Researchers analyzed interviews, using grounded theory, with workplace factors as the central topic of interest. Iterative analysis cycles involved researchers individually coding transcripts followed by group analysis meetings until they reached consensus.

Results: Thirty-four FPs participated with 13 interviewed longitudinally; 66 interviews analyzed. While diverse in personal importance of spirituality, all FPs endorsed SC as part of whole-person care. Workplace SC facilitators/barriers include: practice setting/patient population; doctor-patient relationships; resources available; workplace demands; and workplace culture. Throughout 20 years, FPs readily identified patients needing SC. Workplaces that lacked SC referral resources or undervalued comprehensive care and/or physician wellness negatively impacted SC provision for patients and physician job satisfaction.

Conclusions: While FPs value SC provision as part of whole-person care, workplace factors have a profound impact on physicians' SC provision. Misalignment of physician and workplace values could contribute to physician burnout.

Background: Kidney function declines with age, increasing risk of harm from raised blood levels of many medicines. Prescribing is often inappropriate for older people with reduced creatinine clearance (CrCl).

Objective: To examine the feasibility and acceptability of providing performance feedback to increase CrCl calculation and coding and reduce potentially inappropriate prescribing.

Methods: We delivered evidence-based feedback on CrCl coding and prescribing for common medicines requiring dose adjustment in renal impairment. This mixed-methods study in seven UK general practices collected data at three time points for evidence-based feedback (October 2021, December 2021, February 2022) and additionally pre-/post-feedback intervention. An institutional ethnography explored responses. We observed and conducted semi-structured interviews with primary care clinicians. We thematically analysed qualitative data, guided by Clinical Performance Feedback Intervention Theory.

Results: Mean CrCl coding for ≥75s rose from 46% to 50.4% (difference 4.4%; range -10.5% to 14.7%). The number of patients with CrCl-associated inappropriate prescribing fell. We observed in 6 settings and interviewed 11 clinicians. Feedback engaged practices, was seen as important and allowed flexible action. All feedback cycle components were evident. Participants mentioned difficulties in remembering to consider kidney function, calculating and coding CrCl, recalling relevant medicines, and deciding appropriate dosing. Pharmacy teams were considered important facilitators in the response.

Conclusions: Feedback on prescribing in reduced kidney function can encourage improvement but is not sufficient alone. Systematized CrCl calculation and coding may improve patient safety by facilitating decision support for prescribing, review, and audit/research. A rigorous, larger-scale effectiveness evaluation is likely to be feasible and acceptable.

Objective: To conduct a systematic review of the literature on the impact of team-based primary care on downstream health care utilization (all-cause or mental health-specific emergency department (ED) visits and hospitalizations) among people with mental or substance use disorders.

Methods: A literature search was conducted using the Scopus, MEDLINE, and Web of Science databases. Gray literature and forward and backward citation searches yielded additional results. Two independent reviewers screened the abstracts and full texts. Both reviewers performed a critical appraisal of the methodological quality using a modified Downs and Black checklist. The data were extracted using a standardized data extraction spreadsheet, and the effect sizes of studies were synthesized.

Results: A total of 18 studies were included (16 in the USA and 2 in Canada). Seven of the 15 studies that assessed the effect of team-based care on all-cause ED visits found they were associated with a lower number or odds of visits. Of the 15 studies that assessed the effect of team-based approaches on all-cause hospitalizations, 8 found that they were associated with an overall decrease. Very few studies assessed mental health-related ED visits (n = 2) or hospitalizations (n = 4), and the findings varied. All included studies were of fair quality (mean score ± standard deviation: 17.4 ± 1.3).

Conclusion: Team-based care is likely associated with a decrease in all-cause ED visits and hospitalizations. A team-based primary care approach has the potential to reduce downstream healthcare utilization for patients with mental or substance use disorders and improve health outcomes.

Background: Patient preferences about their role in decision-making in medical practice are a very important phenomenon, especially since patient participation allows decision-making to be more responsive to their needs and improves the quality of care.

Objective: To evaluate the proportion of patients with preferences toward an active, passive, or shared role in medical consultation in a sample of patients with chronic diseases who attend family medicine and general hospital level of care and to explore the relationship of preferences with sociodemographic and clinical variables.

Methods: Participants were recruited from their scheduled consultation in August, 2019, at one family medicine and one general hospital of the Mexican Institute of Social Security. People >18 years of age with different chronic disease diagnoses were surveyed. The Control Preferences Scale was applied to identify the participants' preferred role in decision-making related to medical care. The evaluation of health status and health-related quality of life was included. Multivariate analyses determined the predictors of participation preferences in decision-making.

Results: A total of 530 patients participated. Most preferred the passive role (47.7%), followed by the shared role (27.7%) and the active role (24.5%). Age influenced preferences; participants ≥45 years preferred a shared role. Patients who reported poorer quality of life preferred the shared role in decision-making.

Conclusion: The study showed that patients with chronic diseases prefer to leave the decisions to doctors. Only patients <45 years with a good quality of life had a greater preference for participation in decision-making.

Background: The aim of the study was to assess the effect of an interdisciplinary, digital consultation platform on the proportion of appropriate referrals from general practitioners (GPs) to an orthopaedic outpatient hospital.

Methods: We performed a stepped wedge, cluster, randomized controlled trial. Sixty GP practices in the catchment area of a large teaching hospital in the Netherlands were randomized. Groups of GP practices entered the trial in four steps at 13-week intervals, at which point they received access to the Prisma platform. The platform allowed them to post questions about anonymized cases to a multidisciplinary group of specialists. During the control condition, GPs did not receive platform access. In both conditions, GPs provided care as usual. The proportion of appropriate referrals, defined as referrals for which a patient had either (i) more than one consultation with an orthopaedic surgeon or (ii) one consultation with additional diagnostics or interventions, was the primary outcome.

Results: Participating GPs referred 4928 patients to hospital. Intention-to-treat analysis showed a 4.4% estimated increase in the proportion of appropriate referrals among GP practices randomized to have access to the platform compared to the control group, with an odds ratio (OR) of 1.22 [95% confidence interval (CI), 1.01-1.46; P = 0.037]. Per-protocol analysis showed a smaller, but non-significant, 2.2% difference between interventions, with an OR of 1.11 (95% CI, of 0.96%-1.28%; P = 0.178).

Conclusions: We observed a modest increase in appropriate referrals for orthopaedic review among GP practices randomized to the platform. On a larger scale, this could contribute to more sustainable access to specialist care.

Background: In Canada, primary care manages most diabetes care. The COVID-19 pandemic disrupted primary care, reducing access to care and monitoring.

Objectives: We aim to describe changes in diabetes monitoring during the first 21 months of the pandemic, patients' experiences with these changes, and impact on HbA1c and blood pressure (BP) control.

Methods: We conducted a two-phase mixed methods study: (i) A retrospective pre-post cohort study using de-identified electronic medical record data to compare HbA1c and BP measurement frequency and results in diabetic patients prepandemic (22 June 2018 to 12 March 2020) and during the pandemic (13 March 2020 to 3 December 2021); (ii) A qualitative descriptive analysis using semistructured interviews to understand patient experiences navigating diabetes care during the pandemic.

Results: The cohort included 84 617 patients with validated diabetes case definition. Proportion of patients with <1 HbA1c test increased by 10% during the pandemic. For those with ≥1 test, mean HbA1c remained unchanged [mean (SD) HbA1cPre: 7.2 (1.3); HbA1cDuring: 7.2 (1.3); P = .51]. Proportion of patients with <1 BP measurement increased by 23%. For those with ≥1 measurement, mean BP remained clinically similar [mean (SD) sBPPre: 131.8 (13.7); sBPDuring: 132.9 (15.2); P < .01. Mean dBPPre: 74.9 (8.6); dBPDuring: 75.1 (9.1); P = .63]. Nineteen participants were interviewed, discussing virtual care, challenges with self-monitoring, and self-management strategies.

Conclusions: Mean HbA1c and BP values remained clinically stable during the pandemic despite reductions in monitoring frequency, likely due to continuity of care and patient self-management. Future research should evaluate a de-intensified frequency of diabetes monitoring and address care gaps.