J. Konya, Richard Neal, C. Clark, D. Bearman, J. Campbell
The key to the success of cancer treatments and better clinical outcomes is early detection. The incidence and mortality from cancer is higher in patients with lower socioeconomic status compared to that for more affluent patients.1 General practice is crucial for the early diagnosis of cancer. The COVID-19 pandemic highlighted pre-existing GP workforce and access inequalities, which are expected to get worse.2 The 2020 General Practice Patient Survey suggests that patients from deprived areas have more difficulties accessing general practice than patients from affluent areas.3 Secondary care treatment waiting times have also become longer compared to pre-pandemic levels, and have increased significantly in deprived populations.4
{"title":"Can early cancer detection be improved in deprived areas by involving community pharmacists?","authors":"J. Konya, Richard Neal, C. Clark, D. Bearman, J. Campbell","doi":"10.3399/bjgp22X718865","DOIUrl":"https://doi.org/10.3399/bjgp22X718865","url":null,"abstract":"The key to the success of cancer treatments and better clinical outcomes is early detection. The incidence and mortality from cancer is higher in patients with lower socioeconomic status compared to that for more affluent patients.1 General practice is crucial for the early diagnosis of cancer. The COVID-19 pandemic highlighted pre-existing GP workforce and access inequalities, which are expected to get worse.2 The 2020 General Practice Patient Survey suggests that patients from deprived areas have more difficulties accessing general practice than patients from affluent areas.3 Secondary care treatment waiting times have also become longer compared to pre-pandemic levels, and have increased significantly in deprived populations.4","PeriodicalId":22333,"journal":{"name":"The British Journal of General Practice","volume":"28 1","pages":"153 - 154"},"PeriodicalIF":0.0,"publicationDate":"2022-03-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"83593839","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Marie Moullet, G. Funston, L. Mounce, G. Abel, N. D. de Wit, F. Walter, Yin Zhou
Background The majority of colorectal cancer is diagnosed in patients following symptomatic presentation in the UK. Aim To identify windows of opportunity for timely investigations or referrals in patients presenting with colon and rectal cancer-relevant symptoms or abnormal blood tests. Design and setting A retrospective cohort study was undertaken using linked primary care and cancer registry data for patients with colorectal cancer diagnosed in England between 2012 and 2015. Method Monthly consultation rates for relevant clinical features (change in bowel habit, rectal bleeding, abdominal pain, abdominal mass, constitutional symptoms, and other bowel symptoms) and abnormal blood test results (low haemoglobin, high platelets, and high inflammatory markers) up to 24 months pre-diagnosis were calculated. Poisson regression adjusted for age, sex, and relevant comorbidities was used to estimate the most likely month when consultation rates increased above baseline. Results In total, 5033 patients with colon cancer and 2516 with rectal cancer were included. Consultations for all examined clinical features and abnormal blood tests increased in the year pre-diagnosis. Rectal bleeding was the earliest clinical feature to increase from the baseline rate: at 10 months (95% confidence interval [CI] = 8.3 to 11.7) pre-diagnosis for colon cancer and at 8 months (95% CI = 6.1 to 9.9) pre-diagnosis for rectal cancer. Low haemoglobin, high platelets, and high inflammatory markers increased from as early as 9 months pre-diagnosis. Conclusion This study found evidence for an early increase in rates of consultation for relevant clinical features and abnormal blood tests in patients with colorectal cancer, suggesting that earlier instigation of cancer-specific investigations or referrals may be warranted in some patients who were symptomatic.
背景:在英国，大多数结直肠癌是在症状出现后被诊断出来的。目的为出现结肠癌和直肠癌相关症状或血液检查异常的患者确定及时调查或转诊的机会窗口。设计与设置本研究对2012年至2015年间英国诊断为结直肠癌的患者进行了回顾性队列研究，使用了相关的初级保健和癌症登记数据。方法计算诊断前24个月的相关临床特征(排便习惯改变、直肠出血、腹痛、腹部肿块、体质症状和其他肠道症状)和异常血检结果(低血红蛋白、高血小板、高炎症标志物)的每月咨询率。用泊松回归校正年龄、性别和相关合并症来估计问诊率高于基线的最可能月份。结果共纳入5033例结肠癌患者和2516例直肠癌患者。在诊断前一年，对所有检查的临床特征和异常血液检查的咨询增加了。直肠出血是较基线率增加最早的临床特征:在结肠癌诊断前10个月(95%可信区间[CI] = 8.3至11.7)和直肠癌诊断前8个月(95% CI = 6.1至9.9)。低血红蛋白、高血小板和高炎症标志物早在诊断前9个月就增加了。结论:本研究发现，结直肠癌患者的相关临床特征和异常血液检查的咨询率在早期有所增加，这表明，对一些有症状的患者，早期进行癌症特异性调查或转诊可能是有必要的。
{"title":"Pre-diagnostic clinical features and blood tests in patients with colorectal cancer: a retrospective linked-data study","authors":"Marie Moullet, G. Funston, L. Mounce, G. Abel, N. D. de Wit, F. Walter, Yin Zhou","doi":"10.3399/BJGP.2021.0563","DOIUrl":"https://doi.org/10.3399/BJGP.2021.0563","url":null,"abstract":"Background The majority of colorectal cancer is diagnosed in patients following symptomatic presentation in the UK. Aim To identify windows of opportunity for timely investigations or referrals in patients presenting with colon and rectal cancer-relevant symptoms or abnormal blood tests. Design and setting A retrospective cohort study was undertaken using linked primary care and cancer registry data for patients with colorectal cancer diagnosed in England between 2012 and 2015. Method Monthly consultation rates for relevant clinical features (change in bowel habit, rectal bleeding, abdominal pain, abdominal mass, constitutional symptoms, and other bowel symptoms) and abnormal blood test results (low haemoglobin, high platelets, and high inflammatory markers) up to 24 months pre-diagnosis were calculated. Poisson regression adjusted for age, sex, and relevant comorbidities was used to estimate the most likely month when consultation rates increased above baseline. Results In total, 5033 patients with colon cancer and 2516 with rectal cancer were included. Consultations for all examined clinical features and abnormal blood tests increased in the year pre-diagnosis. Rectal bleeding was the earliest clinical feature to increase from the baseline rate: at 10 months (95% confidence interval [CI] = 8.3 to 11.7) pre-diagnosis for colon cancer and at 8 months (95% CI = 6.1 to 9.9) pre-diagnosis for rectal cancer. Low haemoglobin, high platelets, and high inflammatory markers increased from as early as 9 months pre-diagnosis. Conclusion This study found evidence for an early increase in rates of consultation for relevant clinical features and abnormal blood tests in patients with colorectal cancer, suggesting that earlier instigation of cancer-specific investigations or referrals may be warranted in some patients who were symptomatic.","PeriodicalId":22333,"journal":{"name":"The British Journal of General Practice","volume":"53 1","pages":"e556 - e563"},"PeriodicalIF":0.0,"publicationDate":"2022-03-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"76261930","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Amy Clark, R. Cannings‐John, Megan Blyth, Alastair D Hay, Christopher C. Butler, K. Hughes
Background The National Institute for Health and Care Excellence (NICE) traffic light system was created to facilitate the assessment of unwell children in primary care. To the authors’ knowledge, no studies have validated this tool in UK general practice. Aim To evaluate the accuracy of this system for detecting serious illness in children presenting to general practice. Design and setting A retrospective diagnostic accuracy study was undertaken, using a cohort of acutely unwell children aged <5 years presenting to general practice in England and Wales. Method The traffic light categories of 6703 children were linked with hospital data to identify admissions and diagnoses. The sensitivity and specificity of these categories were calculated against the reference standard: a hospital-diagnosed serious illness within 7 days of GP consultation, measured using International Classification of Diseases, 10th Revision codes. Results In total, 2116 (31.6%) children were categorised as ‘red’; 4204 (62.7%) as ‘amber’; and 383 (5.7%) as ‘green’. There were 139 (2.1%) children who were admitted to hospital within 7 days of consultation, of whom 17 (12.2%; 0.3% overall) had a serious illness. The sensitivity of the red category (versus amber and green) was 58.8% (95% confidence interval [CI] = 32.9 to 81.6) and the specificity 68.5% (95% CI = 67.4 to 69.6). The sensitivity and specificity of red and amber combined (versus green) was 100% (95% CI = 80.5 to 100) and 5.7% (95% CI = 5.2 to 6.3), respectively. Conclusion The NICE traffic light system did not accurately detect children admitted with a serious illness, nor those not seriously ill who could have been managed at home. This system is not suitable for use as a clinical tool in general practice. Further research is required to update or replace the system.
背景:国家健康与护理卓越研究所(NICE)红绿灯系统的建立是为了方便对初级保健中的不适儿童进行评估。据作者所知，没有研究在英国的一般实践中验证了这一工具。目的评价全科就诊儿童重症诊断系统的准确性。设计和设置进行了一项回顾性诊断准确性研究，研究对象是英格兰和威尔士全科就诊的5岁以下急性不适儿童。方法将6703例儿童的交通灯分类与医院数据相关联，识别入院和诊断。这些分类的敏感性和特异性是根据参考标准计算的:在全科医生咨询后7天内医院诊断的严重疾病，使用国际疾病分类第10次修订代码进行测量。结果共有2116例(31.6%)患儿被归为“红色”;4204(62.7%)为“琥珀”;383人(5.7%)选择“绿色”。139名(2.1%)儿童在咨询后7天内入院，其中17名(12.2%);0.3%)患有严重疾病。红色分类的敏感性(相对于琥珀色和绿色分类)为58.8%(95%可信区间[CI] = 32.9 ~ 81.6)，特异性为68.5% (95% CI = 67.4 ~ 69.6)。红色和琥珀色联合(相对于绿色)的敏感性和特异性分别为100% (95% CI = 80.5 ~ 100)和5.7% (95% CI = 5.2 ~ 6.3)。结论NICE交通灯系统不能准确地检测出入院的重症儿童，也不能准确地检测出那些本可以在家治疗的非重症儿童。该系统不适合在一般实践中作为临床工具使用。需要进一步研究以更新或替换该系统。
{"title":"Accuracy of the NICE traffic light system in children presenting to general practice: a retrospective cohort study","authors":"Amy Clark, R. Cannings‐John, Megan Blyth, Alastair D Hay, Christopher C. Butler, K. Hughes","doi":"10.3399/BJGP.2021.0633","DOIUrl":"https://doi.org/10.3399/BJGP.2021.0633","url":null,"abstract":"Background The National Institute for Health and Care Excellence (NICE) traffic light system was created to facilitate the assessment of unwell children in primary care. To the authors’ knowledge, no studies have validated this tool in UK general practice. Aim To evaluate the accuracy of this system for detecting serious illness in children presenting to general practice. Design and setting A retrospective diagnostic accuracy study was undertaken, using a cohort of acutely unwell children aged <5 years presenting to general practice in England and Wales. Method The traffic light categories of 6703 children were linked with hospital data to identify admissions and diagnoses. The sensitivity and specificity of these categories were calculated against the reference standard: a hospital-diagnosed serious illness within 7 days of GP consultation, measured using International Classification of Diseases, 10th Revision codes. Results In total, 2116 (31.6%) children were categorised as ‘red’; 4204 (62.7%) as ‘amber’; and 383 (5.7%) as ‘green’. There were 139 (2.1%) children who were admitted to hospital within 7 days of consultation, of whom 17 (12.2%; 0.3% overall) had a serious illness. The sensitivity of the red category (versus amber and green) was 58.8% (95% confidence interval [CI] = 32.9 to 81.6) and the specificity 68.5% (95% CI = 67.4 to 69.6). The sensitivity and specificity of red and amber combined (versus green) was 100% (95% CI = 80.5 to 100) and 5.7% (95% CI = 5.2 to 6.3), respectively. Conclusion The NICE traffic light system did not accurately detect children admitted with a serious illness, nor those not seriously ill who could have been managed at home. This system is not suitable for use as a clinical tool in general practice. Further research is required to update or replace the system.","PeriodicalId":22333,"journal":{"name":"The British Journal of General Practice","volume":"8 1","pages":"e398 - e404"},"PeriodicalIF":0.0,"publicationDate":"2022-03-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"82423057","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
K. Howells, Mat Amp, Martin Burrows, Jo-Ann Brown, R. Brennan, Joanne Dickinson, Shaun Jackson, Wan-Ley Yeung, D. Ashcroft, S. Campbell, T. Blakeman, C. Sanders
Background The COVID-19 pandemic has caused unprecedented disruption and change to the organisation of primary care, including for people experiencing homelessness who may not have access to a phone. Little is known about whether the recent changes required to deliver services to people experiencing homelessness will help to address or compound inequality in accessing care. Aim To explore the experience and impact of organisational and technology changes in response to COVID-19 on access to health care for people experiencing homelessness. Design and setting An action-led and participatory research methodology was employed in three case study sites made up of primary care services delivering care for people experiencing homelessness. Method Individual semi-structured interviews were conducted with 21 people experiencing homelessness and 22 clinicians and support workers. Interviews were analysed using a framework approach. Results The move to remote telephone consultations highlighted the difficulties experienced by participants in accessing health care. These barriers included problems at the practice level associated with remote triage as participants did not always have access to a phone or the means to pay for a phone call. This fostered increased reliance on support workers and clinicians working in the community to provide or facilitate a primary care appointment. Conclusion The findings have emphasised the importance of addressing practical and technology barriers as well as supporting communication and choice for mode of consultation. The authors argue that consultations should not be remote ‘by default’ and instead take into consideration both the clinical and social factors underpinning health.
{"title":"Remote primary care during the COVID-19 pandemic for people experiencing homelessness: a qualitative study","authors":"K. Howells, Mat Amp, Martin Burrows, Jo-Ann Brown, R. Brennan, Joanne Dickinson, Shaun Jackson, Wan-Ley Yeung, D. Ashcroft, S. Campbell, T. Blakeman, C. Sanders","doi":"10.3399/BJGP.2021.0596","DOIUrl":"https://doi.org/10.3399/BJGP.2021.0596","url":null,"abstract":"Background The COVID-19 pandemic has caused unprecedented disruption and change to the organisation of primary care, including for people experiencing homelessness who may not have access to a phone. Little is known about whether the recent changes required to deliver services to people experiencing homelessness will help to address or compound inequality in accessing care. Aim To explore the experience and impact of organisational and technology changes in response to COVID-19 on access to health care for people experiencing homelessness. Design and setting An action-led and participatory research methodology was employed in three case study sites made up of primary care services delivering care for people experiencing homelessness. Method Individual semi-structured interviews were conducted with 21 people experiencing homelessness and 22 clinicians and support workers. Interviews were analysed using a framework approach. Results The move to remote telephone consultations highlighted the difficulties experienced by participants in accessing health care. These barriers included problems at the practice level associated with remote triage as participants did not always have access to a phone or the means to pay for a phone call. This fostered increased reliance on support workers and clinicians working in the community to provide or facilitate a primary care appointment. Conclusion The findings have emphasised the importance of addressing practical and technology barriers as well as supporting communication and choice for mode of consultation. The authors argue that consultations should not be remote ‘by default’ and instead take into consideration both the clinical and social factors underpinning health.","PeriodicalId":22333,"journal":{"name":"The British Journal of General Practice","volume":"114 1","pages":"e492 - e500"},"PeriodicalIF":0.0,"publicationDate":"2022-03-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"77714718","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2021-08-28DOI: 10.1101/2021.08.26.21262657
R. Mathur, S. Hull, S. Hodgson, S. Finer
Background: Subgroups of type 2 diabetes (T2DM) have been well characterised in experimental studies. However, it is unclear whether T2DM subgroups can be identified in UK based real-world populations and if they impact clinical outcomes. Aim: To derive T2DM subgroups using primary care data from a multi-ethnic population, evaluate associations with glycaemic control, treatment initiation and vascular outcomes, and understand how these vary by ethnicity. Design and setting: An observational cohort study in the East London Primary Care Database from 2008-2018. Method: Latent class analysis using age, sex, glycated haemoglobin, and body mass index at diagnosis was used to derive T2DM subgroups in White, South Asian, and Black groups. Time to treatment initiation and vascular outcomes was estimated using multivariable Cox-proportional hazards regression. Results: 31,931 adults with T2DM were included: 47% south Asian, 25% White, 20% Black. We replicated two previously described subgroups, "Mild Age-Related Diabetes" (MARD), "Mild Obesity-related Diabetes" (MOD), and characterised a third "Severe Hyperglycaemic Diabetes" (SHD). Compared to MARD, SHD had the poorest long term glycaemic control, fastest initiation of antidiabetic treatment (HR 2.02, 1.76-2.32), and highest risk of microvascular complications (HR 1.38, 1.28-1.49). MOD had the highest risk of macrovascular complications (HR 1.50, 1.23-1.83). Subgroup differences in treatment initiation were most pronounced for the White group, and vascular complications for the Black group. Conclusions: Clinically useful T2DM subgroups, identified at diagnosis, can be generated in routine real-world multi-ethnic populations, and may offer a pragmatic means to develop stratified primary care pathways and improve healthcare resource allocation.
{"title":"Characterisation of type 2 diabetes subgroups and their association with ethnicity and clinical outcomes: a UK real-world data study using the East London Database","authors":"R. Mathur, S. Hull, S. Hodgson, S. Finer","doi":"10.1101/2021.08.26.21262657","DOIUrl":"https://doi.org/10.1101/2021.08.26.21262657","url":null,"abstract":"Background: Subgroups of type 2 diabetes (T2DM) have been well characterised in experimental studies. However, it is unclear whether T2DM subgroups can be identified in UK based real-world populations and if they impact clinical outcomes. Aim: To derive T2DM subgroups using primary care data from a multi-ethnic population, evaluate associations with glycaemic control, treatment initiation and vascular outcomes, and understand how these vary by ethnicity. Design and setting: An observational cohort study in the East London Primary Care Database from 2008-2018. Method: Latent class analysis using age, sex, glycated haemoglobin, and body mass index at diagnosis was used to derive T2DM subgroups in White, South Asian, and Black groups. Time to treatment initiation and vascular outcomes was estimated using multivariable Cox-proportional hazards regression. Results: 31,931 adults with T2DM were included: 47% south Asian, 25% White, 20% Black. We replicated two previously described subgroups, \"Mild Age-Related Diabetes\" (MARD), \"Mild Obesity-related Diabetes\" (MOD), and characterised a third \"Severe Hyperglycaemic Diabetes\" (SHD). Compared to MARD, SHD had the poorest long term glycaemic control, fastest initiation of antidiabetic treatment (HR 2.02, 1.76-2.32), and highest risk of microvascular complications (HR 1.38, 1.28-1.49). MOD had the highest risk of macrovascular complications (HR 1.50, 1.23-1.83). Subgroup differences in treatment initiation were most pronounced for the White group, and vascular complications for the Black group. Conclusions: Clinically useful T2DM subgroups, identified at diagnosis, can be generated in routine real-world multi-ethnic populations, and may offer a pragmatic means to develop stratified primary care pathways and improve healthcare resource allocation.","PeriodicalId":22333,"journal":{"name":"The British Journal of General Practice","volume":"15 1","pages":"e421 - e429"},"PeriodicalIF":0.0,"publicationDate":"2021-08-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"85703529","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2021-02-01DOI: 10.1101/2021.01.30.21250563
H. Dambha‐Miller, G. Simpson, Lucy Hobson, Doyinsola Olaniyan, S. Hodgson, P. Roderick, S. Fraser, P. Little, H. Everitt, M. Santer
Background: Growing demand from an ageing population, chronic preventable disease and multimorbidity has resulted in complex health and social care needs requiring more integrated services. Integrating primary care with social services could more efficiently utilise resources, and improve experiences for patients, their families and carers. There is limited evidence on progress including key barriers and drivers of integration to inform large-scale national change. Aim: To elicit stakeholder views on drivers and barriers of integrated primary care and social services. and highlight opportunities for successful implementation. Design and setting: A qualitative interview study. Method: Semi-structured interviews with maximum variation sampling to capture stakeholder views across services and professions. Results: Thirty-seven interviews were conducted across England including GPs, nurses, social care staff, commissioners, local government, voluntary and private sectors, patients and carers. Drivers of integration included groups of like-minded individuals supported by good leadership, expanded interface roles to bridge gaps between systems and co-location of services. Barriers included structural and interdisciplinary tension between professions, organisational self-interest and challenges in record-sharing. Conclusions: Drivers and barriers to integration identified in other contexts are also present in primary care and social services. Benefits of integration are unlikely to be realised if these are not addressed in the design and execution of new initiatives. Efforts should go beyond local and professional level change to include wider systems and policy-level initiatives. This will support a more systems-wide approach to integrated care reform, which is necessary to meet the complex and growing needs of an ageing multimorbid population.
{"title":"Integrating primary care and social services for older adults with multimorbidity: a qualitative study","authors":"H. Dambha‐Miller, G. Simpson, Lucy Hobson, Doyinsola Olaniyan, S. Hodgson, P. Roderick, S. Fraser, P. Little, H. Everitt, M. Santer","doi":"10.1101/2021.01.30.21250563","DOIUrl":"https://doi.org/10.1101/2021.01.30.21250563","url":null,"abstract":"Background: Growing demand from an ageing population, chronic preventable disease and multimorbidity has resulted in complex health and social care needs requiring more integrated services. Integrating primary care with social services could more efficiently utilise resources, and improve experiences for patients, their families and carers. There is limited evidence on progress including key barriers and drivers of integration to inform large-scale national change. Aim: To elicit stakeholder views on drivers and barriers of integrated primary care and social services. and highlight opportunities for successful implementation. Design and setting: A qualitative interview study. Method: Semi-structured interviews with maximum variation sampling to capture stakeholder views across services and professions. Results: Thirty-seven interviews were conducted across England including GPs, nurses, social care staff, commissioners, local government, voluntary and private sectors, patients and carers. Drivers of integration included groups of like-minded individuals supported by good leadership, expanded interface roles to bridge gaps between systems and co-location of services. Barriers included structural and interdisciplinary tension between professions, organisational self-interest and challenges in record-sharing. Conclusions: Drivers and barriers to integration identified in other contexts are also present in primary care and social services. Benefits of integration are unlikely to be realised if these are not addressed in the design and execution of new initiatives. Efforts should go beyond local and professional level change to include wider systems and policy-level initiatives. This will support a more systems-wide approach to integrated care reform, which is necessary to meet the complex and growing needs of an ageing multimorbid population.","PeriodicalId":22333,"journal":{"name":"The British Journal of General Practice","volume":"1 1","pages":"e753 - e761"},"PeriodicalIF":0.0,"publicationDate":"2021-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"88608731","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
L. Jefferson, K. Atkin, Rebecca Sheridan, S. Oliver, U. Macleod, G. Hall, Sarah Forbes, T. Green, V. Allgar, P. Knapp
Background The 2-week-wait urgent referral policy in the UK has sought to improve cancer outcomes by accelerating diagnosis and treatment. However, around 5–7% of symptomatic referred patients cancel or do not attend their hospital appointment. While subsequent cancer diagnosis was less likely in non-attenders, those with a diagnosis had worse early mortality outcomes. Aim To examine how interpersonal, communication, social, and organisational factors influence a patient’s non-attendance. Design and setting Qualitative study in GP practices in one Northern English city. Method In-depth, individual interviews were undertaken face-to-face or by telephone between December 2016 and May 2018, followed by thematic framework analysis. Results In this study 21 GPs, and 24 patients who did not attend or had cancelled their appointment were interviewed, deriving a range of potential explanations for non-attendance, including: system flaws; GP difficulties with booking appointments; patient difficulties with navigating the appointment system, particularly older patients and those from more deprived areas; patients leading ‘difficult lives’; and patients’ expectations of the referral, informed by their beliefs, circumstances, priorities, and the perceived prognosis. GPs recognised the importance of communication with the patient, particularly the need to tailor communication to perceived patient understanding and anxiety. GPs and practices varied in their responses to patient non-attendance, influenced by time pressures and perceptions of patient responsibility. Conclusion Failure to be seen within 2 weeks of urgent referral resulted from a number of patient and provider factors. The urgent referral process in general practice and cancer services should accommodate patient perceptions and responses, facilitate referral and attendance, and enable responses to patient non-attendance.
{"title":"Non-attendance at urgent referral appointments for suspected cancer: a qualitative study to gain understanding from patients and GPs","authors":"L. Jefferson, K. Atkin, Rebecca Sheridan, S. Oliver, U. Macleod, G. Hall, Sarah Forbes, T. Green, V. Allgar, P. Knapp","doi":"10.3399/bjgp19X706625","DOIUrl":"https://doi.org/10.3399/bjgp19X706625","url":null,"abstract":"Background The 2-week-wait urgent referral policy in the UK has sought to improve cancer outcomes by accelerating diagnosis and treatment. However, around 5–7% of symptomatic referred patients cancel or do not attend their hospital appointment. While subsequent cancer diagnosis was less likely in non-attenders, those with a diagnosis had worse early mortality outcomes. Aim To examine how interpersonal, communication, social, and organisational factors influence a patient’s non-attendance. Design and setting Qualitative study in GP practices in one Northern English city. Method In-depth, individual interviews were undertaken face-to-face or by telephone between December 2016 and May 2018, followed by thematic framework analysis. Results In this study 21 GPs, and 24 patients who did not attend or had cancelled their appointment were interviewed, deriving a range of potential explanations for non-attendance, including: system flaws; GP difficulties with booking appointments; patient difficulties with navigating the appointment system, particularly older patients and those from more deprived areas; patients leading ‘difficult lives’; and patients’ expectations of the referral, informed by their beliefs, circumstances, priorities, and the perceived prognosis. GPs recognised the importance of communication with the patient, particularly the need to tailor communication to perceived patient understanding and anxiety. GPs and practices varied in their responses to patient non-attendance, influenced by time pressures and perceptions of patient responsibility. Conclusion Failure to be seen within 2 weeks of urgent referral resulted from a number of patient and provider factors. The urgent referral process in general practice and cancer services should accommodate patient perceptions and responses, facilitate referral and attendance, and enable responses to patient non-attendance.","PeriodicalId":22333,"journal":{"name":"The British Journal of General Practice","volume":"36 1","pages":"e850 - e859"},"PeriodicalIF":0.0,"publicationDate":"2019-11-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"73962424","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
S. Mills, D. Buchanan, B. Guthrie, P. Donnan, Blair H. Smith
Background People with advanced cancer frequently attend unscheduled care, but little is known about the factors influencing presentations. Most research focuses on accident and emergency (A&E) and does not consider GP out-of-hours (GPOOH). Aim To describe the frequency and patterns of unscheduled care use by people with cancer in their last year of life and to examine the associations of demographic and clinical factors with unscheduled care attendance. Design and setting Retrospective cohort study of all 2443 people who died from cancer in Tayside, Scotland, during 2012–2015. Clinical population datasets were linked to routinely collected clinical data using the Community Health Index (CHI) number. Method Anonymised CHI-linked data were analysed in SafeHaven, with descriptive analysis, using binary logistic regression for adjusted associations. Results Of the people who died from cancer, 77.9% (n = 1904) attended unscheduled care in the year before death. Among unscheduled care users, most only attended GPOOH (n = 1070, 56.2%), with the rest attending A&E only (n = 204, 10.7%), or both (n = 630, 33.1%). Many attendances occurred in the last week (n =1360, 19.7%), last 4 weeks (n = 2541, 36.7%), and last 12 weeks (n = 4174, 60.3%) of life. Age, sex, deprivation, and cancer type were not significantly associated with unscheduled care attendance. People living in rural areas were less likely to attend unscheduled care: adjusted odds ratio (aOR) 0.64 (95% confidence interval = 0.50 to 0.82). Pain was the commonest coded clinical reason for presenting (GPOOH: n = 482, 10.5%; A&E: n = 336, 28.8%). Of people dying from cancer, n = 514, 21.0%, were frequent users (≥5 attendances/year), and accounted for over half (n = 3986, 57.7%) of unscheduled care attendances. Conclusion Unscheduled care attendance by people with advanced cancer was substantially higher than previously reported, increased dramatically towards the end of life, was largely independent of demographic factors and cancer type, and was commonly for pain and palliative care.
{"title":"Factors affecting use of unscheduled care for people with advanced cancer: a retrospective cohort study in Scotland","authors":"S. Mills, D. Buchanan, B. Guthrie, P. Donnan, Blair H. Smith","doi":"10.3399/bjgp19X706637","DOIUrl":"https://doi.org/10.3399/bjgp19X706637","url":null,"abstract":"Background People with advanced cancer frequently attend unscheduled care, but little is known about the factors influencing presentations. Most research focuses on accident and emergency (A&E) and does not consider GP out-of-hours (GPOOH). Aim To describe the frequency and patterns of unscheduled care use by people with cancer in their last year of life and to examine the associations of demographic and clinical factors with unscheduled care attendance. Design and setting Retrospective cohort study of all 2443 people who died from cancer in Tayside, Scotland, during 2012–2015. Clinical population datasets were linked to routinely collected clinical data using the Community Health Index (CHI) number. Method Anonymised CHI-linked data were analysed in SafeHaven, with descriptive analysis, using binary logistic regression for adjusted associations. Results Of the people who died from cancer, 77.9% (n = 1904) attended unscheduled care in the year before death. Among unscheduled care users, most only attended GPOOH (n = 1070, 56.2%), with the rest attending A&E only (n = 204, 10.7%), or both (n = 630, 33.1%). Many attendances occurred in the last week (n =1360, 19.7%), last 4 weeks (n = 2541, 36.7%), and last 12 weeks (n = 4174, 60.3%) of life. Age, sex, deprivation, and cancer type were not significantly associated with unscheduled care attendance. People living in rural areas were less likely to attend unscheduled care: adjusted odds ratio (aOR) 0.64 (95% confidence interval = 0.50 to 0.82). Pain was the commonest coded clinical reason for presenting (GPOOH: n = 482, 10.5%; A&E: n = 336, 28.8%). Of people dying from cancer, n = 514, 21.0%, were frequent users (≥5 attendances/year), and accounted for over half (n = 3986, 57.7%) of unscheduled care attendances. Conclusion Unscheduled care attendance by people with advanced cancer was substantially higher than previously reported, increased dramatically towards the end of life, was largely independent of demographic factors and cancer type, and was commonly for pain and palliative care.","PeriodicalId":22333,"journal":{"name":"The British Journal of General Practice","volume":"115 1","pages":"e860 - e868"},"PeriodicalIF":0.0,"publicationDate":"2019-11-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"91047179","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Annabelle Gordon, David B. Lehane, J. Burr, C. Mitchell
Background Homeless women are twice as likely to become pregnant and are less likely to receive antenatal care than women who are not homeless. Prevalent biopsychosocial complexity and comorbidities, including substance use and mental illness, increase the risk of obstetric complications, postnatal depression, and child loss to social services. Aim To explore the perspectives of women who have experienced pregnancy and homelessness to ascertain how to improve perinatal care. Design and setting A qualitative study with a purposive sample of women who had experienced pregnancy and homelessness, recruited from three community settings. Method Semi-structured interviews continued to data saturation and were recorded, transcribed, and analysed thematically using a self-conscious approach, with independent verification of emergent themes. Results Eleven women, diverse in age (18–40 years) and parity (one to five children), participated. Most women had experienced childhood trauma, grief, mental illness, and substance use. Overarching themes of ‘mistrust‘ and ‘fear of child loss to social services’ (CLSS) influenced their interactions with practitioners. The women experienced stigma from practitioners, and lacked effective support networks. Women who mistrusted practitioners attended appointments but concealed their needs, preventing necessary care. Further themes were being seen to do ‘the best for the baby’; pregnancy-enabled access to necessary holistic biopsychosocial care; and lack of postnatal support for CLSS or parenting. Conclusion Pregnancy offered a pivotal opportunity for homeless women to engage with care for their complex needs and improve self-care, despite mistrust of practitioners. Poor postnatal support and the distress of CLSS reinforced an ongoing cycle of grief, mental health crises, substance use relapse, and homelessness.
{"title":"Influence of past trauma and health interactions on homeless women’s views of perinatal care: a qualitative study","authors":"Annabelle Gordon, David B. Lehane, J. Burr, C. Mitchell","doi":"10.3399/bjgp19X705557","DOIUrl":"https://doi.org/10.3399/bjgp19X705557","url":null,"abstract":"Background Homeless women are twice as likely to become pregnant and are less likely to receive antenatal care than women who are not homeless. Prevalent biopsychosocial complexity and comorbidities, including substance use and mental illness, increase the risk of obstetric complications, postnatal depression, and child loss to social services. Aim To explore the perspectives of women who have experienced pregnancy and homelessness to ascertain how to improve perinatal care. Design and setting A qualitative study with a purposive sample of women who had experienced pregnancy and homelessness, recruited from three community settings. Method Semi-structured interviews continued to data saturation and were recorded, transcribed, and analysed thematically using a self-conscious approach, with independent verification of emergent themes. Results Eleven women, diverse in age (18–40 years) and parity (one to five children), participated. Most women had experienced childhood trauma, grief, mental illness, and substance use. Overarching themes of ‘mistrust‘ and ‘fear of child loss to social services’ (CLSS) influenced their interactions with practitioners. The women experienced stigma from practitioners, and lacked effective support networks. Women who mistrusted practitioners attended appointments but concealed their needs, preventing necessary care. Further themes were being seen to do ‘the best for the baby’; pregnancy-enabled access to necessary holistic biopsychosocial care; and lack of postnatal support for CLSS or parenting. Conclusion Pregnancy offered a pivotal opportunity for homeless women to engage with care for their complex needs and improve self-care, despite mistrust of practitioners. Poor postnatal support and the distress of CLSS reinforced an ongoing cycle of grief, mental health crises, substance use relapse, and homelessness.","PeriodicalId":22333,"journal":{"name":"The British Journal of General Practice","volume":"33 1","pages":"e760 - e767"},"PeriodicalIF":0.0,"publicationDate":"2019-09-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"89634151","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
A. McKechanie, A. Barnicoat, I. Trender‐Gerhard, M. Allison, A. Stanfield
Fragile X syndrome (FXS) is a triplet-repeat expansion disorder of the X chromosome, with repeats of more than 200 (sometimes referred to as the full mutation) causing FXS and ∼59–200 repeats (the so-called premutation) being responsible for a variety of clinical presentations. Clinicians in primary care should be aware of these conditions and in particular be vigilant for common comorbidities to allow for early treatment. This article summarises the common issues for individuals with FXS and carriers of the premutation. FXS is the most common inherited cause of intellectual disability, occurring in approximately 1 in 3000–4000 males and 1 in 6000–8000 females. Although the genetic underpinnings of FXS are similar across individuals, the manifestations vary widely and in some ways there is no ‘typical’ presentation. Nonetheless, males with the syndrome generally have an intellectual disability ranging from mild to severe, whereas females are much more variably affected (due to random X-inactivation) and can range from being essentially asymptomatic to having a severe intellectual disability. There are a number of common physical comorbidities associated with the syndrome including epilepsy (∼25%), mitral valve prolapse (≤80%), hyperextensible joints, and an increased risk of inguinal hernias. Anxiety, attention deficit hyperactivity disorder (ADHD), and autism spectrum disorders (ASDs) are also significantly more common. Hyperarousal and sensory hypersensitivity are frequent symptoms, which may occur across a range of diagnoses. It is worth noting that, although one-third to two-thirds of individuals with FXS may meet criteria for an ASD, the presentation often varies subtly from that seen in idiopathic ASDs. In particular, some traits such as social difficulties and atypical eye contact may have very different underpinnings in FXS as compared with ASDs. …
{"title":"Fragile X-associated conditions: implications for the whole family","authors":"A. McKechanie, A. Barnicoat, I. Trender‐Gerhard, M. Allison, A. Stanfield","doi":"10.3399/bjgp19X705425","DOIUrl":"https://doi.org/10.3399/bjgp19X705425","url":null,"abstract":"Fragile X syndrome (FXS) is a triplet-repeat expansion disorder of the X chromosome, with repeats of more than 200 (sometimes referred to as the full mutation) causing FXS and ∼59–200 repeats (the so-called premutation) being responsible for a variety of clinical presentations. Clinicians in primary care should be aware of these conditions and in particular be vigilant for common comorbidities to allow for early treatment. This article summarises the common issues for individuals with FXS and carriers of the premutation.\u0000\u0000FXS is the most common inherited cause of intellectual disability, occurring in approximately 1 in 3000–4000 males and 1 in 6000–8000 females. Although the genetic underpinnings of FXS are similar across individuals, the manifestations vary widely and in some ways there is no ‘typical’ presentation. Nonetheless, males with the syndrome generally have an intellectual disability ranging from mild to severe, whereas females are much more variably affected (due to random X-inactivation) and can range from being essentially asymptomatic to having a severe intellectual disability. There are a number of common physical comorbidities associated with the syndrome including epilepsy (∼25%), mitral valve prolapse (≤80%), hyperextensible joints, and an increased risk of inguinal hernias. Anxiety, attention deficit hyperactivity disorder (ADHD), and autism spectrum disorders (ASDs) are also significantly more common. Hyperarousal and sensory hypersensitivity are frequent symptoms, which may occur across a range of diagnoses. It is worth noting that, although one-third to two-thirds of individuals with FXS may meet criteria for an ASD, the presentation often varies subtly from that seen in idiopathic ASDs. In particular, some traits such as social difficulties and atypical eye contact may have very different underpinnings in FXS as compared with ASDs. …","PeriodicalId":22333,"journal":{"name":"The British Journal of General Practice","volume":"69 1","pages":"460 - 461"},"PeriodicalIF":0.0,"publicationDate":"2019-08-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"81573848","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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