O. van Hecke, A. Fuller, C. Bankhead, S. Jenkins-Jones, N. Francis, M. Moore, Chris Butler, Kay Wang
Background Childhood antibiotic exposure has important clinically relevant implications. These include disruption to the microbiome, antibiotic resistance, and clinical workload manifesting as treatment ‘failure’. Aim To examine the relationship between the number of antibiotic courses prescribed to preschool children for acute respiratory tract infections (RTI), in the preceding year, and subsequent RTIs that failed to respond to antibiotic treatment (‘response failures’). Design and setting A cohort study using UK primary care data from the Clinical Practice Research Datalink, 2009 to 2016. Method Children aged 12 to 60 months (1 to 5 years) who were prescribed an antibiotic for an acute RTI (upper and lower RTI or otitis media) were included. One random index antibiotic course for RTI per child was selected. Exposure was the number of antibiotic prescriptions for acute RTI up to 12 months before the index antibiotic prescription. The outcome was ‘response failure’ up to 14 days after index antibiotic prescription, defined as: subsequent antibiotic prescription; referral; hospital admission; death; or emergency department attendance within 3 days. The authors used logistic regression models to estimate the odds between antibiotic exposure and response failure. Results Out of 114 329 children who were prescribed an antibiotic course for acute RTI, children who received ≥2 antibiotic courses for acute RTIs in the preceding year had greater odds of response failure; one antibiotic course: adjusted odds ratio (OR) 1.03 (95% confidence interval [CI] = 0.88 to 1.21), P = 0.67, n = 230 children; ≥2 antibiotic courses: adjusted OR 1.32 (CI = 1.04 to 1.66), P = 0.02, n = 97. Conclusion Childhood antibiotic exposure for acute RTI may be a good predictor for subsequent response failure (but not necessarily because of antibiotic treatment failure). Further research is needed to improve understanding of the mechanisms underlying response failure.
儿童抗生素暴露具有重要的临床意义。这些包括微生物群的破坏、抗生素耐药性和临床工作量表现为治疗“失败”。目的研究前一年学龄前儿童急性呼吸道感染(RTI)的抗生素疗程数与随后对抗生素治疗无效的RTIs(“反应失败”)之间的关系。设计和设置一项队列研究，使用2009年至2016年临床实践研究数据链中的英国初级保健数据。方法选取年龄在12 ~ 60个月(1 ~ 5岁)，因急性呼吸道感染(上、下呼吸道感染或中耳炎)使用抗生素治疗的患儿。每个儿童随机选择一个RTI指标抗生素疗程。暴露量是指在指数抗生素处方前12个月的急性呼吸道感染抗生素处方数量。结果为指标抗生素处方后14天“反应失败”，定义为:后续抗生素处方;推荐;住院;死亡;或3天内到急诊科就诊。作者使用逻辑回归模型来估计抗生素暴露和反应失败之间的几率。结果在114329例接受过抗生素治疗的儿童中，前一年接受过≥2个抗生素治疗的儿童反应失败的几率更大;一个抗生素疗程:调整优势比(OR) 1.03(95%可信区间[CI] = 0.88 ~ 1.21)， P = 0.67, n = 230名儿童;≥2个抗生素疗程:调整OR为1.32 (CI = 1.04 ~ 1.66)， P = 0.02, n = 97。结论急性呼吸道感染的儿童抗生素暴露可能是随后反应失败的良好预测因素(但不一定是因为抗生素治疗失败)。需要进一步的研究来提高对反应失败机制的理解。
{"title":"Antibiotic exposure and ‘response failure’ for subsequent respiratory tract infections: an observational cohort study of UK preschool children in primary care","authors":"O. van Hecke, A. Fuller, C. Bankhead, S. Jenkins-Jones, N. Francis, M. Moore, Chris Butler, Kay Wang","doi":"10.3399/bjgp19X705089","DOIUrl":"https://doi.org/10.3399/bjgp19X705089","url":null,"abstract":"Background Childhood antibiotic exposure has important clinically relevant implications. These include disruption to the microbiome, antibiotic resistance, and clinical workload manifesting as treatment ‘failure’. Aim To examine the relationship between the number of antibiotic courses prescribed to preschool children for acute respiratory tract infections (RTI), in the preceding year, and subsequent RTIs that failed to respond to antibiotic treatment (‘response failures’). Design and setting A cohort study using UK primary care data from the Clinical Practice Research Datalink, 2009 to 2016. Method Children aged 12 to 60 months (1 to 5 years) who were prescribed an antibiotic for an acute RTI (upper and lower RTI or otitis media) were included. One random index antibiotic course for RTI per child was selected. Exposure was the number of antibiotic prescriptions for acute RTI up to 12 months before the index antibiotic prescription. The outcome was ‘response failure’ up to 14 days after index antibiotic prescription, defined as: subsequent antibiotic prescription; referral; hospital admission; death; or emergency department attendance within 3 days. The authors used logistic regression models to estimate the odds between antibiotic exposure and response failure. Results Out of 114 329 children who were prescribed an antibiotic course for acute RTI, children who received ≥2 antibiotic courses for acute RTIs in the preceding year had greater odds of response failure; one antibiotic course: adjusted odds ratio (OR) 1.03 (95% confidence interval [CI] = 0.88 to 1.21), P = 0.67, n = 230 children; ≥2 antibiotic courses: adjusted OR 1.32 (CI = 1.04 to 1.66), P = 0.02, n = 97. Conclusion Childhood antibiotic exposure for acute RTI may be a good predictor for subsequent response failure (but not necessarily because of antibiotic treatment failure). Further research is needed to improve understanding of the mechanisms underlying response failure.","PeriodicalId":22333,"journal":{"name":"The British Journal of General Practice","volume":"45 1","pages":"e638 - e646"},"PeriodicalIF":0.0,"publicationDate":"2019-08-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"78577074","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}
B. Fletcher, Lisa Hinton, R. McManus, Oliver Rivero-Arias
Background With a variety of potentially effective hypertension management options, it is important to determine how patients value different models of care, and the relative importance of factors in their decision-making process. Aim To explore patient preferences for the management of hypertension in the UK. Design and setting Online survey of patients who have hypertension in the UK including an unlabelled discrete choice experiment (DCE). Method A DCE was developed to assess patient preferences for the management of hypertension based on four attributes: model of care, frequency of blood pressure (BP) measurement, reduction in 5-year cardiovascular risk, and costs to the NHS. A mixed logit model was used to estimate preferences, willingness-to-pay was modelled, and a scenario analysis was conducted to evaluate the impact of changes in attribute levels on the uptake of different models of care. Results One hundred and sixty-seven participants completed the DCE (aged 61.4 years, 45.0% female, 82.0% >5 years since diagnosis). All four attributes were significant in choice (P<0.05). Reduction in 5-year cardiovascular risk was the main driver of patient preference as evidenced in the scenario and willingness-to-pay analyses. GP management was significantly preferred over self-management. Patients preferred scenarios with more frequent BP measurement, and lower costs to the NHS. Conclusion Participants had similar preferences for GP management, pharmacist management, and telehealth, but a negative preference for self-management. When introducing new models of care for hypertension to patients, discussion of the potential benefits in terms of risk reduction should be prioritised to maximise uptake.
{"title":"Patient preferences for management of high blood pressure in the UK: a discrete choice experiment","authors":"B. Fletcher, Lisa Hinton, R. McManus, Oliver Rivero-Arias","doi":"10.3399/bjgp19X705101","DOIUrl":"https://doi.org/10.3399/bjgp19X705101","url":null,"abstract":"Background With a variety of potentially effective hypertension management options, it is important to determine how patients value different models of care, and the relative importance of factors in their decision-making process. Aim To explore patient preferences for the management of hypertension in the UK. Design and setting Online survey of patients who have hypertension in the UK including an unlabelled discrete choice experiment (DCE). Method A DCE was developed to assess patient preferences for the management of hypertension based on four attributes: model of care, frequency of blood pressure (BP) measurement, reduction in 5-year cardiovascular risk, and costs to the NHS. A mixed logit model was used to estimate preferences, willingness-to-pay was modelled, and a scenario analysis was conducted to evaluate the impact of changes in attribute levels on the uptake of different models of care. Results One hundred and sixty-seven participants completed the DCE (aged 61.4 years, 45.0% female, 82.0% >5 years since diagnosis). All four attributes were significant in choice (P<0.05). Reduction in 5-year cardiovascular risk was the main driver of patient preference as evidenced in the scenario and willingness-to-pay analyses. GP management was significantly preferred over self-management. Patients preferred scenarios with more frequent BP measurement, and lower costs to the NHS. Conclusion Participants had similar preferences for GP management, pharmacist management, and telehealth, but a negative preference for self-management. When introducing new models of care for hypertension to patients, discussion of the potential benefits in terms of risk reduction should be prioritised to maximise uptake.","PeriodicalId":22333,"journal":{"name":"The British Journal of General Practice","volume":"16 1","pages":"e629 - e637"},"PeriodicalIF":0.0,"publicationDate":"2019-08-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"84032703","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. Scott, J. Kesten, K. Bache, M. Hickman, R. Campbell, A. Pickering, S. Redwood, K. Thomas
Background Opioid prescribing to treat chronic non-cancer pain has rapidly increased, despite a lack of evidence for long-term safety and effectiveness. A pain review service was developed to work with patients taking opioids long-term to explore opioid use, encourage non-drug-based alternatives, and, where appropriate, support dose reduction. Aim To evaluate the service and its potential impact on opioid use, health and wellbeing outcomes, and quality of life (QoL). Design and setting Mixed-methods evaluation of a one-to-one service based in two GP practices in South Gloucestershire, England, which took place from September 2016 to December 2017. Method Quantitative data were collected on baseline demographics; data on opioid use, misuse, and dose, health, wellbeing, QoL, and pain and interference with life measures were collected at baseline and follow-up. Twenty-five semi-structured interviews (n = 18 service users, n = 7 service providers) explored experiences of the service including perceived impacts and benefits. Results Of 59 patients who were invited, 34 (57.6%) enrolled in the service. The median prescribed opioid dose reduced from 90 mg (average daily morphine equivalent; interquartile range [IQR] 60 to 240) at baseline to 72 mg (IQR 30 to 160) at follow-up (P<0.001); three service users stopped using opioids altogether. On average, service users showed improvement on most health, wellbeing, and QoL outcomes. Perceived benefits were related to wellbeing, for example, improved confidence and self-esteem, use of pain management strategies, changes in medication use, and reductions in dose. Conclusion The service was well received, and health and wellbeing outcomes suggest a potential benefit. Following further service development, a randomised controlled trial to test this type of care pathway is warranted.
{"title":"Evaluation of a primary care-based opioid and pain review service: a mixed-methods evaluation in two GP practices in England","authors":"L. Scott, J. Kesten, K. Bache, M. Hickman, R. Campbell, A. Pickering, S. Redwood, K. Thomas","doi":"10.3399/bjgp19X707237","DOIUrl":"https://doi.org/10.3399/bjgp19X707237","url":null,"abstract":"Background Opioid prescribing to treat chronic non-cancer pain has rapidly increased, despite a lack of evidence for long-term safety and effectiveness. A pain review service was developed to work with patients taking opioids long-term to explore opioid use, encourage non-drug-based alternatives, and, where appropriate, support dose reduction. Aim To evaluate the service and its potential impact on opioid use, health and wellbeing outcomes, and quality of life (QoL). Design and setting Mixed-methods evaluation of a one-to-one service based in two GP practices in South Gloucestershire, England, which took place from September 2016 to December 2017. Method Quantitative data were collected on baseline demographics; data on opioid use, misuse, and dose, health, wellbeing, QoL, and pain and interference with life measures were collected at baseline and follow-up. Twenty-five semi-structured interviews (n = 18 service users, n = 7 service providers) explored experiences of the service including perceived impacts and benefits. Results Of 59 patients who were invited, 34 (57.6%) enrolled in the service. The median prescribed opioid dose reduced from 90 mg (average daily morphine equivalent; interquartile range [IQR] 60 to 240) at baseline to 72 mg (IQR 30 to 160) at follow-up (P<0.001); three service users stopped using opioids altogether. On average, service users showed improvement on most health, wellbeing, and QoL outcomes. Perceived benefits were related to wellbeing, for example, improved confidence and self-esteem, use of pain management strategies, changes in medication use, and reductions in dose. Conclusion The service was well received, and health and wellbeing outcomes suggest a potential benefit. Following further service development, a randomised controlled trial to test this type of care pathway is warranted.","PeriodicalId":22333,"journal":{"name":"The British Journal of General Practice","volume":"37 1","pages":"e111 - e119"},"PeriodicalIF":0.0,"publicationDate":"2019-07-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"88369864","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}
Eilís Keeble, H. Roberts, Christopher Williams, J. V. van Oppen, S. Conroy
Background ‘Frailty crises’ are a common cause of hospital admission among older people and there is significant focus on admission avoidance. However, identifying frailty before a crisis occurs is challenging, making it difficult to effectively target community services. Better longer-term outcome data are needed if services are to reflect the needs of the growing population of older people with frailty. Aim To determine long-term outcomes of older people discharged from hospital following short (<72 hours) and longer hospital admissions compared by frailty status. Design and setting Two populations aged ≥70 years discharged from hospital units: those following short ‘ambulatory’ admissions (<72 hours) and those following longer inpatient stays. Method Data for 2-year mortality and hospital use were compared using frailty measures derived from clinical and hospital data. Results Mortality after 2 years was increased for frail compared with non-frail individuals in both cohorts. Patients in the ambulatory cohort classified as frail had increased mortality (Rockwood hazard ratio 2.3 [95% confidence interval {CI} = 1.5 to 3.4]) and hospital use (Rockwood rate ratio 2.1 [95% CI = 1.7 to 2.6]) compared with those patients classified as non-frail. Conclusion Individuals with frailty who are discharged from hospital experience increased mortality and resource use, even after short ‘ambulatory’ admissions. This is an easily identifiable group that is at increased risk of poor outcomes. Health and social care systems might wish to examine their current care response for frail older people discharged from hospital. There may be value in a ‘secondary prevention’ approach to frailty crises targeting individuals who are discharged from hospital.
背景:“虚弱危机”是老年人住院的常见原因，人们非常关注避免住院。然而，在危机发生之前确定脆弱性是具有挑战性的，因此难以有效地针对社区服务。如果服务要反映日益增长的体弱多病老年人的需求，就需要更好的长期结果数据。目的比较老年人在短时间(<72小时)和较长时间住院后的长期预后。设计和设定两组年龄≥70岁的出院人群:一组是短期“门诊”住院(<72小时)，另一组是长期住院。方法采用来自临床和医院资料的衰弱指标，对2年死亡率和住院率进行比较。结果两组患者2年后体弱者的死亡率均高于非体弱者。与非虚弱的患者相比，被分类为虚弱的患者的死亡率(Rockwood风险比为2.3[95%可信区间{CI} = 1.5至3.4])和住院率(Rockwood风险比为2.1 [95% CI = 1.7至2.6])均有所增加。结论:即使在短暂的“门诊”住院后，出院的虚弱患者死亡率和资源利用率也会增加。这是一个容易识别的群体，其不良后果的风险增加。卫生和社会保健系统可能希望检查他们目前对出院的体弱老年人的护理反应。针对出院人员的虚弱危机采取“二级预防”方法可能有价值。
{"title":"Outcomes of hospital admissions among frail older people: a 2-year cohort study","authors":"Eilís Keeble, H. Roberts, Christopher Williams, J. V. van Oppen, S. Conroy","doi":"10.3399/bjgp19X704621","DOIUrl":"https://doi.org/10.3399/bjgp19X704621","url":null,"abstract":"Background ‘Frailty crises’ are a common cause of hospital admission among older people and there is significant focus on admission avoidance. However, identifying frailty before a crisis occurs is challenging, making it difficult to effectively target community services. Better longer-term outcome data are needed if services are to reflect the needs of the growing population of older people with frailty. Aim To determine long-term outcomes of older people discharged from hospital following short (<72 hours) and longer hospital admissions compared by frailty status. Design and setting Two populations aged ≥70 years discharged from hospital units: those following short ‘ambulatory’ admissions (<72 hours) and those following longer inpatient stays. Method Data for 2-year mortality and hospital use were compared using frailty measures derived from clinical and hospital data. Results Mortality after 2 years was increased for frail compared with non-frail individuals in both cohorts. Patients in the ambulatory cohort classified as frail had increased mortality (Rockwood hazard ratio 2.3 [95% confidence interval {CI} = 1.5 to 3.4]) and hospital use (Rockwood rate ratio 2.1 [95% CI = 1.7 to 2.6]) compared with those patients classified as non-frail. Conclusion Individuals with frailty who are discharged from hospital experience increased mortality and resource use, even after short ‘ambulatory’ admissions. This is an easily identifiable group that is at increased risk of poor outcomes. Health and social care systems might wish to examine their current care response for frail older people discharged from hospital. There may be value in a ‘secondary prevention’ approach to frailty crises targeting individuals who are discharged from hospital.","PeriodicalId":22333,"journal":{"name":"The British Journal of General Practice","volume":"56 1","pages":"e555 - e560"},"PeriodicalIF":0.0,"publicationDate":"2019-07-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"91081124","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. Nicholson, A. Terry, M. Fortin, T. Williamson, Michael A Bauer, A. Thind
Background Multimorbidity is a complex issue in modern medicine and a more nuanced understanding of how this phenomenon occurs over time is needed. Aim To determine the prevalence, characteristics, and patterns of patients living with multimorbidity, specifically the unique combinations (unordered patterns) and unique permutations (ordered patterns) of multimorbidity in primary care. Design and setting A retrospective cohort analysis of the prospectively collected data from 1990 to 2013 from the Canadian Primary Care Sentinel Surveillance Network electronic medical record database. Method Adult primary care patients who were aged ≥18 years at their first recorded encounter were followed over time. A list of 20 chronic condition categories was used to detect multimorbidity. Computational analyses were conducted using the Multimorbidity Cluster Analysis Tool to identify all combinations and permutations. Results Multimorbidity, defined as two or more and three or more chronic conditions, was prevalent among adult primary care patients and most of these patients were aged <65 years. Among female patients with two or more chronic conditions, 6075 combinations and 14 891 permutations were detected. Among male patients with three or more chronic conditions, 4296 combinations and 9716 permutations were detected. While specific patterns were identified, combinations and permutations became increasingly rare as the total number of chronic conditions and patient age increased. Conclusion This research confirms that multimorbidity is common in primary care and provides empirical evidence that clinical management requires a tailored, patient-centred approach. While the prevalence of multimorbidity was found to increase with increasing patient age, the largest proportion of patients with multimorbidity in this study were aged <65 years.
{"title":"Prevalence, characteristics, and patterns of patients with multimorbidity in primary care: a retrospective cohort analysis in Canada","authors":"K. Nicholson, A. Terry, M. Fortin, T. Williamson, Michael A Bauer, A. Thind","doi":"10.3399/bjgp19X704657","DOIUrl":"https://doi.org/10.3399/bjgp19X704657","url":null,"abstract":"Background Multimorbidity is a complex issue in modern medicine and a more nuanced understanding of how this phenomenon occurs over time is needed. Aim To determine the prevalence, characteristics, and patterns of patients living with multimorbidity, specifically the unique combinations (unordered patterns) and unique permutations (ordered patterns) of multimorbidity in primary care. Design and setting A retrospective cohort analysis of the prospectively collected data from 1990 to 2013 from the Canadian Primary Care Sentinel Surveillance Network electronic medical record database. Method Adult primary care patients who were aged ≥18 years at their first recorded encounter were followed over time. A list of 20 chronic condition categories was used to detect multimorbidity. Computational analyses were conducted using the Multimorbidity Cluster Analysis Tool to identify all combinations and permutations. Results Multimorbidity, defined as two or more and three or more chronic conditions, was prevalent among adult primary care patients and most of these patients were aged <65 years. Among female patients with two or more chronic conditions, 6075 combinations and 14 891 permutations were detected. Among male patients with three or more chronic conditions, 4296 combinations and 9716 permutations were detected. While specific patterns were identified, combinations and permutations became increasingly rare as the total number of chronic conditions and patient age increased. Conclusion This research confirms that multimorbidity is common in primary care and provides empirical evidence that clinical management requires a tailored, patient-centred approach. While the prevalence of multimorbidity was found to increase with increasing patient age, the largest proportion of patients with multimorbidity in this study were aged <65 years.","PeriodicalId":22333,"journal":{"name":"The British Journal of General Practice","volume":"16 1","pages":"e647 - e656"},"PeriodicalIF":0.0,"publicationDate":"2019-07-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"84698975","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}
Jessica Drinkwater, N. Stanley, E. Szilassy, C. Larkins, M. Hester, G. Feder
Background Domestic violence and abuse (DVA) and child safeguarding are interlinked problems, impacting on all family members. Documenting in electronic patient records (EPRs) is an important part of managing these families. Current evidence and guidance, however, treats DVA and child safeguarding separately. This does not reflect the complexity clinicians face when documenting both issues in one family. Aim To explore how and why general practice clinicians document DVA in families with children. Design and setting A qualitative interview study using vignettes with GPs and practice nurses (PNs) in England. Method Semi-structured telephone interviews with 54 clinicians (42 GPs and 12 PNs) were conducted across six sites in England. Data were analysed thematically using a coding frame incorporating concepts from the literature and emerging themes. Results Most clinicians recognised DVA and its impact on child safeguarding, but struggled to work out the best way to document it. They described tensions among the different roles of the EPR: a legal document; providing continuity of care; information sharing to improve safety; and a patient-owned record. This led to strategies to hide information, so that it was only available to other clinicians. Conclusion Managing DVA in families with children is complex and challenging for general practice clinicians. National integrated guidance is urgently needed regarding how clinicians should manage the competing roles of the EPR, while maintaining safety of the whole family, especially in the context of online EPRs and patient access.
{"title":"Juggling confidentiality and safety: a qualitative study of how general practice clinicians document domestic violence in families with children","authors":"Jessica Drinkwater, N. Stanley, E. Szilassy, C. Larkins, M. Hester, G. Feder","doi":"10.3399/bjgp17X689353","DOIUrl":"https://doi.org/10.3399/bjgp17X689353","url":null,"abstract":"Background Domestic violence and abuse (DVA) and child safeguarding are interlinked problems, impacting on all family members. Documenting in electronic patient records (EPRs) is an important part of managing these families. Current evidence and guidance, however, treats DVA and child safeguarding separately. This does not reflect the complexity clinicians face when documenting both issues in one family. Aim To explore how and why general practice clinicians document DVA in families with children. Design and setting A qualitative interview study using vignettes with GPs and practice nurses (PNs) in England. Method Semi-structured telephone interviews with 54 clinicians (42 GPs and 12 PNs) were conducted across six sites in England. Data were analysed thematically using a coding frame incorporating concepts from the literature and emerging themes. Results Most clinicians recognised DVA and its impact on child safeguarding, but struggled to work out the best way to document it. They described tensions among the different roles of the EPR: a legal document; providing continuity of care; information sharing to improve safety; and a patient-owned record. This led to strategies to hide information, so that it was only available to other clinicians. Conclusion Managing DVA in families with children is complex and challenging for general practice clinicians. National integrated guidance is urgently needed regarding how clinicians should manage the competing roles of the EPR, while maintaining safety of the whole family, especially in the context of online EPRs and patient access.","PeriodicalId":22333,"journal":{"name":"The British Journal of General Practice","volume":"1 1","pages":"e437 - e444"},"PeriodicalIF":0.0,"publicationDate":"2017-01-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"83754463","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}
O. Kostopoulou, Talya Porat, Derek Corrigan, Samhar Mahmoud, B. Delaney
Background Observational and experimental studies of the diagnostic task have demonstrated the importance of the first hypotheses that come to mind for accurate diagnosis. A prototype decision support system (DSS) designed to support GPs’ first impressions has been integrated with a commercial electronic health record (EHR) system. Aim To evaluate the prototype DSS in a high-fidelity simulation. Design and setting Within-participant design: 34 GPs consulted with six standardised patients (actors) using their usual EHR. On a different day, GPs used the EHR with the integrated DSS to consult with six other patients, matched for difficulty and counterbalanced. Method Entering the reason for encounter triggered the DSS, which provided a patient-specific list of potential diagnoses, and supported coding of symptoms during the consultation. At each consultation, GPs recorded their diagnosis and management. At the end, they completed a usability questionnaire. The actors completed a satisfaction questionnaire after each consultation. Results There was an 8–9% absolute improvement in diagnostic accuracy when the DSS was used. This improvement was significant (odds ratio [OR] 1.41, 95% confidence interval [CI] = 1.13 to 1.77, P<0.01). There was no associated increase of investigations ordered or consultation length. GPs coded significantly more data when using the DSS (mean 12.35 with the DSS versus 1.64 without), and were generally satisfied with its usability. Patient satisfaction ratings were the same for consultations with and without the DSS. Conclusion The DSS prototype was successfully employed in simulated consultations of high fidelity, with no measurable influences on patient satisfaction. The substantially increased data coding can operate as motivation for future DSS adoption.
{"title":"Diagnostic accuracy of GPs when using an early-intervention decision support system: a high-fidelity simulation","authors":"O. Kostopoulou, Talya Porat, Derek Corrigan, Samhar Mahmoud, B. Delaney","doi":"10.3399/bjgp16X688417","DOIUrl":"https://doi.org/10.3399/bjgp16X688417","url":null,"abstract":"Background Observational and experimental studies of the diagnostic task have demonstrated the importance of the first hypotheses that come to mind for accurate diagnosis. A prototype decision support system (DSS) designed to support GPs’ first impressions has been integrated with a commercial electronic health record (EHR) system. Aim To evaluate the prototype DSS in a high-fidelity simulation. Design and setting Within-participant design: 34 GPs consulted with six standardised patients (actors) using their usual EHR. On a different day, GPs used the EHR with the integrated DSS to consult with six other patients, matched for difficulty and counterbalanced. Method Entering the reason for encounter triggered the DSS, which provided a patient-specific list of potential diagnoses, and supported coding of symptoms during the consultation. At each consultation, GPs recorded their diagnosis and management. At the end, they completed a usability questionnaire. The actors completed a satisfaction questionnaire after each consultation. Results There was an 8–9% absolute improvement in diagnostic accuracy when the DSS was used. This improvement was significant (odds ratio [OR] 1.41, 95% confidence interval [CI] = 1.13 to 1.77, P<0.01). There was no associated increase of investigations ordered or consultation length. GPs coded significantly more data when using the DSS (mean 12.35 with the DSS versus 1.64 without), and were generally satisfied with its usability. Patient satisfaction ratings were the same for consultations with and without the DSS. Conclusion The DSS prototype was successfully employed in simulated consultations of high fidelity, with no measurable influences on patient satisfaction. The substantially increased data coding can operate as motivation for future DSS adoption.","PeriodicalId":22333,"journal":{"name":"The British Journal of General Practice","volume":"81 1","pages":"e201 - e208"},"PeriodicalIF":0.0,"publicationDate":"2017-01-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"78991045","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}
Jane Davies, Jonathan Richards, K. Conway, J. Kenkre, J. Lewis, E. Mark Williams
Background Early identification of peripheral arterial disease (PAD) and subsequent instigation of risk modification strategies could minimise disease progression and reduce overall risk of cardiovascular (CV) mortality. However, the feasibility and value of primary care PAD screening is uncertain. Aim This study (the PIPETTE study — Peripheral arterial disease In Primary carE: Targeted screening and subsequenT managEment) aimed to determine the value of a proposed primary care PAD screening strategy. Outcomes assessed were: prevalence of PAD and agreement of ankle– brachial index (ABI)-defined PAD (ABI ≤0.9) with QRISK®2-defined high CV risk (≥20). Design and setting A cross-sectional observational study was undertaken in a large general practice in Merthyr Tydfil, Wales. Method In total, 1101 individuals with ≥2 pre-identified CV risk factors but no known CV disease or diabetes were invited to participate. Participants underwent ABI measurement and QRISK2 assessment, and completed Edinburgh Claudication Questionnaires. Results A total of 368 people participated in the study (participation rate: 33%). Prevalence of PAD was 3% (n = 12). The number needed to screen (NNS) to detect one new case of PAD was 31. Refining the study population to those aged ≥50 years with a smoking history reduced the NNS to 14, while still identifying 100% of PAD cases. Of participants with PAD, 33% reported severe lifestyle-limiting symptoms of intermittent claudication that warranted subsequent endovascular intervention, yet had not previously presented to their GP. The QRISK2 score predicted high CV risk in 92% of participants with PAD. Conclusion The low PAD yield and the fact that QRISK2 was largely comparable to the ABI in predicting high CV risk suggests that routine PAD screening may be unwarranted. Instead, strategies to improve public awareness of PAD are needed.
{"title":"Primary care screening for peripheral arterial disease: a cross-sectional observational study","authors":"Jane Davies, Jonathan Richards, K. Conway, J. Kenkre, J. Lewis, E. Mark Williams","doi":"10.3399/bjgp17X689137","DOIUrl":"https://doi.org/10.3399/bjgp17X689137","url":null,"abstract":"Background Early identification of peripheral arterial disease (PAD) and subsequent instigation of risk modification strategies could minimise disease progression and reduce overall risk of cardiovascular (CV) mortality. However, the feasibility and value of primary care PAD screening is uncertain. Aim This study (the PIPETTE study — Peripheral arterial disease In Primary carE: Targeted screening and subsequenT managEment) aimed to determine the value of a proposed primary care PAD screening strategy. Outcomes assessed were: prevalence of PAD and agreement of ankle– brachial index (ABI)-defined PAD (ABI ≤0.9) with QRISK®2-defined high CV risk (≥20). Design and setting A cross-sectional observational study was undertaken in a large general practice in Merthyr Tydfil, Wales. Method In total, 1101 individuals with ≥2 pre-identified CV risk factors but no known CV disease or diabetes were invited to participate. Participants underwent ABI measurement and QRISK2 assessment, and completed Edinburgh Claudication Questionnaires. Results A total of 368 people participated in the study (participation rate: 33%). Prevalence of PAD was 3% (n = 12). The number needed to screen (NNS) to detect one new case of PAD was 31. Refining the study population to those aged ≥50 years with a smoking history reduced the NNS to 14, while still identifying 100% of PAD cases. Of participants with PAD, 33% reported severe lifestyle-limiting symptoms of intermittent claudication that warranted subsequent endovascular intervention, yet had not previously presented to their GP. The QRISK2 score predicted high CV risk in 92% of participants with PAD. Conclusion The low PAD yield and the fact that QRISK2 was largely comparable to the ABI in predicting high CV risk suggests that routine PAD screening may be unwarranted. Instead, strategies to improve public awareness of PAD are needed.","PeriodicalId":22333,"journal":{"name":"The British Journal of General Practice","volume":"136 1","pages":"e103 - e110"},"PeriodicalIF":0.0,"publicationDate":"2017-01-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"83523705","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}
N. Heron, F. Kee, C. Cardwell, M. Tully, M. Donnelly, M. Cupples
Background Strokes are often preceded by a transient ischaemic attack (TIA) or ‘minor’ stroke. The immediate period after a TIA/minor stroke is a crucial time to initiate secondary prevention. However, the optimal approach to prevention, including non-pharmacological measures, after TIA is not clear. Aim To systematically review evidence about the effectiveness of delivering secondary prevention, with lifestyle interventions, in comprehensive rehabilitation programmes, initiated within 90 days of a TIA/minor stroke. Also, to categorise the specific behaviour change techniques used. Design and setting The review identified randomised controlled trials by searching the Cochrane Library, Ovid MEDLINE, Ovid EMBASE, Web of Science, EBSCO CINAHL and Ovid PsycINFO. Method Two review authors independently screened titles and abstracts for eligibility (programmes initiated within 90 days of event; outcomes reported for TIA/minor stroke) and extracted relevant data from appraised studies; a meta-analysis was used to synthesise the results. Results A total of 31 potentially eligible papers were identified and four studies, comprising 774 patients post-TIA or minor stroke, met the inclusion criteria; two had poor methodological quality. Individual studies reported increased aerobic capacity but meta-analysis found no significant change in resting and peak systolic blood pressure, resting heart rate, aerobic capacity, falls, or mortality. The main behaviour change techniques were goal setting and instructions about how to perform given behaviours. Conclusion There is limited evidence of the effectiveness of early post-TIA rehabilitation programmes with preventive lifestyle interventions. Further robust randomised controlled trials of comprehensive rehabilitation programmes that promote secondary prevention and lifestyle modification immediately after a TIA are needed.
中风通常发生在短暂性脑缺血发作(TIA)或“轻微”中风之前。短暂性脑缺血发作/轻微中风后的一段时间是开始二级预防的关键时间。然而，TIA后的最佳预防方法，包括非药物措施尚不清楚。目的系统地回顾在TIA/轻微卒中后90天内开始的综合康复规划中提供二级预防和生活方式干预的有效性证据。此外，对所使用的具体行为改变技术进行分类。本综述通过检索Cochrane Library、Ovid MEDLINE、Ovid EMBASE、Web of Science、EBSCO CINAHL和Ovid PsycINFO来确定随机对照试验。方法两位综述作者独立筛选标题和摘要的合格性(事件90天内启动的方案;报告TIA/轻微卒中的结果)，并从评价研究中提取相关数据;荟萃分析用于综合结果。结果共纳入31篇可能符合纳入标准的论文，其中4项研究，包括774例tia后或轻微卒中患者，符合纳入标准;其中两个研究方法质量较差。个别研究报告了有氧能力的增加，但荟萃分析发现静息和峰值收缩压、静息心率、有氧能力、跌倒或死亡率没有显著变化。主要的行为改变技巧是设定目标和指导如何执行给定的行为。结论:tia后早期康复方案与预防性生活方式干预的有效性证据有限。需要进一步开展全面康复规划的可靠随机对照试验，以促进TIA后的二级预防和生活方式改变。
{"title":"Secondary prevention lifestyle interventions initiated within 90 days after TIA or ‘minor’ stroke: a systematic review and meta-analysis of rehabilitation programmes","authors":"N. Heron, F. Kee, C. Cardwell, M. Tully, M. Donnelly, M. Cupples","doi":"10.3399/bjgp16X688369","DOIUrl":"https://doi.org/10.3399/bjgp16X688369","url":null,"abstract":"Background Strokes are often preceded by a transient ischaemic attack (TIA) or ‘minor’ stroke. The immediate period after a TIA/minor stroke is a crucial time to initiate secondary prevention. However, the optimal approach to prevention, including non-pharmacological measures, after TIA is not clear. Aim To systematically review evidence about the effectiveness of delivering secondary prevention, with lifestyle interventions, in comprehensive rehabilitation programmes, initiated within 90 days of a TIA/minor stroke. Also, to categorise the specific behaviour change techniques used. Design and setting The review identified randomised controlled trials by searching the Cochrane Library, Ovid MEDLINE, Ovid EMBASE, Web of Science, EBSCO CINAHL and Ovid PsycINFO. Method Two review authors independently screened titles and abstracts for eligibility (programmes initiated within 90 days of event; outcomes reported for TIA/minor stroke) and extracted relevant data from appraised studies; a meta-analysis was used to synthesise the results. Results A total of 31 potentially eligible papers were identified and four studies, comprising 774 patients post-TIA or minor stroke, met the inclusion criteria; two had poor methodological quality. Individual studies reported increased aerobic capacity but meta-analysis found no significant change in resting and peak systolic blood pressure, resting heart rate, aerobic capacity, falls, or mortality. The main behaviour change techniques were goal setting and instructions about how to perform given behaviours. Conclusion There is limited evidence of the effectiveness of early post-TIA rehabilitation programmes with preventive lifestyle interventions. Further robust randomised controlled trials of comprehensive rehabilitation programmes that promote secondary prevention and lifestyle modification immediately after a TIA are needed.","PeriodicalId":22333,"journal":{"name":"The British Journal of General Practice","volume":"25 1","pages":"e57 - e66"},"PeriodicalIF":0.0,"publicationDate":"2016-12-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"81343437","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}
Next month will see the launch of BJGP Open , our new open access, online-only journal of primary care research, practice, and policy. BJGP Open will have original, high-quality, peer-reviewed primary care research at its core, complemented by case studies, clinical reports, policy analysis, and the opportunity for discussion and debate. For some time we have been aware that the BJGP receives far more high quality original material that it can publish: less than one in four research articles is accepted, pressure on the non-research sections of the Journal is intense, and many of the research articles that we decline are of good scientific quality. The same goes for articles submitted to other sections of the Journal. Primary care everywhere needs to continue to build an evidence base for health care and clinical practice, and to continue to make its political and health policy arguments …
{"title":"BJGP Open: a new, online-only, open access journal","authors":"Roger B. Jones, Euan Lawson","doi":"10.3399/bjgp16X688033","DOIUrl":"https://doi.org/10.3399/bjgp16X688033","url":null,"abstract":"Next month will see the launch of BJGP Open , our new open access, online-only journal of primary care research, practice, and policy. BJGP Open will have original, high-quality, peer-reviewed primary care research at its core, complemented by case studies, clinical reports, policy analysis, and the opportunity for discussion and debate.\u0000\u0000For some time we have been aware that the BJGP receives far more high quality original material that it can publish: less than one in four research articles is accepted, pressure on the non-research sections of the Journal is intense, and many of the research articles that we decline are of good scientific quality. The same goes for articles submitted to other sections of the Journal. Primary care everywhere needs to continue to build an evidence base for health care and clinical practice, and to continue to make its political and health policy arguments …","PeriodicalId":22333,"journal":{"name":"The British Journal of General Practice","volume":"83 1","pages":"603 - 603"},"PeriodicalIF":0.0,"publicationDate":"2016-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"79334470","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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