Natasha Elmore, J. Burt, G. Abel, F. Maratos, J. Montague, John L Campbell, M. Roland
Background Longer consultations in primary care have been linked with better quality of care and improved health-related outcomes. However, there is little evidence of any potential association between consultation length and patient experience. Aim To examine the relationship between consultation length and patient-reported communication, trust and confidence in the doctor, and overall satisfaction. Design and setting Analysis of 440 videorecorded consultations and associated patient experience questionnaires from 13 primary care practices in England. Method Patients attending a face-to-face consultation with participating GPs consented to having their consultations videoed and completed a questionnaire. Consultation length was calculated from the videorecording. Linear regression (adjusting for patient and doctor demographics) was used to investigate associations between patient experience (overall communication, trust and confidence, and overall satisfaction) and consultation length. Results There was no evidence that consultation length was associated with any of the three measures of patient experience (P >0.3 for all). Adjusted changes on a 0–100 scale per additional minute of consultation were: communication score 0.02 (95% confidence interval [CI] = −0.20 to 0.25), trust and confidence in the doctor 0.07 (95% CI = −0.27 to 0.41), and satisfaction −0.14 (95% CI = −0.46 to 0.18). Conclusion The authors found no association between patient experience measures of communication and consultation length, and patients may sometimes report good experiences from very short consultations. However, longer consultations may be required to achieve clinical effectiveness and patient safety: aspects also important for achieving high quality of care. Future research should continue to study the benefits of longer consultations, particularly for patients with complex multiple conditions.
背景:较长的初级保健咨询与更好的护理质量和改善的健康相关结果有关。然而，几乎没有证据表明会诊时间和患者经验之间有任何潜在的联系。目的探讨会诊时间与患者报告沟通、对医生的信任和信心以及总体满意度之间的关系。设计与设置分析了英国13个初级保健实践的440个视频咨询记录和相关的患者体验问卷。方法与参与会诊的全科医生面对面会诊的患者同意进行会诊录像并填写问卷。会诊时间根据录像计算。使用线性回归(调整患者和医生的人口统计数据)来调查患者体验(总体沟通、信任和信心以及总体满意度)与咨询时间之间的关系。结果:没有证据表明会诊时间与患者体验的三种测量方法中的任何一种都相关(P >0.3)。在0-100量表上，每增加一分钟会诊的调整变化为:沟通得分0.02(95%置信区间[CI] = - 0.20至0.25)，对医生的信任和信心0.07 (95% CI = - 0.27至0.41)，满意度- 0.14 (95% CI = - 0.46至0.18)。结论:作者发现患者体验的沟通措施与会诊时间之间没有关联，患者有时可能会在很短的会诊中报告良好的体验。然而，为了达到临床效果和患者安全，可能需要更长时间的会诊，这些方面对于实现高质量的护理也很重要。未来的研究应该继续研究长时间咨询的好处，特别是对患有复杂多种疾病的患者。
{"title":"Investigating the relationship between consultation length and patient experience: a cross-sectional study in primary care","authors":"Natasha Elmore, J. Burt, G. Abel, F. Maratos, J. Montague, John L Campbell, M. Roland","doi":"10.3399/bjgp16X687733","DOIUrl":"https://doi.org/10.3399/bjgp16X687733","url":null,"abstract":"Background Longer consultations in primary care have been linked with better quality of care and improved health-related outcomes. However, there is little evidence of any potential association between consultation length and patient experience. Aim To examine the relationship between consultation length and patient-reported communication, trust and confidence in the doctor, and overall satisfaction. Design and setting Analysis of 440 videorecorded consultations and associated patient experience questionnaires from 13 primary care practices in England. Method Patients attending a face-to-face consultation with participating GPs consented to having their consultations videoed and completed a questionnaire. Consultation length was calculated from the videorecording. Linear regression (adjusting for patient and doctor demographics) was used to investigate associations between patient experience (overall communication, trust and confidence, and overall satisfaction) and consultation length. Results There was no evidence that consultation length was associated with any of the three measures of patient experience (P >0.3 for all). Adjusted changes on a 0–100 scale per additional minute of consultation were: communication score 0.02 (95% confidence interval [CI] = −0.20 to 0.25), trust and confidence in the doctor 0.07 (95% CI = −0.27 to 0.41), and satisfaction −0.14 (95% CI = −0.46 to 0.18). Conclusion The authors found no association between patient experience measures of communication and consultation length, and patients may sometimes report good experiences from very short consultations. However, longer consultations may be required to achieve clinical effectiveness and patient safety: aspects also important for achieving high quality of care. Future research should continue to study the benefits of longer consultations, particularly for patients with complex multiple conditions.","PeriodicalId":22333,"journal":{"name":"The British Journal of General Practice","volume":"5 1","pages":"e896 - e903"},"PeriodicalIF":0.0,"publicationDate":"2016-10-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"80144139","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}
J. Kai, L. Middleton, J. Daniels, H. Pattison, K. Tryposkiadis, J. Gupta
Background Heavy menstrual bleeding (HMB) is a common, chronic problem affecting women and health services. However, long-term evidence on treatment in primary care is lacking. Aim To assess the effectiveness of commencing the levonorgestrel-releasing intrauterine system (LNG-IUS) or usual medical treatments for women presenting with HMB in general practice. Design and setting A pragmatic, multicentre, parallel, open-label, long term, randomised controlled trial in 63 primary care practices across the English Midlands. Method In total, 571 women aged 25–50 years, with HMB were randomised to LNG-IUS or usual medical treatment (tranexamic/mefenamic acid, combined oestrogen–progestogen, or progesterone alone). The primary outcome was the patient reported Menorrhagia Multi-Attribute Scale (MMAS, measuring effect of HMB on practical difficulties, social life, psychological and physical health, and work and family life; scores from 0 to 100). Secondary outcomes included surgical intervention (endometrial ablation/hysterectomy), general quality of life, sexual activity, and safety. Results At 5 years post-randomisation, 424 (74%) women provided data. While the difference between LNG-IUS and usual treatment groups was not significant (3.9 points; 95% confidence interval = −0.6 to 8.3; P = 0.09), MMAS scores improved significantly in both groups from baseline (mean increase, 44.9 and 43.4 points, respectively; P<0.001 for both comparisons). Rates of surgical intervention were low in both groups (surgery-free survival was 80% and 77%; hazard ratio 0.90; 95% CI = 0.62 to 1.31; P = 0.6). There was no difference in generic quality of life, sexual activity scores, or serious adverse events. Conclusion Large improvements in symptom relief across both groups show treatment for HMB can be successfully initiated with long-term benefit and with only modest need for surgery.
{"title":"Usual medical treatments or levonorgestrel-IUS for women with heavy menstrual bleeding: long-term randomised pragmatic trial in primary care","authors":"J. Kai, L. Middleton, J. Daniels, H. Pattison, K. Tryposkiadis, J. Gupta","doi":"10.3399/bjgp16X687577","DOIUrl":"https://doi.org/10.3399/bjgp16X687577","url":null,"abstract":"Background Heavy menstrual bleeding (HMB) is a common, chronic problem affecting women and health services. However, long-term evidence on treatment in primary care is lacking. Aim To assess the effectiveness of commencing the levonorgestrel-releasing intrauterine system (LNG-IUS) or usual medical treatments for women presenting with HMB in general practice. Design and setting A pragmatic, multicentre, parallel, open-label, long term, randomised controlled trial in 63 primary care practices across the English Midlands. Method In total, 571 women aged 25–50 years, with HMB were randomised to LNG-IUS or usual medical treatment (tranexamic/mefenamic acid, combined oestrogen–progestogen, or progesterone alone). The primary outcome was the patient reported Menorrhagia Multi-Attribute Scale (MMAS, measuring effect of HMB on practical difficulties, social life, psychological and physical health, and work and family life; scores from 0 to 100). Secondary outcomes included surgical intervention (endometrial ablation/hysterectomy), general quality of life, sexual activity, and safety. Results At 5 years post-randomisation, 424 (74%) women provided data. While the difference between LNG-IUS and usual treatment groups was not significant (3.9 points; 95% confidence interval = −0.6 to 8.3; P = 0.09), MMAS scores improved significantly in both groups from baseline (mean increase, 44.9 and 43.4 points, respectively; P<0.001 for both comparisons). Rates of surgical intervention were low in both groups (surgery-free survival was 80% and 77%; hazard ratio 0.90; 95% CI = 0.62 to 1.31; P = 0.6). There was no difference in generic quality of life, sexual activity scores, or serious adverse events. Conclusion Large improvements in symptom relief across both groups show treatment for HMB can be successfully initiated with long-term benefit and with only modest need for surgery.","PeriodicalId":22333,"journal":{"name":"The British Journal of General Practice","volume":"76 1","pages":"e861 - e870"},"PeriodicalIF":0.0,"publicationDate":"2016-10-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"89829010","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}
Doireann O’Brien, K. Harvey, Jessica Howse, Tessa Reardon, C. Creswell
Background Mental health problems are common and typically have an early onset. Effective treatments for mental health problems in childhood and adolescence are available, yet only a minority of children who are affected access them. This is of serious concern, considering the far-reaching and long-term negative consequences of such problems. Primary care is usually the first port of call for concerned parents so it is important to understand how primary care practitioners manage child and adolescent mental health problems and the barriers they face. Aim To ascertain primary care practitioners’ perceptions of the barriers that prevent effective management of child and adolescent mental health problems. Design and setting A systematic review of qualitative and quantitative literature in a primary care setting. Method A database search of peer-reviewed articles using PsycINFO, MEDLINE®, Embase, and Web of Science, from inception (earliest 1806) until October 2014, was conducted. Additional studies were identified through hand searches and forward-citation searches. Studies needed to have at least one search term in four categories: primary care, childhood/adolescence, mental health, and barriers. Results A total of 4151 articles were identified, of which 43 were included (30 quantitative studies and 13 qualitative studies). The majority of the barriers related to identification, management, and/or referral. Considerable barriers included a lack of providers and resources, extensive waiting lists, and financial restrictions. Conclusion The identification of a broad range of significant barriers highlights the need to strengthen the ability to deal with these common difficulties in primary care. There is a particular need for tools and training to aid accurate identification and management, and for more efficient access to specialist services.
心理健康问题很常见，而且通常早发。儿童和青少年的心理健康问题可以得到有效治疗，但只有少数受影响的儿童能够获得治疗。考虑到这些问题的深远和长期的消极后果，这是令人严重关切的。初级保健通常是关心的父母的第一站，因此了解初级保健从业人员如何管理儿童和青少年心理健康问题及其面临的障碍是很重要的。目的了解初级保健从业人员对儿童和青少年心理健康问题有效管理障碍的认识。设计和设置对初级保健设置的定性和定量文献进行系统回顾。方法使用PsycINFO、MEDLINE®、Embase和Web of Science数据库检索自创立(最早1806年)至2014年10月的同行评议文章。通过手工检索和引文前移检索确定了其他研究。研究需要在以下四个类别中至少有一个搜索词:初级保健、儿童/青少年、心理健康和障碍。结果共纳入文献4151篇，其中纳入文献43篇(定量研究30篇，定性研究13篇)。大多数障碍与识别、管理和/或转诊有关。相当大的障碍包括缺乏提供者和资源、大量的等待名单和财政限制。结论广泛的重大障碍的识别突出了需要加强处理这些初级保健常见困难的能力。特别需要工具和培训，以帮助准确识别和管理，并更有效地获得专门服务。
{"title":"Barriers to managing child and adolescent mental health problems: a systematic review of primary care practitioners’ perceptions","authors":"Doireann O’Brien, K. Harvey, Jessica Howse, Tessa Reardon, C. Creswell","doi":"10.3399/bjgp16X687061","DOIUrl":"https://doi.org/10.3399/bjgp16X687061","url":null,"abstract":"Background Mental health problems are common and typically have an early onset. Effective treatments for mental health problems in childhood and adolescence are available, yet only a minority of children who are affected access them. This is of serious concern, considering the far-reaching and long-term negative consequences of such problems. Primary care is usually the first port of call for concerned parents so it is important to understand how primary care practitioners manage child and adolescent mental health problems and the barriers they face. Aim To ascertain primary care practitioners’ perceptions of the barriers that prevent effective management of child and adolescent mental health problems. Design and setting A systematic review of qualitative and quantitative literature in a primary care setting. Method A database search of peer-reviewed articles using PsycINFO, MEDLINE®, Embase, and Web of Science, from inception (earliest 1806) until October 2014, was conducted. Additional studies were identified through hand searches and forward-citation searches. Studies needed to have at least one search term in four categories: primary care, childhood/adolescence, mental health, and barriers. Results A total of 4151 articles were identified, of which 43 were included (30 quantitative studies and 13 qualitative studies). The majority of the barriers related to identification, management, and/or referral. Considerable barriers included a lack of providers and resources, extensive waiting lists, and financial restrictions. Conclusion The identification of a broad range of significant barriers highlights the need to strengthen the ability to deal with these common difficulties in primary care. There is a particular need for tools and training to aid accurate identification and management, and for more efficient access to specialist services.","PeriodicalId":22333,"journal":{"name":"The British Journal of General Practice","volume":"1 1","pages":"e693 - e707"},"PeriodicalIF":0.0,"publicationDate":"2016-09-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"90359293","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}
I. Gágyor, J. Haasenritter, J. Bleidorn, W. McIsaac, G. Schmiemann, E. Hummers-Pradier, W. Himmel
Background Uncomplicated urinary tract infection (UTI) is often treated with antibiotics, resulting in increasing resistance levels. A randomised controlled trial showed that two-thirds of females with UTI treated symptomatically recovered without subsequent antibiotic treatment. Aim To investigate whether there are differences between females with a UTI who were subsequently prescribed antibiotics and those who recovered with symptomatic treatment only, and to develop a model to predict those who can safely and effectively be treated symptomatically. Design and setting This is a subgroup analysis of females assigned to ibuprofen in a UTI trial in general practices. Method Multiple logistic regression analysis was used to select variables for a prediction model, The discriminative value of the model was estimated by the area under the receiver operator curve (AUC) and the effects of different thresholds were calculated within the model predicting antibiotic prescription and need for follow-up visits. Results Of the 235 females in the ibuprofen group, 79 were subsequently prescribed antibiotics within 28 days of follow-up. The final model included five predictors: urgency/frequency, impaired daily activities, and positive dipstick test results for erythrocytes, leucocytes, and nitrite. The AUC was 0.73 (95% CI = 0.67 to 0.80). A reasonable threshold for antibiotic initiation would result in 58% of females presenting with UTI being treated with antibiotics. Of the remaining females, only 6% would return to the practice because of symptomatic treatment failure. Conclusion The present model revealed moderately good accuracy and could be the basis for a decision aid for GPs and females to find the treatment option that fits best.
背景:非复杂性尿路感染(UTI)通常使用抗生素治疗，导致耐药性水平上升。一项随机对照试验显示，经对症治疗的女性尿路感染患者中，有三分之二在没有后续抗生素治疗的情况下康复。目的探讨感染尿路感染的女性患者在接受抗生素治疗后与仅对症治疗后是否存在差异，并建立一个模型来预测哪些女性患者能够安全有效地接受对症治疗。设计和背景:这是一项在普通实践中分配使用布洛芬的女性尿路感染试验的亚组分析。方法采用多元logistic回归分析方法选择预测模型的变量，通过接受算子曲线下面积(AUC)估计模型的判别值，并在预测抗生素处方和随访需求的模型内计算不同阈值的影响。结果布洛芬组235例女性患者中，79例在随访28天内开抗生素。最终的模型包括五个预测因素:急迫性/频率、日常活动受损、红细胞、白细胞和亚硝酸盐试纸试验阳性结果。AUC为0.73 (95% CI = 0.67 ~ 0.80)。合理的抗生素起始阈值将导致58%的女性尿路感染患者接受抗生素治疗。在剩下的女性中，只有6%的人会因为对症治疗失败而返回诊所。结论该模型具有较好的准确性，可为全科医生和女性寻找最适合的治疗方案提供决策辅助依据。
{"title":"Predicting antibiotic prescription after symptomatic treatment for urinary tract infection: development of a model using data from an RCT in general practice","authors":"I. Gágyor, J. Haasenritter, J. Bleidorn, W. McIsaac, G. Schmiemann, E. Hummers-Pradier, W. Himmel","doi":"10.3399/bjgp16X684361","DOIUrl":"https://doi.org/10.3399/bjgp16X684361","url":null,"abstract":"Background Uncomplicated urinary tract infection (UTI) is often treated with antibiotics, resulting in increasing resistance levels. A randomised controlled trial showed that two-thirds of females with UTI treated symptomatically recovered without subsequent antibiotic treatment. Aim To investigate whether there are differences between females with a UTI who were subsequently prescribed antibiotics and those who recovered with symptomatic treatment only, and to develop a model to predict those who can safely and effectively be treated symptomatically. Design and setting This is a subgroup analysis of females assigned to ibuprofen in a UTI trial in general practices. Method Multiple logistic regression analysis was used to select variables for a prediction model, The discriminative value of the model was estimated by the area under the receiver operator curve (AUC) and the effects of different thresholds were calculated within the model predicting antibiotic prescription and need for follow-up visits. Results Of the 235 females in the ibuprofen group, 79 were subsequently prescribed antibiotics within 28 days of follow-up. The final model included five predictors: urgency/frequency, impaired daily activities, and positive dipstick test results for erythrocytes, leucocytes, and nitrite. The AUC was 0.73 (95% CI = 0.67 to 0.80). A reasonable threshold for antibiotic initiation would result in 58% of females presenting with UTI being treated with antibiotics. Of the remaining females, only 6% would return to the practice because of symptomatic treatment failure. Conclusion The present model revealed moderately good accuracy and could be the basis for a decision aid for GPs and females to find the treatment option that fits best.","PeriodicalId":22333,"journal":{"name":"The British Journal of General Practice","volume":"33 1","pages":"e234 - e240"},"PeriodicalIF":0.0,"publicationDate":"2016-03-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"90429014","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}
Background Influenza is a significant cause of morbidity and excess mortality, yet vaccine coverage in the UK remains below target. Community pharmacies are increasingly being promoted as an alternative to vaccination by GPs. Aim To explore and verify the factors that influence the relative performance of pharmacies providing NHS influenza vaccinations. Design and setting A mixed methods study utilising qualitative, semi-structured interviews and quantitative analysis of predictors of vaccination numbers in community pharmacies in Wales. Method Interviews were conducted with 16 pharmacists who participated in the Welsh national pharmacy influenza service in 2013–2014. A purposive sampling strategy was used. Qualitative findings were analysed using framework analysis. Potential predictors of vaccination numbers were identified from interviews and a literature review, and included in a multivariable regression model. Results The contribution of community pharmacies towards vaccination in Wales is small. Findings suggest that community pharmacies reach younger at-risk individuals, in whom vaccine uptake is low, in greater proportion than influenza vaccination programmes as a whole. Extended opening hours and urban locations were positively associated with the number of vaccinations given, although pharmacists reported that workload, vaccine costs, unforeseen delays, lack of public awareness, and GPs’ views of the service limited their contribution. Pharmacists, aware of the potential for conflict with GPs, moderated their behaviour to mitigate such risk. Conclusion Before community pharmacies take greater responsibility for delivering healthcare services, obstacles including increasing pharmacist capacity, vaccine procurement, health service delays, managing GP–pharmacy relationships, and improving public awareness must be overcome.
{"title":"National community pharmacy NHS influenza vaccination service in Wales: a primary care mixed methods study","authors":"A. Evans, F. Wood, B. Carter","doi":"10.3399/bjgp16X684349","DOIUrl":"https://doi.org/10.3399/bjgp16X684349","url":null,"abstract":"Background Influenza is a significant cause of morbidity and excess mortality, yet vaccine coverage in the UK remains below target. Community pharmacies are increasingly being promoted as an alternative to vaccination by GPs. Aim To explore and verify the factors that influence the relative performance of pharmacies providing NHS influenza vaccinations. Design and setting A mixed methods study utilising qualitative, semi-structured interviews and quantitative analysis of predictors of vaccination numbers in community pharmacies in Wales. Method Interviews were conducted with 16 pharmacists who participated in the Welsh national pharmacy influenza service in 2013–2014. A purposive sampling strategy was used. Qualitative findings were analysed using framework analysis. Potential predictors of vaccination numbers were identified from interviews and a literature review, and included in a multivariable regression model. Results The contribution of community pharmacies towards vaccination in Wales is small. Findings suggest that community pharmacies reach younger at-risk individuals, in whom vaccine uptake is low, in greater proportion than influenza vaccination programmes as a whole. Extended opening hours and urban locations were positively associated with the number of vaccinations given, although pharmacists reported that workload, vaccine costs, unforeseen delays, lack of public awareness, and GPs’ views of the service limited their contribution. Pharmacists, aware of the potential for conflict with GPs, moderated their behaviour to mitigate such risk. Conclusion Before community pharmacies take greater responsibility for delivering healthcare services, obstacles including increasing pharmacist capacity, vaccine procurement, health service delays, managing GP–pharmacy relationships, and improving public awareness must be overcome.","PeriodicalId":22333,"journal":{"name":"The British Journal of General Practice","volume":"53 1","pages":"e248 - e257"},"PeriodicalIF":0.0,"publicationDate":"2016-03-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"82632205","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}
On 1 February 2016 the World Health Organization declared a Public Health Emergency of International Concern following reports of large clusters of microcephaly and Guillain-Barre Syndrome associated with an increase in cases of Zika virus (ZIKV) infection in French Polynesia (2014) and Brazil (2015– 2016).1 The Committee emphasised that there was ‘... no public health justification for restrictions on travel or trade’ and the main interventions were to control mosquito populations and prevent bites in pregnant women. Why has this happened and how might it affect patients attending primary care in the UK? ZIKV was first isolated from a Rhesus monkey in Uganda in 1947.2 The following year it was identified in Aedes mosquitoes, which differ from malaria-transmitting Anopheles mosquitoes by biting during the day. ZIKV has been found throughout Africa and South East Asia where infection is asymptomatic or produces a mild febrile illness and rash which goes undiagnosed. The first outbreak was not recorded until 2007 when three-quarters of the population of Yap Island in Micronesia became infected.3 The current epidemic of ZIKV infection began in early 2015 in northeastern Brazil. Since then ZIKV transmission has been confirmed in 35 countries.4 One theory is that ZIKV was carried to Brazil by infected Pacific Islanders visiting an international canoeing event in Rio de Janeiro in August 2014. In September 2015 clinicians working in Pernambuco state noticed an increase in newborn babies with microcephaly. The Ministry of Health quickly established a register and within 3 months recorded 4180 suspected cases, including 68 deaths, compared to a total of 147 reports in …
{"title":"Zika virus infection during pregnancy: what, where, and why?","authors":"R. Burke, P. Pandya, E. Nastouli, P. Gothard","doi":"10.3399/bjgp16X683917","DOIUrl":"https://doi.org/10.3399/bjgp16X683917","url":null,"abstract":"On 1 February 2016 the World Health Organization declared a Public Health Emergency of International Concern following reports of large clusters of microcephaly and Guillain-Barre Syndrome associated with an increase in cases of Zika virus (ZIKV) infection in French Polynesia (2014) and Brazil (2015– 2016).1 The Committee emphasised that there was ‘... no public health justification for restrictions on travel or trade’ and the main interventions were to control mosquito populations and prevent bites in pregnant women. Why has this happened and how might it affect patients attending primary care in the UK?\u0000\u0000ZIKV was first isolated from a Rhesus monkey in Uganda in 1947.2 The following year it was identified in Aedes mosquitoes, which differ from malaria-transmitting Anopheles mosquitoes by biting during the day. ZIKV has been found throughout Africa and South East Asia where infection is asymptomatic or produces a mild febrile illness and rash which goes undiagnosed. The first outbreak was not recorded until 2007 when three-quarters of the population of Yap Island in Micronesia became infected.3\u0000\u0000The current epidemic of ZIKV infection began in early 2015 in northeastern Brazil. Since then ZIKV transmission has been confirmed in 35 countries.4 One theory is that ZIKV was carried to Brazil by infected Pacific Islanders visiting an international canoeing event in Rio de Janeiro in August 2014. In September 2015 clinicians working in Pernambuco state noticed an increase in newborn babies with microcephaly. The Ministry of Health quickly established a register and within 3 months recorded 4180 suspected cases, including 68 deaths, compared to a total of 147 reports in …","PeriodicalId":22333,"journal":{"name":"The British Journal of General Practice","volume":"2000 1","pages":"122 - 123"},"PeriodicalIF":0.0,"publicationDate":"2016-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"82803880","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. Ahern, P. Aveyard, E. Boyland, J. Halford, S. Jebb
Background Primary care referral to a commercial open-group behavioural weight-loss programme is a cost-effective intervention, but only 10% of patients receiving this intervention are male. Aim To explore whether observed biases in participation in these interventions reflect biases in the uptake of the invitation to participate. Design and setting Comparison of invited population and recruited participants in a multicentre randomised controlled trial of primary care referral to a commercial open-group behavioural weight-loss programme in England (WRAP [Weight loss Referrals for Adults in Primary care]). Method Between October 2012 and February 2014, participants were recruited through 23 primary care practices in England; 17 practices provided data on the characteristics of invited participants. Results Females were twice as likely as males to enrol in the trial (odds ratio [OR] 2.01, 95% confidence interval [CI] = 1.75 to 2.32). However, the proportion of males was threefold higher than seen in routine primary care referrals or similar trials that invited patients opportunistically. People from less deprived areas were more likely to enrol than those in more deprived areas (OR 1.77, 95% CI = 1.55 to 2.03). Older patients (≥40 years) were more likely to enrol than younger patients (OR 1.60, 95% CI = 1.34 to 1.91). Conclusion Males, younger people, and those from more deprived areas were less likely to take up the invitation to participate in this trial. The gender bias was smaller than observed in routine practice, suggesting that a substantial proportion of the inequity observed previously is a consequence of bias with regard to the offer of intervention. This study suggests that a simple way to overcome much of the gender bias is to write to patients who are overweight and offer referral. Uptake of the invitation to participate was lower in groups of lower socioeconomic status suggesting the need to preferentially offer referrals to this group to reduce health inequalities and for research to explore barriers to uptake.
初级保健转介到商业开放组行为减肥计划是一种具有成本效益的干预措施，但接受这种干预的患者中只有10%是男性。目的探讨观察到的参与这些干预的偏差是否反映了参与邀请的接受偏差。设计和设置:在英国进行的一项多中心随机对照试验中，初级保健转介到商业开放组行为减肥计划(WRAP[初级保健成人减肥转介])的邀请人群和招募参与者的比较。方法2012年10月至2014年2月，参与者通过英国23个初级保健诊所招募;17种做法提供了关于受邀参与者特征的数据。结果女性参加试验的可能性是男性的两倍(优势比[OR] 2.01, 95%可信区间[CI] = 1.75 ~ 2.32)。然而，男性的比例比常规的初级保健转诊或类似的机会性邀请患者的试验高出三倍。较贫困地区的人比较贫困地区的人更有可能入学(OR 1.77, 95% CI = 1.55至2.03)。老年患者(≥40岁)比年轻患者更有可能入组(OR 1.60, 95% CI = 1.34 ~ 1.91)。结论:男性、年轻人和来自贫困地区的人不太可能接受邀请参加这项试验。性别偏见比在常规实践中观察到的要小，这表明之前观察到的不平等的很大一部分是关于提供干预的偏见的结果。这项研究表明，克服大部分性别偏见的一个简单方法是写信给超重的患者并提供转诊。社会经济地位较低的群体对参加邀请的接受程度较低，这表明需要优先向这一群体提供转诊，以减少健康不平等现象，并研究探索接受邀请的障碍。
{"title":"Inequalities in the uptake of weight management interventions in a pragmatic trial: an observational study in primary care","authors":"A. Ahern, P. Aveyard, E. Boyland, J. Halford, S. Jebb","doi":"10.3399/bjgp16X684337","DOIUrl":"https://doi.org/10.3399/bjgp16X684337","url":null,"abstract":"Background Primary care referral to a commercial open-group behavioural weight-loss programme is a cost-effective intervention, but only 10% of patients receiving this intervention are male. Aim To explore whether observed biases in participation in these interventions reflect biases in the uptake of the invitation to participate. Design and setting Comparison of invited population and recruited participants in a multicentre randomised controlled trial of primary care referral to a commercial open-group behavioural weight-loss programme in England (WRAP [Weight loss Referrals for Adults in Primary care]). Method Between October 2012 and February 2014, participants were recruited through 23 primary care practices in England; 17 practices provided data on the characteristics of invited participants. Results Females were twice as likely as males to enrol in the trial (odds ratio [OR] 2.01, 95% confidence interval [CI] = 1.75 to 2.32). However, the proportion of males was threefold higher than seen in routine primary care referrals or similar trials that invited patients opportunistically. People from less deprived areas were more likely to enrol than those in more deprived areas (OR 1.77, 95% CI = 1.55 to 2.03). Older patients (≥40 years) were more likely to enrol than younger patients (OR 1.60, 95% CI = 1.34 to 1.91). Conclusion Males, younger people, and those from more deprived areas were less likely to take up the invitation to participate in this trial. The gender bias was smaller than observed in routine practice, suggesting that a substantial proportion of the inequity observed previously is a consequence of bias with regard to the offer of intervention. This study suggests that a simple way to overcome much of the gender bias is to write to patients who are overweight and offer referral. Uptake of the invitation to participate was lower in groups of lower socioeconomic status suggesting the need to preferentially offer referrals to this group to reduce health inequalities and for research to explore barriers to uptake.","PeriodicalId":22333,"journal":{"name":"The British Journal of General Practice","volume":"104 1","pages":"e258 - e263"},"PeriodicalIF":0.0,"publicationDate":"2016-02-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"77728963","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}
I. Carey, Sunil M. Shah, F. Hosking, S. DeWilde, T. Harris, C. Beighton, D. Cook
Background People with intellectual disability (ID) are a group with high levels of healthcare needs; however, comprehensive information on these needs and service use is very limited. Aim To describe chronic disease, comorbidity, disability, and general practice use among people with ID compared with the general population. Design and setting This study is a cross-sectional analysis of a primary care database including 408 English general practices in 2012. Method A total of 14 751 adults with ID, aged 18–84 years, were compared with 86 221 age-, sex- and practice-matched controls. Depending on the outcome, prevalence (PR), risk (RR), or odds (OR) ratios comparing patients with ID with matched controls are shown. Results Patients with ID had a markedly higher prevalence of recorded epilepsy (18.5%, PR 25.33, 95% confidence interval [CI] = 23.29 to 27.57), severe mental illness (8.6%, PR 9.10, 95% CI = 8.34 to 9.92), and dementia (1.1%, PR 7.52, 95% CI = 5.95 to 9.49), as well as moderately increased rates of hypothyroidism and heart failure (PR>2.0). However, recorded prevalence of ischaemic heart disease and cancer was approximately 30% lower than the general population. The average annual number of primary care consultations was 6.29 for patients with ID, compared with 3.89 for matched controls. Patients with ID were less likely to have longer doctor consultations (OR 0.73, 95% CI = 0.69 to 0.77), and had lower continuity of care with the same doctor (OR 0.77, 95% CI = 0.73 to 0.82). Conclusion Compared with the general population, people with ID have generally higher overall levels of chronic disease and greater primary care use. Ensuring access to high-quality chronic disease management, especially for epilepsy and mental illness, will help address these greater healthcare needs. Continuity of care and longer appointment times are important potential improvements in primary care.
智力残疾者(ID)是一个医疗保健需求较高的群体;但是，关于这些需求和服务使用情况的全面资料非常有限。目的描述ID患者与普通人群相比的慢性疾病、合并症、残疾和一般实践使用情况。本研究是对2012年包含408名英国全科医生的初级保健数据库进行横断面分析。方法将14 751名18-84岁的成年ID患者与86 221名年龄、性别和实践相匹配的对照组进行比较。根据结果，显示ID患者与匹配对照组的患病率(PR)、风险(RR)或比值(or)比。结果癫痫(18.5%，PR 25.33, 95%可信区间[CI] = 23.29 ~ 27.57)、严重精神疾病(8.6%，PR 9.10, 95% CI = 8.34 ~ 9.92)、痴呆(1.1%，PR 7.52, 95% CI = 5.95 ~ 9.49)、甲状腺功能减退和心力衰竭(PR>2.0)的发生率明显增高。然而，有记录的缺血性心脏病和癌症的患病率比一般人群低约30%。ID患者的平均年初级保健咨询次数为6.29次，而匹配对照组为3.89次。ID患者就诊时间较长的可能性较小(OR 0.73, 95% CI = 0.69至0.77)，且与同一位医生的连续性较低(OR 0.77, 95% CI = 0.73至0.82)。结论与一般人群相比，ID患者总体慢性疾病水平较高，且使用初级保健服务较多。确保获得高质量的慢性病管理，特别是癫痫和精神疾病的管理，将有助于满足这些更大的卫生保健需求。护理的连续性和更长的预约时间是初级保健的重要潜在改进。
{"title":"Health characteristics and consultation patterns of people with intellectual disability: a cross-sectional database study in English general practice","authors":"I. Carey, Sunil M. Shah, F. Hosking, S. DeWilde, T. Harris, C. Beighton, D. Cook","doi":"10.3399/bjgp16X684301","DOIUrl":"https://doi.org/10.3399/bjgp16X684301","url":null,"abstract":"Background People with intellectual disability (ID) are a group with high levels of healthcare needs; however, comprehensive information on these needs and service use is very limited. Aim To describe chronic disease, comorbidity, disability, and general practice use among people with ID compared with the general population. Design and setting This study is a cross-sectional analysis of a primary care database including 408 English general practices in 2012. Method A total of 14 751 adults with ID, aged 18–84 years, were compared with 86 221 age-, sex- and practice-matched controls. Depending on the outcome, prevalence (PR), risk (RR), or odds (OR) ratios comparing patients with ID with matched controls are shown. Results Patients with ID had a markedly higher prevalence of recorded epilepsy (18.5%, PR 25.33, 95% confidence interval [CI] = 23.29 to 27.57), severe mental illness (8.6%, PR 9.10, 95% CI = 8.34 to 9.92), and dementia (1.1%, PR 7.52, 95% CI = 5.95 to 9.49), as well as moderately increased rates of hypothyroidism and heart failure (PR>2.0). However, recorded prevalence of ischaemic heart disease and cancer was approximately 30% lower than the general population. The average annual number of primary care consultations was 6.29 for patients with ID, compared with 3.89 for matched controls. Patients with ID were less likely to have longer doctor consultations (OR 0.73, 95% CI = 0.69 to 0.77), and had lower continuity of care with the same doctor (OR 0.77, 95% CI = 0.73 to 0.82). Conclusion Compared with the general population, people with ID have generally higher overall levels of chronic disease and greater primary care use. Ensuring access to high-quality chronic disease management, especially for epilepsy and mental illness, will help address these greater healthcare needs. Continuity of care and longer appointment times are important potential improvements in primary care.","PeriodicalId":22333,"journal":{"name":"The British Journal of General Practice","volume":"60 1","pages":"e264 - e270"},"PeriodicalIF":0.0,"publicationDate":"2016-02-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"86786457","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}
Background Respiratory tract infections (RTIs) are a major primary care challenge in children because they are common and costly, there is uncertainty regarding their diagnosis, prognosis, and management, and the overuse of antibiotics leads to illness medicalisation and bacterial resistance. Aim To investigate healthcare professional (HCP) diagnostic and antibiotic prescribing decisions for children with RTIs. Design and setting Semi-structured interviews conducted with 22 GPs and six nurses. HCPs were recruited from six general practices and one walk-in centre, serving a mix of deprived and affluent areas. Method Interviews were audiorecorded, transcribed, imported into NVivo 9, and analysed thematically. Results HCPs varied in the symptom and clinical examination findings used to identify children they thought might benefit from antibiotics. Their diagnostic reasoning and assessment of perceived clinical need for antibiotics used a dual process, combining an initial rapid assessment with subsequent detailed deductive reasoning. HCPs reported confidence diagnosing and managing most minor and severe RTIs. However, residual prognostic uncertainty, particularly for the intermediate illness severity group, frequently led to antibiotic prescribing to mitigate the perceived risk of subsequent illness deterioration. Some HCPs perceived a need for more paediatrics training to aid treatment decisions. The study also identified a number of non-clinical factors influencing prescribing. Conclusion Prognostic uncertainty remains an important driver of HCPs’ antibiotic prescribing. Experience and training in recognising severe RTIs, together with more evidence to help HCPs identify the children at risk of future illness deterioration, may support HCPs’ identification of the children most and least likely to benefit from antibiotics.
{"title":"Primary care clinician antibiotic prescribing decisions in consultations for children with RTIs: a qualitative interview study","authors":"J. Horwood, C. Cabral, A. Hay, J. Ingram","doi":"10.3399/bjgp16X683821","DOIUrl":"https://doi.org/10.3399/bjgp16X683821","url":null,"abstract":"Background Respiratory tract infections (RTIs) are a major primary care challenge in children because they are common and costly, there is uncertainty regarding their diagnosis, prognosis, and management, and the overuse of antibiotics leads to illness medicalisation and bacterial resistance. Aim To investigate healthcare professional (HCP) diagnostic and antibiotic prescribing decisions for children with RTIs. Design and setting Semi-structured interviews conducted with 22 GPs and six nurses. HCPs were recruited from six general practices and one walk-in centre, serving a mix of deprived and affluent areas. Method Interviews were audiorecorded, transcribed, imported into NVivo 9, and analysed thematically. Results HCPs varied in the symptom and clinical examination findings used to identify children they thought might benefit from antibiotics. Their diagnostic reasoning and assessment of perceived clinical need for antibiotics used a dual process, combining an initial rapid assessment with subsequent detailed deductive reasoning. HCPs reported confidence diagnosing and managing most minor and severe RTIs. However, residual prognostic uncertainty, particularly for the intermediate illness severity group, frequently led to antibiotic prescribing to mitigate the perceived risk of subsequent illness deterioration. Some HCPs perceived a need for more paediatrics training to aid treatment decisions. The study also identified a number of non-clinical factors influencing prescribing. Conclusion Prognostic uncertainty remains an important driver of HCPs’ antibiotic prescribing. Experience and training in recognising severe RTIs, together with more evidence to help HCPs identify the children at risk of future illness deterioration, may support HCPs’ identification of the children most and least likely to benefit from antibiotics.","PeriodicalId":22333,"journal":{"name":"The British Journal of General Practice","volume":"66 1","pages":"e207 - e213"},"PeriodicalIF":0.0,"publicationDate":"2016-02-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"89330834","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}
J. Watson, Isabel de Salis, W. Hamilton, C. Salisbury
Background Inflammatory markers can be helpful as part of the diagnostic workup for specific diseases or for monitoring disease activity. A third use is as a screening and/or triage tool to differentiate between the presence or absence of disease. Most research into inflammatory markers looks at diagnosis of specific diseases and comes from secondary care. Qualitative studies to explore when and why clinicians use these tests in primary care are lacking. Aim To identify clinicians’ approaches to inflammatory marker testing in primary care. Design and setting Qualitative study with 26 GPs and nurse practitioners. Method Interviews were conducted using a semi-structured topic guide. Clinicians reviewed recent cases of inflammatory marker testing in their pathology inbox. Interviews were audiorecorded and transcribed. Qualitative analysis was conducted by two of the authors. Results Clinicians are uncertain about the appropriate use of inflammatory markers and differ in their approach to testing patients with undifferentiated symptoms. Normal or significantly elevated inflammatory markers are seen as helpful, but mildly raised inflammatory markers in the context of non-specific symptoms are difficult to interpret. Clinicians describe a tension between not wanting to ‘miss anything’ and, on the other hand, being wary of picking up borderline abnormalities that can lead to cascades of further tests. Diagnostic uncertainty is a common reason for inflammatory marker testing, with the aim to reassure; however, paradoxically, inconclusive results can generate a cycle of uncertainty and anxiety. Conclusion Further research is needed to define when inflammatory marker testing is useful in primary care and how to interpret results.
{"title":"‘I’m fishing really’ — inflammatory marker testing in primary care: a qualitative study","authors":"J. Watson, Isabel de Salis, W. Hamilton, C. Salisbury","doi":"10.3399/bjgp16X683857","DOIUrl":"https://doi.org/10.3399/bjgp16X683857","url":null,"abstract":"Background Inflammatory markers can be helpful as part of the diagnostic workup for specific diseases or for monitoring disease activity. A third use is as a screening and/or triage tool to differentiate between the presence or absence of disease. Most research into inflammatory markers looks at diagnosis of specific diseases and comes from secondary care. Qualitative studies to explore when and why clinicians use these tests in primary care are lacking. Aim To identify clinicians’ approaches to inflammatory marker testing in primary care. Design and setting Qualitative study with 26 GPs and nurse practitioners. Method Interviews were conducted using a semi-structured topic guide. Clinicians reviewed recent cases of inflammatory marker testing in their pathology inbox. Interviews were audiorecorded and transcribed. Qualitative analysis was conducted by two of the authors. Results Clinicians are uncertain about the appropriate use of inflammatory markers and differ in their approach to testing patients with undifferentiated symptoms. Normal or significantly elevated inflammatory markers are seen as helpful, but mildly raised inflammatory markers in the context of non-specific symptoms are difficult to interpret. Clinicians describe a tension between not wanting to ‘miss anything’ and, on the other hand, being wary of picking up borderline abnormalities that can lead to cascades of further tests. Diagnostic uncertainty is a common reason for inflammatory marker testing, with the aim to reassure; however, paradoxically, inconclusive results can generate a cycle of uncertainty and anxiety. Conclusion Further research is needed to define when inflammatory marker testing is useful in primary care and how to interpret results.","PeriodicalId":22333,"journal":{"name":"The British Journal of General Practice","volume":"61 1","pages":"e200 - e206"},"PeriodicalIF":0.0,"publicationDate":"2016-02-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"87059860","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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