BJGP Open最新文献

Background: The UK National Institute for Health and Care (NICE) recommends that GPs inform patients referred onto the Urgent Suspected Cancer (USC) pathway about what to expect from the service. However, there is a lack of evidence on patient experience and information needs at the point of referral. It is a challenge for GPs to communicate the reasons for referral and provide reassurance.

Aim: This study aimed to examine how GPs communicate a potential cancer diagnosis and USC referral in practice.

Design & setting: This is a secondary analysis of a dataset of 23 audio-recorded GP-patient consultations, selected from a larger dataset of 200 consultations collected in Surrey and London, UK in 2017-2018. The consultations were selected based on inclusion criteria related to cancer discussions.

Method: This is a qualitative analysis of video recordings of face to face patient consultations.

Results: We found that most GPs informed patients that they might have cancer and engaged in reassurance using personalised risk statements. Some GPs avoided all mention of cancer, using symptom-led language instead. GPs focused on communicating practical rather than support-based information. While most GPs informed patients that they would be seen by a specialist within two weeks, few discussed patients' support needs during the referral period.

Conclusion: Clear communication about cancer in primary care is promoted in UK policy, and has an important role driving patient investigations attendance. The study highlights the need for further research on communication practices around cancer referral to improve patient understanding and experience. Our recommendations for enhanced communication may improve patient outcomes by optimising routes to diagnosis via primary care.

Background: The Quality and Outcomes Framework (QOF), a pay-for-performance programme, has been the most widespread quality initiative in National Health Service (NHS) general practice since 2004. It has contributed between 25% and 8% of practices' income during this time, but concerns about its effect on equity have been raised.

Aim: Understand which practice characteristics are associated with QOF performance.

Design and setting: Systematic review, NHS general practice.

Method: MEDLINE, Embase, CINAHL+, Web-of-Science and grey literature were searched for studies examining the association between general practice characteristics and QOF performance.

Results: Twenty-two studies, published between 2006 and 2022, exploring the relationship between six population and 15 organisational characteristics and QOF measures were found. Most studies were cross-sectional, of English general practices, and used data from the early years of QOF. A negative association was frequently found between overall QOF performance and socioeconomic deprivation; proportion of registered patients>65; list size; mean general practitioner (GP) age; and Alternative Provider Medical Services contracts. Group practices (versus single-handed); more full-time-equivalent GPs; and being a training practice were frequently associated with better overall QOF performance. The associations of most other characteristics with performance were inconsistent.

Conclusion: Associations with characteristics both within and outside practices' control were identified. Pay-for-performance instruments may systematically disadvantage practices serving those at greatest risk of ill-health, such as older and more deprived populations. Given the cross-sectional design of many studies and focus on the early years of QOF, more up-to-date evidence is needed to understand if and why these relationships persist.

Background: Work-related asthma (WRA) is prevalent yet under-recognized in UK primary care.

Aim: We aimed to identify behaviour change interventions (BCI) intended for use in primary care to identify WRA, or any other chronic disease (that could be adapted for use in WRA).

Design & setting: Systematic review METHOD: We searched CCRCT, Embase, PsychINFO and Ovid-MEDLINE databases (1946-2023) for studies describing development and/or evaluation of BCIs for case finding any chronic disease in primary care settings, aimed at either healthcare professionals and/or patients. Two blinded, independent reviewers screened abstracts and assessed full text articles. We undertook narrative synthesis for outcomes of usability and effectiveness, and for BCI development processes.

Results: We included 14 studies from n=768 retrieved citations, comprising 3 randomised control trials, 1 uncontrolled experimental study, and 10 studies employing recognized multi-step BC methodologies. None of the studies were concerned with identification of asthma. BCIs had been developed for facilitating screening programmes (5), implementing guidelines (3) and individual case finding (6). Five studies measured effectiveness, in terms of screening adherence rates, pre-/post-intervention competency, satisfaction and usability, for clinicians, though none measured diagnostic rates.

Conclusion: No single or multi-component BCIs has been developed specifically to aid identification of asthma or WRA, though other chronic diseases have been targeted. Development has used BC methodologies that involved gathering data from a range of sources, and developing content specific to defined at-risk populations, so are not immediately transferable. Such methodologies could be used similarly to develop a primary acre-based BCI for WRA.

Background: Electronic Risk Assessment Tools (eRATs) are intended to improve early primary care cancer diagnosis. eRATs which interrupt a consultation to suggest a possibility of a cancer diagnosis, could impact clinical appraisal and the experience of the consultation. This study explores this issue using data collected within the context of the ERICA trial.

Aim: To explore experiences of General Practitioners (GPs) who used the ERICA eRATs, and how the tool impacted their perception of risk and diagnostic thinking, and communication of this to patients.

Design & setting: Qualitative interviews with GPs from English General Practices undertaking the ERICA trial.

Method: Participants were purposefully sampled from practices participating in the intervention arm of the ERICA trial. 18 GPs undertook semi-structured interviews via MS Teams. Thematic Analysis was used to explore their perspectives the impact of eRATs on consultations, diagnostic thinking related to cancer and other conditions, and how this information is communicated to patients.

Results: Three themes were developed: 1) eRATs were perceived as "Additional Armour", offering a layer of protection against missing a cancer diagnosis, the defence coming at a cost of anxiety and complexity of consultation; 2) eRATs were seen as another actor in the consultation, separate from clinician and patient, and challenging GP autonomy; and 3) GPs were conflicted about whether the numerical eRAT outputs were helpful when communicating with patients.

Conclusion: eRATs are appreciated as a defence against missing a cancer diagnosis. This defence comes at a cost and challenges GP's freedom in communication and decision making.

Background: Poverty can have significant impacts on health and wellbeing. However, asking patients about their broader socio-economic circumstances is not routine within primary care consultations.

Aim: To understand healthcare professionals' experiences of communicating with patients about their socio-economic circumstances and how a bespoke training programme supported these conversations in routine consultations.

Design & setting: Healthcare professionals from 30 GP practices across England received training to improve understanding and communication with patients about the ways that poverty impacted their mental health.

Method: Semi-structured interviews were undertaken with 49 GPs and allied health professionals to understand barriers and enablers to communication around poverty and the impact of the training on their consultation practice.

Results: Health professionals often lacked confidence in discussing socio-economic issues and welcomed information on how to do this sensitively. Asking questions relating to poverty-related stresses was felt to lead to better understanding around the causes of mental distress, avoidance of problematic assumptions and inappropriate antidepressant prescribing and to enable more coordinated and appropriate support from practice teams.

Conclusion: Asking patients about their socio-economic circumstances can facilitate provision of appropriate support.

Background: Social isolation is associated with increased all-cause and premature mortality, poor chronic disease management, and mental health concerns. Limited research exists on interventions addressing social isolation among individuals under 65 despite its increasing prevalence among young and middle-aged adults.

Aim: To identify interventions from the extant literature that address social isolation and loneliness in ambulatory healthcare settings in adults aged 18-64 and to identify elements of successful studies for future intervention design.

Design & setting: Systematic review of interventions targeting social isolation in community-dwelling adults aged 18-64 within ambulatory healthcare settings.

Method: A search strategy was developed to identify relevant articles in the following databases: Ovid MEDLINE, Embase, EBM Reviews, Scopus, CINAHL, and PsychInfo. Data were extracted on study design and setting, intervention type, outcome related to social isolation/loneliness, and scale of measure used.

Results: 25 078 citations were identified and underwent title and abstract screening. 75 articles met our inclusion criteria and were synthesised, including an assessment of bias. Effective interventions were delivered in community health settings, incorporated a group component, and used digital technologies. They also addressed the association between mental health and social isolation using cognitive-behavioural therapy (CBT) approaches and enhanced self-management and coping strategies for chronic conditions through psycho-educational interventions.

Conclusion: Future research should prioritise adults living in low-income and middle-income countries, racialised individuals, as well as those with fewer educational opportunities. There is also a need to advance research in primary care settings, where longitudinal patient-provider relationships would facilitate the success of interventions.

Integration between public health and primary care is rising on the health policy agenda but the terms and concepts involved can be confusing. This article reviews the relevant literature and presents a new framework to help policymakers think through what they are aiming to achieve and why. We unpack different degrees and types of integration and show how they fit together. We argue that the merger of public health and primary care into a single entity with one aim, budget, and one multidisciplinary team isn't necessarily the desired end-point for most health systems, but that seamless collaboration will likely improve patient and health system outcomes, save resources, and improve population outcomes. We recommend that efforts to foster better collaboration should take an activity-based approach, promoting alignment of teams, training, budgets, values and culture around specific tasks, and in proportion to need.

Background: Influenza contributes to the surge in winter infections and the consequent winter pressures on the health service. Molecular point-of-care testing (POCT) for influenza may improve patient management by providing rapid and accurate clinical diagnosis to inform the timely initiation of antiviral therapy and reduce unnecessary admissions and antibiotics use.

Aim: To explore factors that influence the adoption or non-adoption of POCT in English general practices and provide insights to enable its integration into routine practice workflows.

Design & setting: A qualitative implementation evaluation was conducted in 10 general practices within the English national sentinel network (Oxford RCGP Research and Surveillance Centre), from April-July 2023.

Method: Using the Non-adoption, Abandonment, Scale-up, Spread, and Sustainability (NASSS) framework, data collection and analysis were conducted across 10 practices. We made ethnographic observations of the POCT workflow and surveyed the practice staff for their perspectives on POCT implementation. Data were analysed using a mix of descriptive statistics, graphical modelling techniques, and framework analysis.

Results: Ethnographic observations identified the following two modes of POCT integration into practice workflow: (1) clinician POCT workflow, which typically involved batch testing owing to time constraints; and (2) research nurse or healthcare assistant POCT workflow, which was characterised by immediate testing of individual patients. Survey data indicated that most primary care staff considered the POCT training offered was sufficient and these practices were ready for change. Some participants agreed that there was the capacity and resources to integrate POCT into workflows. It was uncertain as to whether POCT required changes to organisational routines and processes.

Conclusion: General practices should demonstrate flexibility in the workflow and workforce they deploy to integrate POCT into routine clinical workflow.

Background: General practice is an essential part of healthcare systems in the UK and internationally but continues to struggle with recruitment. Despite this, few studies have explored factors that influence medical students' career choices around primary care.

Aim: We aimed to revisit factors that had previously been proposed following new ways of working adopted since the COVID-19 pandemic, including the impact of these changes on learning experiences in primary care.

Design & setting: A qualitative study using focus groups across three English medical schools.

Method: Eight focus groups were held involving 33 final and penultimate year medical students. Qualitative data were analysed using a framework approach. Transcripts were coded independently by two researchers from a different institution before themes were identified.

Results: Six themes were identified: students' prior career aspirations, their experience of the medical school curriculum, conceptualisation of general practice, future career predictions, views on the school's curriculum philosophy, and the influence of the COVID-19 pandemic. The curriculum philosophy of each school appeared to be important in this journey and changes since the COVID-19 pandemic had an impact on all themes.

Conclusion: Our study has confirmed previous findings that clinical experiences, the perceived narrative of the school, work-life balance, and working environment remain important to students in making career plans. However, in addition, we have found the changing landscape in general practice since the COVID-19 pandemic, including remote consulting, workload, continuity of care, and team-working, are additional factors that concern students.