BJGP Open最新文献

Background: In individuals with depression a vicious circle tends to occur in which depressive symptoms cause an unhealthy lifestyle, which reversibly causes an increase in depressive symptoms; both of which are associated with a decreased life expectancy. A potential way to break this circle entails a multicomponent lifestyle intervention (MLI).

Aim: Exploring the barriers and facilitators for an MLI in patients with depressive symptoms from the perspective of general practitioners (GP), chronic disease practice nurses (CD-PN), mental health nurses (MHN), lifestyle coaches (LC) and patients (PT).

Design & setting: Qualitative study using semi-structured interviews in Dutch primary care. Methods We interviewed 5 GPs, 6 MHNs, 5 CD-PNs, 5 LCs and 7 PTs. Focus was on possible barriers and facilitators for an MLI. Data were analyzed using thematic analysis. A focus group was used as a member check.

Results: Five themes were identified: 'expectations of effectiveness, 'motivation', 'stigma', 'logistics and organization' and 'communication by professionals'.

Conclusion: Ideas on effectiveness were crucial and could be either a facilitator or a barrier for a DT-MLI. Professionals often had high expectations, based on work experience, making this a facilitator. Other facilitators are motivating participants, good logistics and good communication by professionals, thus destigmatizing depression. Patients considered being motivated by the program as a reason for participating, as they did not expect a DT-MLI would give them new information. Support from others was considered a motivator to participate.

Background: Social prescribing (SP) link workers (LWs) listen to patients' concerns and difficulties, and connect them to relevant community assets (groups/organisations/charities) that can help with their non-medical issues (eg, loneliness, debt, housing). LW retention is key to sustaining SP within primary care.

Aim: To examine occupational self-efficacy, job discrepancy and other factors as potential predictors of LWs' intentions to leave or remain in their post.

Design & setting: Cross-sectional survey involving LWs from the United Kingdom.

Method: An online questionnaire was distributed via SP-related organisations. Questions were on: a) intention to leave the role, b) demographics, and c) role experience, including occupational self-efficacy and discrepancy between expectations and reality of the job. Questions were mainly closed, although some allowed LWs to provide a written response. Logistic regression models were fitted to identify predictors, and content analysis used to categorise open ended responses.

Results: 342 questionnaire responses were included in the analysis. Higher job discrepancy was associated with past (odds ratio [OR] per 30 unit increase=6.86; 95% CI: 3.91 to 12.0; P=0.003) and future (OR=4.86; 95% CI: 2.70 to 8.72; P<0.001) intentions to leave, whilst lower occupational self-efficacy was associated only with past intentions to leave (OR per 10 unit decrease=1.91; 95% CI: 1.24 to 2.93; P=0.003).

Conclusion: Findings highlight factors influencing LW retention, offering a foundation for targeted interventions, which could include clearer communication about the role during recruitment, and adjusting job descriptions and support when required.

Background: C-reactive protein point-of-care tests (CRP-POCTs) can support GPs' clinical decision making but they are not widely used in German general practices.

Aim: To investigate the utilisation of semi-quantitative CRP-POCTs in routine primary care.

Design & setting: Prospective observational study in 49 general practices in Germany (from November 2022-April 2023).

Method: GPs were provided with CRP-POCTs and collected data for each CRP-POCT use, with standardised data-collection sheets.

Results: Data from 1740 CRP-POCT uses were recorded. GPs employed CRP-POCTs mainly for patients with respiratory tract infections (RTIs; 71.2% of all cases) and to a lesser extent for gastrointestinal infections (GIs; 10.4%). In RTIs, CRP-POCTs were frequently used to distinguish between bacterial and viral aetiology (60.8%) and to guide decisions on antibiotic prescribing (62.8%). In GIs, CRP-POCTs were mainly used to rule out severe disease progressions (53.2%) and for decisions on further diagnostic procedures (45.6%). In RTIs, CRP-POCTs influenced antibiotic prescribing in 77.5% of the cases (32.3% in favour versus 45.2% waiver). In GIs, CRP levels mainly affected decisions on further diagnostic procedures. GPs reported that CRP-POCTs were helpful in 88.6% of all cases.

Conclusion: When available, German GPs predominantly use semi-quantitative CRP-POCTs to guide decisions on antibiotic prescribing in patients with RTIs. CRP-POCT use improves clinical decision making and increases the GP's clinical confidence.

Background: Previous research has called for general practice funding to be adjusted by deprivation data. However, there is no evidence that this adjustment would better meet clinical need.

Aim: To assess (1) how accurately the capitation formula (Carr-Hill), and total general practice funding predicts clinical need and (2) whether adjusting by the Index of Multiple Deprivation (IMD) score improves accuracy.

Design & setting: A cross-sectional analysis of 32 844 Lower layer Super Output Areas (LSOAs) in England in 2021-2022. Sensitivity analysis used data from 2015-2019.

Method: Weighted average Carr-Hill Index (CHI), total general practice funding, and five measures of clinical need were calculated for each LSOA. For both CHI and total funding, four sets of generalised linear models were calculated for each outcome measure: unadjusted; adjusted for age; adjusted for IMD; and adjusted for age and IMD. Adjusted R ² assessed model accuracy.

Results: In unadjusted models, CHI was a better predictor than total funding of combined morbidity index (CMI) (R ² = 49.81%, 29.31%, respectively), combined diagnosed and undiagnosed morbidity (R ² = 43.52%, 21.39%) and emergency admissions (R ² = 32.75%, 16.95%). Total funding was a better predictor than CHI of GP appointments per patient (R ² = 28.5%, 22.5%, respectively) and age and sex standardised mortality rates (R ² = 0.42%, 0.37%). Adjusting for age and IMD improved all 10 models (R ² = 62.15%, 53.15%, 48.57%, 38.47%, 40.53%, 32.84%, 29.11%, 34.58%, 25.21%, 25.23%, respectively). All age and IMD adjusted models significantly outperformed age-adjusted models (P<0.001). Sensitivity analysis confirmed findings.

Conclusion: Adjusting capitation or total funding by IMD would increase funding efficiency, especially for long-term outcomes such as mortality. However, adjusting for IMD without age could have unwanted consequences.

Background: Women who use drugs face specific challenges compared with men such as higher rates of HIV infection, unsafe injecting practices, and intimate partner violence (IPV). However, this population's access to drug dependence treatment and gender-sensitive interventions remains limited, leading to unmet needs and increased vulnerability.

Aim: To investigate the characteristics of and associations with retention in care among women on opioid substitution therapy (OST) in a community-based primary care setting.

Design & setting: A descriptive observational study within the Community Orientated Substance Use Programme in Tshwane, South Africa.

Method: Data from 199 women (aged >18 years) on OST was extracted from an electronic database and paper-based files. Data were analysed descriptively, and inferential analysis looked for association of variables with retention on OST for ≥6 months.

Results: The majority of participants were unemployed, with 44.3% aged 20-29 years. During the initiation and course of OST, 39.2% of women had an intimate partner of which 37.2% reported IPV, and 19.2% were pregnant. Retention on OST was significantly associated with increasing age at initiation (P = 0.047), knowledge of HIV status (P = 0.029), an increase in the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) score (P = 0.023), and methadone dose (P<0.001). Factors such as race, employment status, health-system level, pregnancy, intimate partner using substances, IPV, route of administering opioids, and having tuberculosis and/or hepatitis C exposure did not show a significant relationship with retention on OST (P>0.05).

Conclusion: This study reveals specific vulnerabilities in women receiving OST, emphasising the need for the integration of interventions to address reproductive health, violence mitigation, infectious disease, and polydrug use into care.

Background: GPs can detect cognitive impairment (CI) at a very early stage, allowing early support for people and their caregivers. The early onset of CI is between 50 years and 60 years. Currently, in France, the Mini-Mental State Examination (MMSE) remains the most used screening test, although it has a lower sensitivity and specificity than the Montreal Cognitive Assessment (MoCA) for detecting mild CI, taking an average of 15 minutes to complete.

Aim: To investigate the feasibility of the MoCA during routine consultations in general practice for the early detection of CI and to determine prevalence of CI in a primary care setting.

Design & setting: A quantitative, prospective feasibility study was carried out in real-life working conditions during routine GP consultations in France.

Method: GPs performed MoCA on adults aged ≥50 years, without suspected or confirmed CI.

Results: Sixty-one GPs performed 221 MoCA with a mean duration of 8 minutes and detected mild neurocognitive impairment in 62% of patients.

Conclusion: The MoCA is feasible and easy to perform during routine consultations in general practice by trained and experienced physicians.

Background: Type two diabetes (T2D) is linked to impaired mental health. International guidelines emphasise the importance of including psychological aspects in diabetes care. Yet, no systematic approach has been implemented to assess mental health in patients with T2D in general practice.

Aim: To evaluate the mental health of patients with T2D in general practice, and to investigate the effectiveness of asking patients about their wellbeing by using a single-item question compared with the five-item World Health Organization-Five Wellbeing Index (WHO-5).

Design & setting: A cross-sectional study was undertaken, which included 230 patients with T2D in Danish general practice, from 1 May 2023-31 January 2024.

Method: Eligible patients were recruited at the annual chronic care consultation. They answered a single-item question on wellbeing and four validated measures of general wellbeing (WHO-5), depression (Patient Health Questionnaire-9; PHQ-9), anxiety (Generalised Anxiety Disorder-7; GAD-7), and diabetes distress (Problem Areas in Diabetes-5; PAID-5).

Results: Overall, 32% of patients expressed symptoms of impaired mental health. Notably, the WHO-5 identified 53% of these patients, whereas only 12% of patients were identified through the single-item question. Importantly, among the patients exhibiting symptoms of impaired mental health, those identified by the WHO-5 displayed statistically significantly lower mental health scores across all measures (except PAID-5) compared with those not identified by the WHO-5.

Conclusion: A significant proportion of patients with T2D in general practice are affected by mental health issues. Our findings indicate that a single-item question may not sufficiently detect these issues, highlighting the importance of incorporating tools, such as the WHO-5, to offer a more comprehensive approach in diabetes care.

Background: The World Health Organization's (WHO) measurement framework for primary health care includes the core functions of primary care: first-contact access, comprehensiveness, coordination, continuity, and person-centredness. The Primary Care Assessment Tool (PCAT), originally developed in the USA, was adapted for use by four African countries, and can measure the core functions of primary care.

Aim: To face and content validate a PCAT for sub-Saharan Africa that measures the core functions of primary care.

Design & setting: Nineteen countries within the Primary Care and Family Medicine (PRIMAFAMED) network for sub-Saharan Africa participated in a validation study.

Method: Two stages included a PRIMAFAMED workshop to assess face validity and a Delphi study to reach consensus on content validity among an expert panel as well as key stakeholders.

Results: Thirteen countries participated in the workshop and suggested rephrasing 39 items, deleting six and adding four new items. Nineteen countries participated in the Delphi study and all 20 panel members reached consensus (>70%) on including the items as written. Seven experts and stakeholders reviewed the PCAT and suggested rephrasing 23 items, deleting one and adding one. The final PCAT for sub-Saharan Africa (SSA-PCAT) consists of 85 items that measure affiliation with the primary care facility, first-contact access and utilisation, comprehensiveness, continuity, coordination, and person-centredness, as well as health, demographic and socioeconomic status.

Conclusion: The SSA-PCAT will now be piloted in Benin, Uganda, and South Africa. Further psychometric evaluation will be possible followed by more widespread use by researchers, district managers, and policymakers in the region.

Background: How GP continuity of care (GP-CoC) affects mortality in patients with type 2 diabetes (T2D) is unclear.

Aim: To examine the effect of having no continuity of care (CoC) and GP-CoC on mortality in primary health care (PHC) patients with T2D.

Design & setting: A cohort study in patients aged ≥60 years with T2D, which was conducted within the public PHC of the city of Vantaa, Finland.

Method: The inclusion period was between 2002 and 2011 and follow-up period between 2011 and 2018. Six groups were formed (no appointments, one appointment and Modified, Modified Continuity Index [MMCI] quartiles). Mortality was measured with standardised mortality ratio (SMR) and adjusted hazard ratio (aHR). GP-CoC was measured with MMCI. Comorbidity status was determined with Charlson Comorbidity Index (CCI).

Results: In total, 11 020 patients were included. Mean follow-up time was 7.3 years. SMRs for the six groups (no appointments, one appointment, MMCI quartiles) were 2.46 (95% confidence interval [CI] = 2.24 to 2.71), 3.55 (95% CI = 3.05 to 4.14), 1.15 (95% CI = 1.06 to 1.25), 0.97 (95% CI = 0.89 to 1.06), 0.92 (95% CI = 0.84 to 1.01) and 1.21 (95% CI = 1.11 to 1.31), respectively. With continuous MMCI, mortality formed a U-curve. The inflection point was at a MMCI value of 0.65 with corresponding SMR of 0.86. Age and CCI aHR for death between men and women was 1.45 (95% CI = 1.35 to 1.58).

Conclusion: Patients with no CoC had the highest mortality. In patients having care over time, the effect of GP-CoC on mortality was minor and mortality increased with high GP-CoC.

Background: The COVID-19 pandemic's long-term mental health implications are increasingly concerning, especially among patients suffering post-acute sequelae of SARS-CoV-2 infection: Long COVID (LC) patients.

Aim: This study explores the presence and distribution of anxiety, depression, and stress in LC individuals with cognitive complaints in northern Barcelona (Spain).

Design & settings: This cross-sectional study involved 155 diagnosed LC individuals from the "Aliança ProHEpiC-19 Cognitiu (APC)" project.

Method: Demographic data and health behavior variables were collected, and the Depression, Anxiety, and Stress Scale (DASS-21) was self-administered to assess mental health. Descriptive statistics, chi-squared tests, and Poisson regression models were used for data analysis.

Results: 'Severe' stress and 'Extremely Severe' anxiety were prevalent in the sample. There were significant differences in anxiety and depression based on age and job role, with older individuals and non-healthcare workers showing higher relative risks.

Conclusions: Our study highlights the significant mental health burden in LC patients, underscoring the need for targeted interventions, especially among adults over 45 years old and non-healthcare workers. Further research is needed to better understand LC's complex mental health impacts and develop effective clinical management strategies.