BJGP Open最新文献

Background: General practice has one of the most diverse medical training programmes in terms of sex and ethnic background. However, this diversity of race and ethnicity is not reflected in academic GP careers, with just 17% (n = 81/473) of academic GPs being from racially minoritised groups, according to the Medical Schools Council.

Aim: To determine whether GP academic clinical fellow (ACF) trainees from racially minoritised backgrounds are proportionally represented, compared with the non-academic training programme, using the annual GP ACF conference as a proxy.

Design & setting: A retrospective analysis of conference programmes from national academic GP training conferences from 2018-2023 and demographic data obtained from Health Education England (HEE).

Method: Using conference programmes and online searches, demographic information on conference speakers was obtained and a freedom of information request was made to HEE for the demographics of GP ACFs for corresponding years. This was compared with demographic data of GP trainees and academics.

Results: On average, there were 40 speakers each year at the conference. White females (average 20.2 speakers each year) were the most well represented group, followed by White males (average 12.5), Asian females (average 3.3), Asian males (average 1.8), Black males (average 0.7), and Black females (average 0.3). HEE data from 2022 revealed that 27 (71.1%) of the 38 (excluding five who did not state their ethnicity) ACFs were White British.

Conclusion: GP academia should be more representative of the non-academic GP training scheme. Work needs to be done to understand and overcome the structural barriers to recruiting from racially minoritised groups.

Background: GPs are particularly vulnerable to job burnout. Tailored prevention and intervention strategies are needed.

Aim: To investigate organisational, interpersonal, and individual factors contributing to exhaustion and disengagement at work among GPs.

Design & setting: We conducted a cross-sectional study in a sample of Belgian GPs.

Method: A total of 358 doctors (73% females, 301 with complete data) completed an online anonymous questionnaire assessing job burnout, psychosocial characteristics of the work environment, perceived social support in the private domain, emotional competence, and self-compassion.

Results: GPs reported moderate levels of exhaustion and disengagement. Regression models showed that included factors jointly explained 69% of the variance in exhaustion and 63% in disengagement. Exhaustion was significantly predicted by female sex (β effect size = -0.1), high perceived emotional demands (β = 0.19), as well as low self-compassion (β = -0.14) and low emotional competence (β = 0.09). Disengagement was significantly predicted by low seniority (β = -0.12) and limited opportunities for development (β = -0.16). Both exhaustion and disengagement were predicted by low perceived quality of work (β = -0.19 and -0.14, respectively), meaning of work (β = -0.17 and -0.31, respectively), and role clarity (β = 0.09 and 0.12, respectively), as well as high perceived work-life conflict (β = 0.46 and 0.21, respectively). Moreover, GPs working in a multidisciplinary group reported lower levels of exhaustion and disengagement than those working in a monodisciplinary group or a solo practice, and this difference was associated with factors such as work-life conflict.

Conclusion: Organisational, interpersonal, and intrapersonal factors interact to predict a substantial part of burnout in general practice. The most significant risk factors were perceived work-life conflict and poor meaning of work. Policymakers should work to support more sustainable practices based on the specific needs and constraints reported by GPs.

Background: Relational continuity of care (patients seeing the same GP) is associated with better outcomes for patients, but it has been declining in general practice in the UK.

Aim: To understand what interventions have been tried to improve relational continuity of care in general practice in the UK.

Design & setting: Scoping review of articles on UK General Practice and written in English.

Method: An electronic search of MEDLINE, Embase, and Scopus from 2002 to the present day was undertaken. Sources of grey literature were also searched. Studies that detailed service-level methods of achieving relational continuity of care with a GP in the UK were eligible for inclusion. Interventions were described narratively in relation to the elements listed in the Template for Intervention Description and Replication (TIDieR). A logic model describing the rationale behind interventions was constructed.

Results: Seventeen unique interventions were identified. The interventions used a wide variety of strategies to try to improve relational continuity. This included personal lists, amended booking processes, regular reviews, digital technology, facilitated follow-ups, altered appointment times, and use of acute hubs. Twelve of the interventions targeted specific patient groups for increased continuity while others focused on increasing continuity for all patients. Changes in continuity levels were measured inconsistently using several different methods.

Conclusion: Several different strategies have been used in UK general practices in an attempt to improve relational continuity of care. While there is a similar underlying logic to these interventions, their scope, aims, and methods vary considerably. Furthermore, owing to a weak evidence base, comparing their efficacy remains challenging.

Background: Clinical practice occurs in the context of uncertainty. Primary care is a clinical environment that accepts and works with uncertainty differently from secondary care. Recent literature reviews have contributed to understanding how clinical uncertainty is taught in educational settings and navigated in secondary care, and, to a lesser extent, by experienced GPs. We do not know how medical students and doctors in training learn to navigate uncertainty in primary care.

Aim: To explore what is known about primary care as an opportunity for learning to navigate uncertainty.

Design & setting: Scoping review of articles written in English.

Method: Using a scoping review methodology, Embase, MEDLINE, and Web of Science databases were searched, with additional articles obtained through citation searching. Studies were included in this review if they: (a) were based within populations of medical students and/or doctors in training; and (b) considered clinical uncertainty or ambiguity in primary care or a simulated primary care setting. Study findings were analysed thematically.

Results: Thirty-six studies were included from which the following three major themes were developed: uncertainty contributes to professional identity formation (PIF); adaptive responses; and maladaptive behaviours. Relational and social factors that influence PIF were identified. Adaptive responses included adjusting epistemic expectations and shared decision making (SDM).

Conclusion: Educators can play a key role in helping learners navigate uncertainty through socialisation, discussing primary care epistemology, recognising maladaptive behaviours, and fostering a culture of constructive responses to uncertainty.

Background: Since COVID-19 there been an increase in the use of remote consultations in General Practice in the UK. This leads to the displacement of the consultation outside of the physical GP practice, and its 'emplacement' elsewhere, with underexplored consequences for inequities of healthcare in marginalised groups.

Aim: This paper examines the place-making demands that remote consultations make on patients, and the ways that these affect their experiences of care, with a focus on the impact on patients from marginalised groups.

Design & setting: Ethnography and interview study (n=15) undertaken at three sites in London: a foodbank, a community development organisation, and a drop-in advice centre for migrants. Additionally, GPs (n=5) working at practices in London Digital Health Hub staff (n=4) and staff at fieldwork sites (n=3) were interviewed.

Method: Ethnographic observation (n=84 hours) and semi-structured interviews (n=27). Interviews were conducted in-person and over the phone and data were analysed through reflexive thematic analysis.

Results: The core themes emerging from the data included challenges securing privacy during remote consultations, and the loss of formal healthcare spaces as important places of care. These findings were closely tied to resource access, leading to inequities in experiences of care.

Conclusion: Remote GP consultations are not "place-less" encounters, and inequities in access to suitable spaces may lead to inequities in experiences of care. Attention should be given to ensuring that patients without appropriate spaces for remote consultations are offered in-person care, or consultation times made more specific to allow for organisation of private space.

Background: Several researchers and policymakers have acknowledged the alarming association between social media (SM) usage and anxiety symptoms in young adults. While primary care holds a crucial role in the improvement of health outcomes for those presenting with anxiety, there has been no research on GPs' perceptions of the impact of SM on anxiety. Furthermore, there has been little discussion of SM as a risk factor in anxiety-related consultations. This study is the first to use empirical research to inform how primary care can adapt to address SM's impact on anxiety within young adults.

Aim: To identify the facilitators and barriers within primary care to addressing SM's impact on anxiety among young adults.

Design & setting: A qualitative study of GPs in the UK.

Method: Following an exploratory pilot interview, semi-structured interviews with GPs (n = 7) were transcribed and thematically analysed, following an inductive approach.

Results: The following six facilitators were identified: a framework to facilitate discussion; open GP attitudes; GP training; referral pathways; larger stakeholder influence; and young adult education of social media's impact on anxiety. The following three barriers were identified: a lack of GP awareness of SM's impact on anxiety; cautious GP attitudes; and increased pressure on the health service.

Conclusion: This qualitative study revealed a diversity of perceptions, and these novel findings are instructive in the adaptation of primary care services to meet the current mental health needs of young adults, as well as better assisting GPs in engaging in these conversations, especially within university practice.

Background: During the COVID-19 pandemic many patients were switched from warfarin to direct-acting oral anticoagulants (DOACs), which require the creatinine clearance (CrCl) calculated to ensure the correct dose is prescribed to avoid bleeding or reduced efficacy.

Aim: To identify the study population proportion prescribed a DOAC. Of these, the proportion with recorded: weight, estimated glomerular filtration rate (eGFR), creatinine, CrCl and atrial fibrillation (AF). To analyse the proportion of patients with recorded AF and CrCl prescribed a recommended DOAC dose.

Design & setting: A retrospective cohort study of 20.5 million adult NHS patients' electronic health records (EHRs) in England in the OpenSAFELY-TPP platform (January 2018-February 2023).

Method: Patients on DOACs were analysed for age, sex, recorded weight, eGFR, creatinine, CrCl and AF. Prescribed DOAC doses in patients with recorded AF were compared with recommended doses for recorded CrCl and determined as either recommended, higher than recommended (overdose), or lower than recommended (underdose).

Results: In February 2023, weight, eGFR, creatinine, CrCl, and AF were recorded in 72.8%, 92.4%, 94.3%, 73.5%, and 73.9% of study population, respectively. Both AF and CrCl were recorded for 56.7% of patients. Of these, 86.2% received the recommended, and 13.8% non-recommended, DOAC doses.

Conclusion: CrCl is not recorded for a substantial number of patients on DOACs. We recommend that national organisations tasked with safety, collectively update guidance on the appropriate weight to use in the Cockcroft-Gault equation, clarify that CrCl is not equivalent to eGFR, and work with GP clinical system suppliers to standardise the calculation of CrCl in the EHR.

Background: Colorectal cancer is the second leading cause of cancer-related mortality in the UK and a significant contributor to morbidity and mortality worldwide. Early diagnosis provides opportunities for intervention and improved survival. Significant event analysis (SEA) is a well-established quality improvement method for learning from new cancer diagnoses.

Aim: To provide additional insights into diagnostic processes for colorectal cancer and to identify areas for improvement in patient care pathways.

Design & setting: Fifty-three general practices across Pennine Lancashire, England, submitted one or more SEA reports as part of an incentivised scheme.

Method: A standardised data collection form was used to collate learning points and recommendations for improvements. In total, 161 reports were analysed using an inductive framework analysis approach.

Results: There was an overarching theme of building vigilance and collaboration between and within general practices and secondary care. The following four main sub-themes were also identified: education; individualised and flexible care; ownership and continuity; and communication.

Conclusion: These findings provide additional insights into colorectal cancer pathways from a primary care perspective. Practices should be supported in developing protocols for assessment and follow-up of patients with varying presentations. Screening and access to investigations are paramount for improving early diagnosis; however, a flexible diagnostic approach is required according to the individual circumstances of each patient.

Background: Oral anticoagulation (OAC) is the mainstay of treatment for the prevention of strokes in patients with atrial fibrillation (AF). Direct oral anticoagulants (DOACs) account for increasing OAC in patients with AF. However, prescribing DOACs for patients with established AF poses various challenges and general practice pharmacists may have an important role in supporting their management.

Aim: To investigate the effectiveness of pharmacist-led interventions in general practice in optimising the use of OAC therapies in AF.

Design & setting: A retrospective observational study in general practices in Bradford.

Method: The data were collected retrospectively from 1 November 2018-31 December 2019 using electronic health record data. The data were analysed: 1) to identify patients with AF not on OAC; 2) to describe inappropriate DOAC prescriptions; and 3) to calculate HAS-BLED scores.

Results: Overall, 76.3% (n = 470) of patients with AF received OAC therapy, and of these, 63.4% received DOACs. Pharmacist-led interventions increased DOAC prescribing by 6.0% (P = 0.03). Inappropriate DOAC use was identified in 24.5% of patients with AF, with underdosed and overdosed identified in 9.7% and 14.8%, respectively. Post-intervention, inappropriate prescribing was reduced to 1.7%. The mean HAS-BLED score decreased from 3.00 to 2.22 (P<0.01). Successful transition from vitamin K antagonist (VKA) therapy to DOACs was achieved in 25.7% of patients.

Conclusion: Pharmacist-led interventions have successfully improved the use of OAC therapies in patients with AF, and effectively managed the bleeding risks and transition from VKA to DOAC therapy, in line with guidelines.

Background: During the COVID-19 pandemic, general practices in Denmark rapidly introduced video consultations (VCs) to prevent viral transmission.

Aim: To study the use of VCs in daytime general practice by describing the rate of VCs, and the patient characteristics associated with having VCs.

Design & setting: Register-based study of consultations in daytime general practice in Denmark.

Method: We included all consultations in daytime general practice from 1 January 2019-30 November 2021. We calculated the rate of video use and categorised the general practices into no, low, and high use. Logistic regression was used to calculate adjusted odds ratios (aOR) for having a VC for different patient characteristics when contacting a video-using practice, stratified for low- and high-using practices.

Results: A total of 30 148 478 eligible consultations were conducted during the pandemic period. VCs were used mostly during the early stage pandemic period, declining to about 2% of all clinic consultations in the late-stage period. Patients having more VCs were young, had a long education, were employed, and lived in big cities. In low-using practices, native Danes and 'western' immigrants had higher odds of receiving a VC than 'non-western' immigrants, and patients with ≥2 comorbidities had lower odds than those without comorbidities.

Conclusion: Patients of a younger age, with long education, or employment had higher odds of receiving a VC, while patients of an older age and patients who had retired had lower odds. This difference in the access to VCs warrants further attention.