BJGP Open最新文献

Background: UK cancer deaths remain high; primary care is key for earlier cancer diagnosis as half of avoidable delays occur here. Improvement is possible through lower referral thresholds, better guideline adherence, and better safety-netting systems. Few interventions target whole practice teams. We developed a novel whole-practice team intervention to address this.

Aim: To test the feasibility and acceptability of a novel, complex behavioural intervention, 'ThinkCancer!', for assessment in a subsequent Phase III trial.

Design & setting: Pragmatic, superiority pilot randomised controlled trial (RCT) with an embedded process evaluation and feasibility economic analysis in Welsh general practices.

Method: Clinical outcome data were collected from practices (the unit of randomisation). Practice characteristics and cancer safety-netting systems were assessed. Individual practice staff completed evaluation and feedback forms and qualitative interviews. The intervention was adapted and refined.

Results: Trial recruitment and workshop deliveries took place between March 2020 and May 2021. Trial progression criteria for recruitment, intervention fidelity, and routine data collection were met. Staff-level fidelity, retention, and individual level data collection processes were reviewed and amended. Interviews highlighted positive participant views on all aspects of the intervention. All practices set out to liberalise referral thresholds appropriately, implement guidelines, and address safety-netting plans in detail.

Conclusion: 'ThinkCancer!' appears feasible and acceptable. The new iteration of the workshops was completed and the Phase III trial has been funded to assess the effectiveness and cost-effectiveness of this novel professional behaviour change intervention. Delivery at scale to multiple practices will likely improve fidelity and reach.

Background: GPs play a key role in the diagnosis and management of eating disorders (EDs).

Aim: To explore GPs' experiences of managing patients with EDs.

Design & setting: A qualitative study utilising remote semi-structured interviews in the UK.

Method: Fourteen GPs were interviewed about their experiences of supporting patients with EDs. The interviews were recorded, transcribed, and analysed using thematic analysis.

Results: The analysis described the following four themes: (i) 'Continuity of care', addressing the GP's relationship with patients and family, patient transitions across life stages and geographical areas, and patient non-attendance; (ii) 'The role of guidance', focusing on guidelines and protocols, referrals and specialist professionals as points of contact; (iii) 'Structural barriers', including waiting times, lack of resources, referral criteria, and relationships between services; (iv) 'Confidence and skills', reflecting professional and personal experience in EDs, previous training and training needs. Transcending these themes was the notion of the 'Limits to the care' GPs can provide owing to professional boundaries and the emotional impact of managing patients with EDs.

Conclusion: This study found that while GPs want to help patients with EDs many limits remain to the care they can provide owing to both internal and external factors. Funding is required for training and accessible specialist ED support, and greater clarity is needed regarding referral processes if ED management in primary care is to be optimised.

Background: The true burden of Lyme disease in primary care in Scotland is unknown. Epidemiological data are currently based on laboratory-confirmed reports as there is no mandatory reporting of clinical cases.

Aim: To analyse data from general practice in NHS Highland (North) over a 6-year period to assess the incidence and management of Lyme disease in primary care.

Design & setting: This was a retrospective descriptive study. Study data from 2017 to 2022 were extracted from all 63 general practices within NHS Highland (North).

Method: Consultations for Lyme disease were identified via Lyme-related clinical Read codes, requests for borrelia tests , free text, 'tags' and/or Lyme disease antibiotic scripts.

Results: Using Read codes to identify patients with Lyme disease or suspected Lyme disease gave an estimated average annual incidence of 124/100 000 population, which was 2.1 times more than estimates based solely on laboratory-confirmed reports. The incidence figures increased 5.2 times (362/100 000 population) when patients with Lyme disease or suspected Lyme disease (identified via Read codes, laboratory test requests, and free text tags) who were given antibiotic treatment were taken into account. Local 'hot spots' of infection were identified. Analysis of the antibiotic data indicates that antibiotic prescribing in NHS Highland largely follows the National Institute for Health and Care Excellence (NICE) guidelines.

Conclusion: This data analysis pathway can, and should, be rolled out across the whole of Scotland to assess the incidence and management of Lyme disease in primary care and allow appropriate allocation of resources.

Background: Organisations providing secondary care in the NHS in England have historically not also provided primary health care, but this is changing. Data on where this kind of 'vertical integration' is happening are lacking, making it difficult to evaluate its impact.

Aim: To compile a comprehensive list of instances of secondary care trusts running general practices in England, to enable evaluation of the impact of such arrangements.

Design & setting: This service mapping study comprises review, collation, synthesis, and analysis of published information describing secondary and primary care provision in the NHS in England in March 2021.

Method: Desk-based collection, including hand-searching, of secondary care organisations' statutory annual reports. Triangulation via comparison with national data on general practices, the general practice workforce and practice contracts.

Results: It was possible to construct a database of all instances of trusts running general practices in England as of 31 March 2021. We have identified 26 trusts running a total of 85 general practices, operating across a total of 116 practice sites. These practices have on average fewer patients and fewer GP full-time equivalents than other general practices, and before becoming vertically integrated were performing less well in the Quality and Outcomes Framework.

Conclusion: We recommend that national statistics recording the details of general practices contracting with the NHS should include whether each practice is owned by another organisation and whether that is an NHS trust, another public body, or a private organisation. Such data are required to enable evaluation of the impacts of this kind of vertical integration.

Background: The English NHS data opt-out allows people to prevent use of their health data for purposes other than direct care. In 2021, the number of opt-outs increased in response to government-led proposals to create a centralised pseudonymised primary care record database.

Aim: To describe the potential impact of NHS national data opt-outs in 2021 on health data research.

Design & setting: We conducted a descriptive analysis of opt-outs using publicly available data and the potential consequences on research are discussed.

Method: Trends in opt-outs in England were described by age, sex, and region. Using a hypothetical study, we explored statistical and epidemiological implications of opt-outs.

Results: During the lead up to a key government-led deadline for registering opt-outs (from 31 May 2021-30 June 2021), 1 339 862 national data opt-outs were recorded; increasing the percentage of opt-outs in England from 2.77% to 4.97% of the population. Among females, percentage opt-outs increased by 83% (from 3.02% to 5.53%) compared with 76% in males (from 2.51% to 4.41%). Across age groups, the highest relative increase was among people aged 40-49 years, which rose from 2.89% to 6.04%. Considerable geographical variation was not clearly related to deprivation. Key research consequences of opt-outs include reductions in sample size and unpredictable distortion of observed measures of the frequency of health events or associations between these events.

Conclusion: Opt-out rates varied by age, sex, and place. The impact of this and variation by other characteristics on research is not quantifiable. Potential effects of opt-outs on research and consequences for health policies based on this research must be considered when creating future opt-out solutions.

Background: Acute abdominal pain is a common complaint, caused by a variety of conditions, ranging from acutely life-threatening to benign and self-limiting, with symptom overlap complicating diagnosis. Signs and symptoms may be valuable when assessing a patient to guide clinical work.

Aim: Summarising evidence on the accuracy of signs and symptoms for diagnosing serious illness in adults with acute abdominal pain in an ambulatory care setting.

Design & setting: We performed a systematic review, searching for prospective diagnostic accuracy studies that included adults presenting with acute abdominal pain to an ambulatory care setting.

Method: Six databases and guideline registers were searched, using a comprehensive search strategy. We assessed the risk of bias, and calculated descriptive statistics and measures of diagnostic accuracy. Results were pooled when at least four studies were available.

Results: Out of 18 923 unique studies, 16 studies with moderate to high-risk bias were included. Fourteen clinical features met our criteria, including systolic blood pressure <100 mmHg (positive likelihood ratio [LR+]7.01), shock index >0.85, uterine cervical motion tenderness (LR+5.62 and negative likelihood ratio [LR-]8.60), and a self-assessment questionnaire score >70 (LR+12.20) or <25 (LR-0.19). Clinical diagnosis made by the clinician had the best rule-in ability (LR+24.6).

Conclusions: We identified 14 signs and symptoms that can influence the likelihood of a serious illness, including pain characteristics, systemic signs, gynaecological signs, and clinician's overall assessment. The risk of bias was moderate to high, leading to uncertainty and preventing us from making firm conclusions. This highlights the need for better research in this setting.

Background: To be effective, interventions aimed at increasing the appropriateness of antibiotic use in primary care should consider the perspectives of prescribing physicians.

Aim: To explore the decision making of general practitioners (GPs) when managing uncomplicated urinary tract infections (uUTIs) in women.

Design & setting: A qualitative study using semi-structured interviews with 22 GPs in Bavaria and Baden-Württemberg (southern Germany).

Method: Verbatim transcripts were analysed through inductive qualitative content analysis.

Results: We generated the following three main themes: factors facilitating the decision making; factors complicating the decision making; and consultation modalities. According to participants, following evidence-based recommendations makes the prescription decision smoother. GPs' and patients' prior experiences and beliefs guides decisions towards certain antibiotics, even if those experiences and beliefs contradict evidence-based recommendations. Patient expectations and demands also condition antibiotic prescribing, favouring it. Organisational constraints, such as time pressure, the day of the week (for example, before weekends), and a lower cost of antibiotics for patients than alternative treatments favour the decision to prescribe antibiotics. Diagnostic and prognostic uncertainty complicates decision making, as does scepticism towards evidence-based recommendations. Discordance within the patient-doctor relationship contributed to this complexity. Regarding consultation modalities, a more in-depth consultation and shared decision making were seen as helpful in this process.

Conclusion: We identified different factors as intervening against or for a straightforward management decision when dealing with women with uUTIs. They reveal the complexity behind the GPs' decision making. Providing GPs with easy-to-apply guidance while removing economic constraints to allocate sufficient consultation time, and supporting shared decision making may help GPs appropriately manage uUTIs in women.

Background: Research examining general practice supervisor wellbeing has often been conducted within the context of trainee wellbeing and educational outcomes.

Aim: To consolidate the current literature regarding the wellbeing of GP supervisors through a 'supervisor-wellbeing' lens.

Design & setting: Literature review of original research studies on Embase, Ovid MEDLINE, and Ovid PsycINFO from inception to December 2022.

Method: The Embase, Ovid MEDLINE, and Ovid PsycINFO databases were systematically searched from inception to December 2022. Original research studies were eligible if they explored any aspect of wellbeing or burnout (that is, construct conceptualisations, risk and protective factors, implications, or interventions) among GPs involved in educating GP trainees. Reporting quality of included studies was assessed using the QualSyst tool. Results from included studies were narratively synthesised.

Results: Data from 26 independent samples were reviewed. Burnout was generally conceptualised using the Leiter and Maslach model. Wellbeing was poorly defined in the literature, largely being conceptualised in personal psychological terms and, to a lesser extent, professional satisfaction. Risk and protective factors were identified and grouped as individual (for example, satisfaction with capacity to teach) and external (for example, autonomy, collegial relationships, resource availability) factors. GP supervisors' wellbeing appeared to affect their job performance and retention. This review identified only two studies evaluating interventions to support GP supervisors' wellbeing.

Conclusion: The present review highlights a lack of conceptual clarity and research examining interventions for GP supervisor wellbeing. It provides guidance for future research designed to maximise the wellbeing of GP supervisors and support the wellbeing of trainees.

Background: Despite programmatic protocolised care and structured support, considerable variation is observed in completeness of registration and achieving targets of cardiovascular risk management (CVRM) between individual GPs in the Netherlands.

Aim: To determine whether completeness of registration and achieved targets of cardiovascular risk factors improves with practice visitation.

Design & setting: Observational study utilising the care group's database (2016-2019), comparing changes in registration and achieved targets in non-visited practices and visited practices.

Method: We compared completeness scores of registration and scores of targets achieved before visitation and 1 year after visitation. Data were analysed on patient level and GP level. Separate analyses were performed among GPs who were ranked in the lower 25% of score distributions.

Results: We observed no clinically relevant improvements in completeness of registration and targets achieved in 2017, 2018, and 2019 that could be attributed to visitations in the previous year, both on individual patient level and on aggregated level per general practice. In practices ranked in the lower 25% of the distribution, improvements over time were clinically relevant and larger than the overall changes. Yet, these findings were irrespective of the number of practice visitations.

Conclusion: Practice visitations in our setting did not seem to lead to improvements in practice performance, nor in completeness of registration of risk factors or in reaching predefined target goals for cardiovascular risk factors.