BJGP Open最新文献

Background: Penicillin allergy (PenA) prevalence is approximately 6%, but fewer than 10% of these people are expected to be truly allergic. Consequently, a significant proportion of the population are prescribed alternative antibiotics with potential increased risk of acquiring multi-drug resistant bacteria and worse health outcomes. The ALABAMA trial aimed to determine if a penicillin allergy assessment pathway (PAAP) initiated in primary care, is effective in de-labelling erroneous records, improving antibiotic prescribing and patient outcomes.

Aim: To investigate healthcare professionals' experiences of the ALABAMA trial.

Design & setting: Qualitative study using semi-structured interviews in general practice in England.

Method: Semi-structured interviews were conducted with healthcare professionals (including general practitioners, research nurses, pharmacists) who delivered the trial. Interviews explored their views about de-labelling incorrect PenA records, their role(s) in the trial, and, where relevant, their experience of prescribing following de-labelling.

Results: Healthcare professionals (n=18) believed many patients were incorrectly labelled PenA and were aware of the individual and public health risks this posed. However, GPs explained labels were rarely challenged in general practice because the perceived risks to patients and their professionalism were too great. The PAAP intervention, alongside the 'protocolisation' within the ALABAMA trial, was successful at mitigating these risks. Consequently, the trial was well-accepted and commended by healthcare professionals.

Conclusions: GPs welcomed and accepted the PAAP as a means of correcting erroneous PenA records. There is great potential for PAAP to be supported in primary care if testing becomes more accessible.

Background: Ensuring sufficient supply of general practitioners (GPs) is critical for servicing increasing healthcare demands. Heightened by pandemic conditions, chronic shortages of GPs persist globally. Whilst many factors reinforcing general practice specialty choices are known, system-level understanding of GP career decision-making influences across medical training requires investigation.

Aim: To explore specialty choice rationales through career selection narratives of recently registered Australian GPs, using a system-level perspective.

Design & setting: Semi-structured interviews were selected for in-depth explorations of GP specialty choice rationale. Within Australia, medical specialty training choices are typically made after both university medical education and mandatory one-to-two year prevocational (hospital-based) training is completed.

Method: Interviews were conducted online with GPs who had completed all training in the last 10 years. De-identified and verified transcripts underwent participant checking. Deductive framework analysis using career counselling constructs, and inductive thematic analysis were performed.

Results: There were 25 participants. Career counselling constructs provided system-level understanding of GP specialty decision-making processes. Large gaps in GP career information were highlighted throughout medical training for many participants. Overcoming negative medical narratives about general practice was necessary for most in choosing a GP career. However, positive experiences with GP communities or work created insights into the broad flexibility of GP person-specialty fit.

Conclusion: GP work experiences and personal GP connections could counteract prominent negative narratives about GP careers. However, lack of systemic and regular exposure to GPs throughout medical training is a critical barrier that should be addressed through sustained policy and professional interventions.

Background: Pharmacological prescription guidelines for hypertension lack differentiation between the sexes, despite reported sex differences in prevalence, awareness, pathophysiology and pharmacological response.

Aim: We aimed to assess prescription patterns of blood pressure lowering medication among women and men in primary care.

Design & setting: We analysed data collected in 2018 during routine primary care practice among those pharmacologically treated for elevated blood pressure, and free from cardiovascular comorbidities or diabetes mellitus.

Method: We assessed sex differences in the number of prescribed drugs, defined daily dosage, type of antihypertensive medication, and blood pressure control. We adjusted for differences between sexes in age and other covariates.

Results: This observational study included 8596 women and 5788 men. Both women and men were prescribed on average 1.8 antihypertensive agents per person. Women compared to men were prescribed a significantly lower defined daily dosage (1.8 vs 2.1, P<0.001), received more often betablockers (35.4% vs 26.3%, P<0.001) and diuretics (53.7% vs 50.5%, P<0.001), while receiving fewer ACE-inhibitors (35.4% vs 46.3%, P<0.001) and calcium channel blockers (28.5% vs 35.6%, P<0.001). No sex differences were found for angiotensin receptor blockers (24.3 vs. 24.4%, P=0.842). Importantly, women had significantly better controlled hypertension than men (50.2% vs 45.5%, P<0.001).

Conclusion: In those pharmacologically treated for elevated blood pressure, differences between women and men exist in defined daily dosage, type of antihypertensive medication, and blood pressure control, with women achieving better hypertension control than men with different type of medication and lower dosage.

Background: There may be distinctly different ways for general practices to serve the growing population of older patients, providing them different combinations of face-to-face-, telephone-, and e-mail consultations, home visits, and chronic care reviews.

Aim: To identify latent general practice profiles of frequency and combination of consultation types for older patients and relate them to practice characteristics.

Design & setting: Register-based cohort study of all Danish citizens aged≥75 years.

Method: For each of the years 2017-2021, a latent profile analysis was conducted on the practices' frequencies of consultation types adjusting for patient population characteristics.

Results: We identified a "Majority" and three temporary latent profiles of provision of consultation services to older patients: The "Phone heavy" profile (8-10% of practices, 2017-2019) providing nearly double the telephone consultations as the "Majority" profile and was associated with the general practitioners being older and working singlehanded, the "High frequency" profile (12-14% of practices, 2017-2018) providing higher levels of face-to-face, telephone, and e-mail consultations than the "Majority" profile, and the "Phone and e-mail heavy" profile (7% of practices, 2020) providing more e-mail than face-to-face consultations, and more of each consultation than the "Majority" profile. The number of profiles decreased from 3 in 2017 to only the "Majority" profile 2021.

Conclusion: There is a trend towards a more uniform pattern of consultations for older patients in general practice. It is unknown whether high provision of certain types of consultations in general practice has downstream effects, such as decreased need for hospital- and out-of-hours services.

Background: Treatment targets for cardiovascular risk management (CVRM) make no distinction between women and men.

Aim: To explore sex differences in achieving treatment targets in patients who participated in a nurse-led, integrated CVRM care programme in primary care between 2013 and 2019.

Design & setting: We conducted a dynamic cohort study in the Eindhoven region, which is the south-eastern part of the Netherlands.

Method: We assessed outcomes of three biological risk factors (systolic blood pressure [SBP], low-density lipoprotein [LDL] cholesterol, and estimated glomerular filtration rate [eGFR]) and four lifestyle factors (smoking, physical activity, alcohol intake, and body mass index [BMI]). Points (1 = on target; 0 = not on target) were assigned for biological risk factors, lifestyle factors, and an overall score. Using the annual results, we applied multivariable regression models to study trends over time and differences in trends between women and men.

Results: The number of participants increased from 24,889 to 38,067, mean age increased from 67.3 years to 71.5 years, with around 52 % women each year. The average of seven risk factors on target increased significantly from 4.6 to 4.9 in women, and from 4.7 to 5.0 in men, with no statistical difference between women and men. Differences between women and men in 2013 in the number of both biological and lifestyle factors on target did not materially change over time.

Conclusion: Integrated cardiovascular management care led to improvements in cardiovascular risk factors on target, equally well in women than in men. Differences in risk factors on target between women and men in 2013 were still present in 2019.

Background: Dementia diagnostics can often be performed in primary care, yet older people with memory complaints are frequently referred to memory clinics (MCs).

Aim: To compare diagnostic information in GP referral letters of patients with and without an eventual dementia diagnosis.

Design & setting: Retrospective cohort study in a Dutch academic MC.

Method: We collected electronic health record (EHR) data of consecutive patients aged ≥65 years referred by their GP between 2016 and 2020. EHR data included patient characteristics, diagnostic information in referral letters, ancillary investigations performed at the MC, and established diagnoses. We performed χ² tests to compare groups.

Results: Of 651 patients included, the average age was 78.0 years (standard deviation 6.8) and 348 (53.5%) were diagnosed with dementia. Most people with dementia were diagnosed without ancillary investigations (n = 235/348, 67.5%). In GP referral letters of people with dementia compared with people without dementia, a collateral history, any physical examination, a differential diagnosis including dementia, a Mini-Mental State Examination score, interference with daily functioning, and decline from previous levels of functioning were mentioned more often. Furthermore, the more diagnostic criteria mentioned in the referral letter, the more often dementia was diagnosed at the MC (no criteria: 35.4%; one criterion: 47.3%; two criteria: 53.4%; three criteria: 69.9%; and four or five criteria: 83.3%).

Conclusion: GPs often correctly mention diagnostic information and dementia criteria in referral letters of people with dementia, and they are often diagnosed without ancillary investigations. This suggests that referral is often unnecessary, and GPs can be empowered to diagnose dementia themselves.

Background: Natriuretic peptides (NPs) are released by increased ventricular wall stress, most often caused by heart failure (HF). NP level measurement helps select patients clinically suspected of HF who need echocardiography. Yet, the diagnostic actions following NP testing in daily primary care are poorly studied.

Aim: To assess the diagnostic actions taken by GPs in patients with an elevated NP level.

Design & setting: Retrospective observational study in general practices in The Netherlands.

Method: In patients with an elevated NP level between July 2017 and July 2022, diagnostic actions were collected during 3 months following NP testing. We compared patients with an elevated NP level referred for echocardiography with those not referred by univariable analyses.

Results: Among 902 patients, 394 (43.7%) had an elevated NP level. Median age was 75.0 (interquartile range [IQR] 18.0) years; 68.8% were female. In total, 166 (42.1%) were referred for echocardiography and 114 (28.9%) underwent additional electrocardiogram (ECG) recording. In total, n = 30/166 (18.1%) referred patients were labelled HF by the cardiologist within 3 months after NP testing compared with n = 29/228 (12.7%) not referred. Referred patients were compared with those not referred and they were found to be younger (69.7 versus 74.1 years, P<0.001), were less often known to cardiologists (45.8% versus 62.3%, P = 0.002), and they had lower marginally elevated B-type natriuretic peptide (BNP) levels (35-50 pg/ml) (19.3% versus 36.6%, P<0.001).

Conclusion: Three out of five patients with an elevated NP level are not referred for echocardiography by GPs. Barriers to refer patients were older age, a marginally elevated BNP value, and already being under supervision of a cardiologist.

Background: The COVID-19 pandemic led to a rapid transition to telehealth, particularly in general practice where continuous care for chronic conditions, such as musculoskeletal (MSK), is provided.

Aim: To determine the appropriateness of telehealth for MSK conditions by identifying whether in-person tasks can be supported remotely via telehealth.

Design & setting: This study is a secondary analysis of the Harnessing Resources from the Internet (HaRI) dataset. This dataset comprises of 281 videos of recorded GP consultations. The dataset includes 10 GPs, across eight separate clinics, and was collected during 2017 in the UK.

Method: Content analysis was conducted to identify the clinical tasks, physical examinations, and physical artefacts used during the consultations. A scoring method applying two key metrics was developed to assess the translatability of clinical tasks to telehealth.

Results: Across the 31 MSK consultations analysed, 12 clinical tasks, five physical examinations, and 12 physical artefacts were observed. Of clinical tasks, 17% (n = 2/12) were deemed to be 'easily translatable over telehealth' and 50% (n = 6/12) were deemed 'relatively easy to be translated over telehealth'. Only 17% (n = 2/12) of tasks were rated 'moderately translatable over telehealth', and 17% (n = 2/12) were deemed 'potentially translatable over telehealth'. No clinical tasks in this study were categorised as untranslatable to telehealth. The average telehealth translatability score was 7.1/10.

Conclusion: Most clinical tasks observed during in-person GP consultations with patients with MSK conditions are translatable to telehealth. Further research is necessary to investigate the long-term efficacy and safety of telehealth utilisation for MSK conditions in primary care.

Background: With ageing of the population both prevalence of chronic kidney disease (CKD) and incidence of kidney replacement therapy (KRT) are rising. Existing research suggests that Read-coding for CKD in those affected is associated with better implementation of recommended care and fewer hospitalisations for heart failure.

Aim: To investigate whether coding for CKD is associated with regional KRT incidence in England.

Design & setting: This is an ecological study using the clinical commissioning groups (CCG) in England as geographical units.

Method: KRT incidence rates were calculated using UK Renal Registry (UKRR) data from 01/2019 to 12/2021. Data on the percentage of uncoded CKD patients (PUCP) who had laboratory evidence of CKD but lacked a diagnostic code were obtained from the CVDPREVENT Audit, a national audit that extracts routinely held general practitioner data. Data on confounders and acute kidney injury (AKI) mortality as a marker for population frailty were obtained from CVDPREVENT and the UKRR, respectively. Poisson models assessed the association between PUCP and KRT incidence.

Results: After adjusting, the PUCP was non-linearly associated with KRT incidence, with the CCGs in the lowest PUCP quintile having a lower KRT incidence than the others. There was evidence that this association was more pronounced in CCGs with high AKI mortality compared to CCGs with low AKI mortality.

Conclusion: At the geographical level in England, the data suggests that the prevalence of not having formally diagnosed CKD is non-linearly associated with a higher KRT incidence rate, especially in areas with a high AKI mortality.