BJGP Open最新文献

Background: In France, 40% of people aged >16 years (20 million) report having at least one chronic disease requiring long-term treatment. Compliance with treatment at home is estimated to be 50% on average.

Aim: To study the practical management of oral treatments at home by people living with one or more chronic diseases.

Design & setting: A quantitative, descriptive, observational, cross-sectional study. Thirty GPs in France were invited by email to enrol 10 consecutive patients with chronic diseases.

Method: Standardised questionnaires were used to assess the sociodemographic profile of doctors and patients, and the management of oral medication at home.

Results: Twenty GPs collected 180 questionnaires of which 70% responders said they did not find taking their medication a problem; 43% used a pillbox; 79% said they knew 'all' their medications; and 61% reported forgetting to take their medication (versus 30% who reported never forgetting to take their medication).

Conclusion: More than half of patients are non-adherent to taking oral medication at home for their long-term conditions. Personalised reminders could reduce unintentional medication non-adherence.

Background: Cancer diagnoses often begin with consultations with GPs, but the non-specific nature of symptoms can lead to delayed diagnosis. Unexpected weight loss (UWL) is a common non-specific symptom linked to undiagnosed cancer, yet guidelines for its diagnostic assessment in general practice lack consistency.

Aim: To synthesise evidence on the association between UWL and cancer diagnosis, and to review clinical guidelines and recommendations for assessing patients with UWL.

Design & setting: Systematic search and analysis of studies conducted in primary care.

Method: Four databases were searched for peer-reviewed literature from 2012 to 2023. Two reviewers conducted all the steps. A narrative review was conducted detailing the evidence for UWL as a risk factor for undiagnosed cancer, existing clinical guidance, and recommended diagnostic approach.

Results: We included 25 studies involving 916 092 patients; 92% provided strong evidence of an association between UWL and undiagnosed cancer. The National Institute for Health Care and Excellence (NICE) Cancer Guideline in the UK was frequently cited. General suggestions encompassed regular weight monitoring, family history, risk factor evaluation, additional signs and symptoms, and a comprehensive physical examination. Commonly recommended pathology tests included C-reactive protein (CRP), complete blood count, alkaline phosphatase, and thyroid-stimulating hormone. Immunochemical faecal occult blood test, abdominal ultrasound, and chest X-ray were also prevalent. One large cohort study provided age, sex, and differential diagnosis-specific recommendations.

Conclusion: This evidence review informs recommendations for investigating patients with UWL and will contribute to a computer decision support tool implementation in primary care, enhance UWL assessment, and potentially facilitate earlier cancer diagnosis.

Background: Guideline-adherent oral anticoagulant treatment (OAC) in atrial fibrillation (AF) remains a challenge. In Denmark, most patients with AF are treated in general practice. Nevertheless, determinants of OAC prescription in primary care are poorly understood.

Aim: To investigate variation in OAC adherence between general practice clinics and identify clinic characteristics associated with a lower propensity to prescribe OAC.

Design & setting: Nationwide register-based cohort study including prevalent and incident patients with AF and CHA₂DS₂-VASc score≥2 (n=165,731) listed with Danish general practice clinics (n=1666) in 2021.

Method: The main outcome was OAC adherence assessed as proportion of days covered. We used clinic OAC propensity to evaluate variation. OAC propensity was quantified as ratios between observed and expected adherence. Expected adherence was estimated based on the composition of the clinic patient populations. Sampled reference populations were constructed to account for random variation. Linear regression models examined associations between OAC propensity and clinic characteristics.

Results: The proportion of days covered with OAC in the AF-population was 78%. OAC propensity in clinics in the 90^th percentile was 20% higher compared to clinics in the 10^th percentile, however this difference was reduced to 3% when accounting for random variation. Modest associations were observed between clinic characteristics and OAC propensity. The most significant difference was in the correlation between geographic location and OAC propensity, showing an 8% gap between top- and bottom-performing regions.

Conclusion: The study suggests persistent underutilisation of OAC in AF patients and little variation in OAC prescription patterns across general practice clinics.

Background: The career decisions of medical students are pivotal in shaping the future healthcare workforce. In many countries, the number of medical students who choose general practice (GP) as their career is insufficient to meet the needs of the healthcare system.

Aim: The aim of this study was to describe the factors influencing medical students' career intentions and their preference for a career in GP.

Design & setting: A cross-sectional study involving medical students from Flanders (Belgium), Estonia and Hungary.

Method: An online questionnaire was used to gather data. Multivariable logistic regression was conducted.

Results: Altogether 1601 medical students participated in this study. 18.5% of the participants were interested in GP. Factors related to medical students and the curriculum which predicted the interest in GP were being a woman, being a medical student from Flanders, being a 6th year medical student, coming from a rural area and having GP role models. Students preferring GP named the following factors as important: short and low intensity training program, having long-term and close relationship with patients, continuity of care, regular and flexible working hours and opportunities to achieve work-life balance.

Conclusion: This study adds further evidence which characteristics and factors can predict medical students' interest in GP, having GP role models being the most important predictor. Further research into which qualities medical students value in their role models could give us better understanding on how we can support GPs to be better advocates for their specialty and thereby help increase interest in GP.

Background: Many primary care organizations do not routinely collect sociodemographic data (SDD) such as race, gender, or income despite the importance of this data in addressing health disparities.

Aim: To understand the experiences of primary care providers and staff in collecting SDD.

Design & setting: A qualitative interview study with 33 primary care and interprofessional team members from eight Ontario Community Health Centres (CHCs).

Method: Semi-structured virtual interviews and content analysis of interview transcripts.

Results: Participants reported using both formal methods of SDD collection, and informal methods of SDD collection that were more organic, varied, and conducted over time. Participants discussed sometimes feeling uncomfortable collecting this data formally, as well as associated burden and limited resources to support collection. Client-provider rapport was noted as facilitating data collection and participants suggested more training, streamlined data collection, and better communication about purpose and use of data.

Conclusion: SDD can be collected informally or formally but there are limitations to informally collected data and barriers to the adoption of formal processes.

Background: Medical Office Assistants (MOAs), also known as receptionists and clerks, are front line workers and the most accessible member of the primary care team. Historically, their contributions to primary care have been unrecognised and undervalued. The COVID-19 pandemic put pressure on existing roles and systems in primary care: how MOAs adapted is unknown.

Aim: To explore the experiences of MOAs working in primary care during the COVID-19 pandemic from the perspectives of MOAs and family physicians (FPs) who worked with MOAs during this period.

Design & setting: A qualitative study using Constructivist Grounded Theory, conducted in Ontario, Canada METHOD: Seventeen participants were recruited through professional contacts of the research team. Individual semi-structured interviews were conducted with MOAs and FPs across the province.

Results: MOAs' many responsibilities in primary care intensified during the pandemic. MOAs leveraged their healthcare system knowledge and therapeutic relationships with patients to reduce patient distress. Unfortunately, MOAs experienced more frustration, and in some cases, abuse from patients. MOAs' ability to adapt to new systems and respond to high patient needs seemed to be positively influenced by their relationships with patients and FPs. FPs expressed concern for MOA welfare and recognised their critical role on primary care teams.

Conclusion: MOAs made significant contributions to primary care during the COVID-19 pandemic. This study suggests MOAs have greater capacity than previously recognised which has important implications for planning in an era of under-resourced healthcare.

Background: To strengthen primary health care (PHC), there is a need to measure its performance.

Aim: To measure primary care performance in one rural Ugandan district.

Design and study setting: A cross-sectional survey of Tororo District administered the Primary Care Assessment Tool (PCAT) across a sample of 51 facilities. There were four levels of health facilities (health centres II to general hospital).

Method: Random sample of 100 users was obtained from each level while including all primary care providers and managers. Data was collected in REDCap software, and analysed using Statistical Package for Social Sciences vs23.

Results: Only 35.1% of users had a strong affiliation with their PHC facility. Overall primary care score suggested that performance was acceptable to the majority of users (58.9% rating performance at least acceptable). Ongoing care was rated by users as very poor (<25% of people rating it at least acceptable). Comprehensiveness (services available) was rated poor by users (<50% finding it at least acceptable). Users rated first contact access and coordination (information systems) acceptable (51-75% finding them at least acceptable). Person-centredness and comprehensiveness (services provided) were rated good by users (>75% rating them as acceptable or more). Providers and users differed significantly in their scoring across all domains, with providers usually more positive. Performance significantly improved as the PHC level increased.

Conclusion: Primary care performance in the study district was sub-optimal. The PCAT identified primary care functions that needed improving and may be a useful tool to measure PHC performance across the region.

Background: Healthcare providers in general practice are expected to deliver mental healthcare to patients through shared decision-making (SDM). It is unclear if they perceive their SDM to be affected by challenging circumstances in mental healthcare, eg, how waiting time for therapy plays a role.

Aim: To explore how healthcare providers and patients in general practice engage in SDM, given the challenging circumstances in mental healthcare.

Design & setting: A qualitative interview study in seven Dutch general practices.

Method: Semi-structured interviews were conducted with general practitioners (GPs; N=9), practice nurses mental health (PNMHs; N=8) and patients that sought mental healthcare (N=18). The interviews were deductively and inductively thematically analyzed.

Results: The participants mainly reported on SDM regarding treatment in secondary mental healthcare. The PNMHs explained they lack an overview of available treatments and waiting times in facilities. The PNMHs therefore instruct patient to also search for options themselves. Most patients found this approach burdensome, especially those new to mental healthcare. These patients were said to often express no strong treatment preferences and rely on advice by their healthcare providers. The GPs and PNMHs explained that in such cases, they often adopt a pragmatic approach and for example refer indecisive patients to facilities with little waiting time.

Conclusion: The healthcare providers and patients in general practice experience they adapt their approach to SDM in reaction to the circumstances in mental healthcare. Further exploration of how SDM is implemented and shaped by challenging circumstances across different healthcare settings is needed.

Background: Access to high-quality perimenopause (PMP) care for UK Armed Forces (UKAF) personnel is crucial, given the increasing proportion of women aged 40-55. However, due to the lack of exposure of General Practitioners (GP) to the PMP in Defence Primary Health Care (DPHC), there are concerns about the confidence in PMP management, particularly in prescribing hormone replacement therapy (HRT).

Aim: To assess the confidence of GPs working in DPHC in the management of the PMP.

Design & setting: This study employed a mixed methods approach and included all GPs (Uniformed and Civilian) working in DPHC.

Method: A cross-sectional survey gathered quantitative data on demographics, views on perimenopause care, and self-rated confidence levels in managing the perimenopause among Defence GPs. Semi-structured interviews of purposefully sampled respondents was thematically analysed to explore this further.

Results: There were 164 responses from 542 Defence GPs (response rate 30.3%). The majority of respondents expressed confidence in managing the perimenopause but reported lower confidence levels in prescribing HRT for younger women and initiating testosterone. Factors influencing confidence included recent perimenopause continuing professional development (CPD), GP gender, and exposure to perimenopause cases. Semi-structured interviews provided deeper insights into GP characteristics, CPD, and awareness of the PMP. Women's health hubs providing PMP care and experiential education were strongly supported.

Conclusions: While the study identified gaps in confidence among Defence GPs, particularly in certain aspects of perimenopause management, similar to those found in NHS GPs. CPD and case exposure were important predictors of confidence, with strong support for regional women's health hubs to optimise PMP care. Further research is warranted to explore strategies for bridging confidence gaps and improving perimenopause care delivery within the UKAF context.

Background: The usage of telehealth in general practice (GP) has risen substantially ever since the COVID-19 pandemic. Over this timeframe, telehealth has provided care for all patient demographics, including the paediatric population (aged<18). However, the translatability of telehealth (ie, whether in-person tasks can be supported remotely via telehealth) rarely considers the paediatric population or their carers.

Aim: To examine the degree of translatability to telehealth for in-person GP consultations on paediatric patients with consideration of the carers' roles.

Design & setting: This study screened 281 videos of in-person GP consultations set within UK general practices, and 20 of them were eligible for analysis.

Method: Secondary analysis of in-person GP consultations to examine tasks, physical artefacts, examinations and the interaction between carer, patient and GP. A novel scoring method revolving around two key metrics, taking into consideration the carer, was designed to analyse whether the tasks performed can be supported via telehealth.

Results: Analysis of 20 eligible consultations revealed 13 distinct physical examinations, 19 physical artefacts and 17 clinical tasks. Of these 17 clinical tasks, 41% were deemed 'definitely or easily translatable to telehealth,' ' 29% 'somewhat translatable with patient-provided equipment,' 12% 'potentially translatable,' and 18% 'currently untranslatable.' The average telehealth translatability score was 6.1/10, which suggests possible challenges with telehealth support. Regarding carer involvement, 90% of consultations involved collecting patient history, 70% placation of child, and 40% had physical support during examinations.

Conclusion: Tasks performed during paediatric in-person GP consultations may not be easily translatable to telehealth and caution should be exercised when considering its translatability to telehealth.