BJGP Open最新文献

Background: There is limited evidence to support the current standard recurrent urinary tract infection (rUTI) definition of ≥2 UTIs within 6 months or ≥3 within 12 months. Information about reinfection risk after meeting criteria for rUTI may aid decisions on the value of prophylactic approaches.

Aim: To estimate the risk of subsequent UTI associated with different rUTI definitions.

Design & setting: Electronic health record study using Infections in Oxfordshire Research Database (IORD, 2008-2019) and the Clinical Practice Research Datalink (CPRD, 2009-2019).

Method: We identified community-acquired UTIs, separated by 28 days, in non-pregnant women aged 16+years. We created candidate rUTI definitions varying the time window from 3-9 months, and the number of UTIs required to meet the definition from 2-3 episodes. For each definition, we calculated Kaplan-Meier risk estimates of subsequent UTIs within 6 and 12 months after meeting rUTI criteria.

Results: Of eligible women with at least one UTI, 18% (15,617/84,809) in IORD and 20% (334,487/1,703,088) in CPRD experienced ≥1 rUTI (current definition). The risk of at least two subsequent UTIs within 12 months after meeting the current rUTI definition rose from 17% (IORD) and 16% (CPRD) to 33% (IORD) and 32% (CPRD) under a rUTI definition of ≥3 UTIs within 6 months. Risk of subsequent UTI also increased with age.

Conclusion: Risk estimates of subsequent UTIs after a rUTI vary according to the definition of rUTI adopted. Estimates provided here could support shared decision making around UTI prophylaxis and stratification of populations included in future rUTI research.

Background: An estimated half a million UK primary care consultations are due to middle ear infections annually. In children, ear infections are one of the most common reasons for antibiotic use.

Aim: To describe parents' experiences and actions for their child's ear infection symptoms.

Design & setting: Online survey with parents of children aged 10 years or younger who had suspected ear infection symptoms in the previous 12 months in England.

Method: Data were collected retrospectively and through self-report. Multivariable logistic regression explored association of variables with consulting and reported prescription of antibiotics.

Results: 503 parents participated. Most parents perceived their child's symptoms as mild (25.8%) or moderate (64.6%). Consulting healthcare was the most reported action (90%); 74% consulted within 1-2 days. Perceived severity and duration of symptoms were associated with consulting. Parents were concerned about serious illness and the need for treatment. Other factors associated with consulting were missing work (AOR 4.8, 95% CI: 1.6 - 14.8), childcare impacts (AOR 3.1, 95% CI: 1.0 - 9.5) and fluid in child's ear (AOR 3.9, 95% CI: 1.48 - 10.5). Of consultors (454/503), 55.7% reported receiving an antibiotic. Of all parents (503), 36% believed children always require antibiotics for ear infections.

Conclusion: Most parents consult for their child's ear infection symptoms and are prompted by impacts on daily life and perceptions of risk and treatment needs. There are knowledge gaps, which if addressed, may help to reduce primary care consultations and antibiotic use by supporting parents to manage self-limiting ear infections in children.

Background: Social media is a pervasive part of young peoples' lives and may influence their mental health. Primary care is often the first point of care when seeking help for mental health problems. However, little is known about how young adults with mental health problems experience and perceive primary care support for managing social media.

Aim: To explore young adults' views on help-seeking for social media use in primary care in relation to mental health problems.

Design & setting: Qualitative interview study with 28 young adults aged 18-25 with self-reported mental health problems across England.

Method: Semi-structured interviews were analysed thematically to identify barriers and facilitators to help-seeking. Themes were organised using the Theory of Planned Behaviour - attitudes, social norms and perceived behavioural control.

Results: Barriers for help-seeking included attitudes that social media was a secondary issue and low expectations of meaningful support; perceived negative attitudes and limited understanding of social media by primary care clinicians, communities and families; and constrained ability to seek help due to limited consultation time and uncertainty around how to seek help. Facilitators included clinicians offering practical strategies, raising the topic non-judgmentally, receiving training to better understand young people's digital lives, longer appointment times, and clearer information about support in primary care for social media-related concerns.

Conclusion: Young adults with mental health concerns face multiple barriers to discussing social media in primary care, shaped by attitudes and structural challenges. Addressing these through clinician training, communication, and service adaptations may enhance engagement and support.

Background: Relational continuity of care (RCC), which is characterised by an ongoing therapeutic relationship between patients and their primary care providers, is critical for ensuring high-quality care in general practice. Despite its importance, challenges, such as staffing shortages, policy shifts, and evolving patient needs, often impede its consistent delivery. With the new GP contract in England highlighting the need for primary care providers to monitor and deliver relational continuity, it is more crucial than ever to understand how best to achieve it.

Aim: To explore how, why, and under what conditions interventions to improve relational continuity are successfully implemented in general practice.

Design & setting: The realist review will be supported by an expert stakeholder panel and a patient advisory group to consider the diverse and dynamic settings of general practice, and generate contexts, mechanisms, and outcomes configurations exploring how interventions to enhance RCC in general practice work.

Method: Through the synthesis of diverse international evidence sources, including qualitative, quantitative, and mixed-methods studies, as well as grey literature, the review will develop an understanding of the mechanisms that produce relational continuity, the contexts in which these mechanisms operate, and the outcomes they produce for the health system, practices, practitioners, and patients.

Conclusion: The findings will provide data to inform future research and refine strategies and policies that support the effective delivery of relational continuity, which in turn may lead to improved patient outcomes and enhanced care experiences.

Background: Ineffective care planning at the end of life carries high rates of unscheduled hospitalisation and avoidable deaths in hospital. Palliative care registration (PCR) and crucially, care planning, helps improve adverse outcomes. However, identification for registration often occurs late or not at all.

Aim: To improve PCR accuracy and uptake by developing an automated digital tool, utilising palliative care process markers, combined with clinical judgement, to identify those with palliative care needs.

Design & setting: A primary care based prospective cohort study in Wolverhampton.

Method: All adults (n=39,079) were included. A robotic process tool (BOT) identified those not on the PCR using any of five palliative care process markers. BOT positive patients were assessed by GPs for the PCR. Performance metrics for prediction of subsequent 1 year mortality were determined.

Results: 546 patients were BOT positive. GPs added 131 patients (24%) to the PCR. This subset had the highest mortality rate (48.1%) compared to; those already on the PCR (37.2%), BOT positive patient who were not added to the PCR (19.5%) and those who were non-registered and BOT negative (0.8%) (P<0.001). The new combined PCR captured 220 (35.5%) of deaths, compared to 25.4% in the original PCR . A 'digital safety net' group, comprising those initially on the PCR and all BOT positive patients, accounted for 48.6% of deaths.

Conclusion: We developed a robotic process technique combined with GP assessment that yielded higher PCR uptake and accuracy, identifying individuals at-risk for ongoing surveillance.

Background: International medical graduates (IMGs) currently account for 41% of the UK medical workforce. IMGs in training posts face challenges in progression including a significant 'award gap' (previously differential attainment) in postgraduate training compared to UK medical graduates. General practice (GP) is disproportionately impacted by these issues as over 50% of GP trainees are IMGs. Previous studies focusing on educational interventions to reduce the award gap have failed to improve training outcomes.

Aim: To identify literature addressing the factors underlying the award gap.

Design & setting: The scoping review will follow the process outlined in the Joanna Briggs Institute (JBI) guidance. Input was sought from a specialist librarian, patient and public contributors, stakeholders with lived experience of working as an IMG and experts in the research field. Studies eligible for inclusion will be those reporting educational outcomes (concept) for IMGs (participants) undertaking UK GP training (context).

Method: Searches will be conducted in Medline, EMBASE, SCOPUS and PsycINFO for articles reporting educational outcomes for IMGs in UK GP training. A two-step screening process will be employed to identify eligible articles. Analysis will involve basic descriptive statistics reporting the number and type of evidence sources. Reporting of the data will be in line with the PRISMA-ScR checklist and will include visual representations of findings including graphs and figures developed with stakeholders and PPI group members.

Conclusion: By exploring the literature which reports the factors underlying the award gap in GP training we will identify areas for further research.

Background: Emergency department (ED) crowding is a growing challenge, highlighting the need for safe and effective prehospital alternatives to hospital conveyance.

Aim: To investigate how a GP-staffed emergency primary care response unit (EPCRU) affects resource allocation and patient pathways.

Design & setting: A prospective observational study conducted in two Norwegian municipalities served by a GP-staffed EPCRU.

Method: All call-outs (n = 2950) performed by the EPCRU from 1 April 2023 to 31 March 2024 were included. Data on dispatch origin, triage (telephone and on site), reason for dispatch, level of care, and participating services were analysed.

Results: Most call-outs were categorised as acute (57.6%) by the call centre and comprised a broad spectrum of conditions and severities. The EPCRU was first on scene in 44.1% of cases. In total, 44.1% of patients were treated on site without hospital conveyance. A mismatch was observed between telephone and on-site triage: 34.2% of acute cases were reassigned to yellow (the midpoint of a 5-point urgency scale) by the Rapid Emergency Triage and Treatment System (RETTS) on-site triage. The EPCRU altered expected care trajectories compared with standard ambulance response by enabling both non-conveyance and direct ED admissions.

Conclusion: A GP-staffed response unit may enhance resource efficiency, patient flow, and timely care, which offers potential benefits for emergency systems facing growing demand.

Background: Since the Declaration of Alma-Ata in 1978, global health policy has prioritised primary and integrated care reform to better manage chronic illness, improve health access, and prevent disease. Yet internationally, primary care, like the health systems it struggles to support, is currently far from strengthened and is increasingly challenged by chronic underfunding, lack of recognition, and a diminishing and demoralised workforce.

Aim: To better understand the policy barriers responsible for the current status from the perspective of general practice in England.

Design & setting: Key informant interviews between August and October 2024 with 12 general practice policy or practice leaders identified from publicly available position statements, publications, or innovative programmes in UK primary care reform over the past decade.

Method: A qualitative deductive approach using thematic analysis to analyse informant data to understand historical barriers and explore facilitators for future reform.

Results: The analysis resulted in eight main themes: 1) dynamics of power and autonomy; 2) underinvestment in primary care; 3) aligning policy and implementation; 4) navigating complexity and change; 5) building trust through relationships and leadership; 6) the revolving door of policy and leadership; 7) valuing the workforce: a key to morale and retention; and 8) strategic communication and media engagement.

Conclusion: Better-targeted funding reform, more effective systems integration building on general practice and community service strengths, and better valuing the complex role of the primary care sector as central to a high-functioning health system were seen as key to the future. Participants also called for more effective policy input from those skilled in the delivery of care and the capacity for earned autonomy and flexibility to deliver care relevant to individual community need. Action to address these opportunities is pressing, as finalisation of the 10 Year Health Plan and more immediate NHS restructure rapidly gathers momentum.

Background: Public surveys indicate demand for privately funded general practice services in England has increased. However, little is known regarding the number, location, and quality of private general practices.

Aim: To examine: (1) the geographical distribution of private general practices across England; (2) the relationships between access, continuity of care, and funding of NHS general practices with nearby private practices; and (3) the quality ratings of NHS and private general practices.

Design & setting: Cross-sectional analysis of NHS and private general practices in England as of April 2024.

Method: We used the Care Quality Commission (CQC) Primary Medical Services Inspectorate to identify all private general practices in England. We used multilevel logistic regression to examine associations between NHS practice characteristics and the presence of a private general practice nearby. We then compared available CQC ratings.

Results: As of April 2024, England had 358 private and 5976 NHS practices. Private general practices are primarily in London and other urban areas. NHS practices with higher patient satisfaction with waits for appointments (odds ratio [OR] 1.08 [95% confidence interval {CI} = 1.03 to 1.13]) and more GPs per 10 000 patients (OR 1.04 [95% CI = 1.01 to 1.06]) were more likely to have a private practice nearby. There was no association with continuity of care or funding. Quality ratings were similar, although 43.6% of private practices were unrated by the CQC.

Conclusion: Private general practices are more common in London, as well as areas with better access to NHS GPs. The growth in private general practices may have widened inequalities in access to primary care.

Background: The Acute Basic Palliation Concept (ABPC) - a structured end-of-life (EoL) care model - increases quality of EoL care when used in hospital settings.

Aim: To measure if the use of the ABPC could increase symptom relief and user satisfaction when applied in general practice.

Design & setting: This cohort study was conducted across nine general practices in Northern Denmark with 29 GPs as well as in the regional Out of hours GP services.

Method: GPs received training in an adapted Acute Basic Palliation Concept (ABPC) and subsequently reported on patient cases managed both with and without the concept. Data on symptom control and satisfaction were collected via questionnaires from relatives, municipal caregivers, and GPs.

Results: A total of 74 EoL care trajectories were included in the analysis, with 51% managed using the structured concept. The mean patient age was 84 ± 8.9 years; 46% women. The median duration from EoL care initiation to death was 3.0 (interquartile range: 2.0;7.0) days. When using the concept, symptom control increased for pain (97% versus 83%), agitation (93% versus 56%), and discomfort (93% versus 81%), all P<0.05. Shortness of breath was less frequent, with a trend toward improved symptom relief using the concept (81% vs. 54%). Most staff were willing to use the concept again (90% GPs, 100% municipal nurses).

Conclusion: The structured ABPC model facilitated adequate symptom management and was widely accepted among general practitioners and municipal nurses, demonstrating promising potential for end-of-life care in a general practice setting.