BJGP Open最新文献

Background: Endometriosis affects about one in 10 women, yet diagnosis often takes 8-12 years after onset of symptoms. In the Faroe Islands, GPs play a key role in recognising symptoms, managing care, and coordinating referrals to specialists. Therefore, GPs' perspectives on how challenges to care arise and how care could be improved are crucial in order to develop effective interventions for change.

Aim: To investigate how GPs in the Faroe Islands experience encounters with patients presenting with endometriosis symptoms.

Design & setting: A qualitative interview study was undertaken with six GPs from various practices across the Faroe Islands.

Method: This study conducted semi-structured individual interviews and analysed participants' responses. Systematic text condensation, inspired by Malterud's thematic analysis, was used to explore GPs' perspectives on their interactions with patients presenting with endometriosis symptoms.

Results: Within the constraints of the Faroese healthcare system, many GPs reported difficulties collaborating with gynaecologists on treatment protocols. Limited referral pathways often led to challenges, particularly when referrals were declined or when patients were returned to general practice without clear diagnosis or management plans. GPs expressed frustration with the limited treatment options available in primary care and a sense of being professionally constrained. They emphasised the need for specialist involvement and highlighted the importance of building long-term relationships with patients offering holistic care, managing expectations early, and maintaining continuity of care.

Conclusion: This study highlights the difficulties GPs face when managing and referring patients with suspected endometriosis. It is crucial to enhance collaboration with specialists and improve referral protocols to optimise patients' care and outcomes.

Background: Over the past decade, remote (non-face-to-face) services - including interactions via the telephone and online platforms - have been increasingly used in primary care. These services bring potential benefits, as well as potential barriers, for patients. Older migrants are a population that could face intersectional barriers when accessing health care; it is important to understand the impact of remote services on them.

Aim: This study explores older Chinese migrants' experiences of, and attitudes to, remote access to primary care services.

Design & setting: A qualitative semi-structured interview study.

Method: Recruitment was carried out in 2023, through community organisations, social media, and snowballing. Participants were individuals aged ≥60 years, who self-identified ethnically as Chinese, and were UK residents; they were purposively sampled for maximum variation in sociodemographics and backgrounds. Data were collected through semi-structured interviews conducted in English and Mandarin. Interviews were recorded and transcribed verbatim; if consent to record the interview had not been given, field notes were taken. Transcripts and field notes were analysed using reflexive thematic analysis. Results were shared with participants for verification.

Results: Nineteen participants were interviewed. Many technical and practical barriers were reported as existing for the participants when accessing primary care remotely. Due to the different levels of access to resources, these barriers affected the most disadvantaged people to the greatest degree. In addition, participants felt the need for in-person interactions to address some concerns and believed remote services should not replace in-person care.

Conclusion: Overall, older Chinese migrants felt few benefits from using remote primary care services. In the current digital context of the NHS, it is crucial to keep multimodal services available while rolling out new service modes, and to consider the needs of different populations to ensure equitable access.

Background: Primary care teams (PCTs) are recognised to improve the quality of care. However, few studies have examined which PCT composition best meets patients' primary care (PC) needs.

Aim: To describe the composition of PCTs in 11 Western countries and investigate potential associations with GPs' opinions about their practice's ability to manage patients with chronic conditions and communicate with caregivers.

Design & setting: A secondary analysis of the data from 11 Western countries that participated in the 2019 Commonwealth Fund International Health Policy Survey of Primary Care Physicians was conducted.

Method: A hierarchical clustering algorithm was used to characterise different types of PCT according to the composition of the healthcare professionals (HCPs) making them up, in addition to GPs. Associations between practice types and two GP-reported indicators were subsequently assessed: their practice's coordination with social services (SS) and other community providers (CPs); and ability to manage patients with chronic conditions.

Results: Overall, 13 200 responses were analysed. Five types of PCT were characterised (traditional, multidisciplinary, nurse-centred, psychologist-centred, and physiotherapist-centred). The traditional type represented 51.6% of all PCTs; they were mainly composed of moderate percentages of all the HCPs. The multidisciplinary type (11.9%) were composed of high percentages of the different HCPs. After controlling for country, the multidisciplinary type reported better coordination with SS and CPs than did traditional ones (odds ratio 0.39, 95% confidence interval = 0.29 to 0.53).

Conclusion: Multidisciplinary PCTs reported better outcomes than traditional ones regarding their coordination with SS and CPs, and perceived ability to manage patients with chronic conditions. These results should encourage governmental efforts to promote PC that uses multidisciplinary PCTs.

Background: People living with and dying from multiple long-term conditions (MLTCs) are high users of healthcare services. Unscheduled care, the unplanned use of healthcare services, rises dramatically in the last year of life, likely reflecting unmet needs.

Aim: To characterise Scotland-based decedents with MLTCs in their last year of life and explore the relationship between characteristics and unscheduled care usage over that year.

Design & setting: Retrospective cohort study of all individuals who died in Scotland between 1 January 2017 and 31 December 2021.

Method: Data were linked across routine NHS Scotland datasets. Associations between sociodemographic factors, MLTCs, and unscheduled care usage in the last year of life were explored through binary logistic regression.

Results: In total, 299 361 individuals died in Scotland between 1 January 2017 and 31 December 2021, of whom 136 593 (45.6%) had ≥2 long-term health conditions leading into their last year of life. More decedents with MLTCs (97.1%) used unscheduled care compared with those without (95.6%). When adjusted for sociodemographic factors, those with MLTCs were more likely to use unscheduled care (adjusted odds ratio 1.51, 95% confidence interval = 1.45 to 1.57).

Conclusion: People dying with MLTCs had particularly high use of unscheduled care in the last year of life, likely reflecting unmet need. Anticipating and addressing these needs, through usual care providers, could reduce avoidable use of unscheduled care.

Background: Compound pressures (CP) impact the role of general practice in supporting human health. These pressures include climate change, pandemics, and financial crises. CP can be predictable, pre-determined, or unpredictable in nature and scope. Strategies to address the demands arising from CP range from short-term initiatives to buffering existing general practice systems to ensure flexible and agile resources. Interventions designed to prevent, identify, and manage CP may result in both intended and unintended outcomes.

Aim: To conduct a realist appreciative inquiry, realist review, and three embedded studies within a review (SWAR) about CP affecting general practice and the delivery of effective, equitable patient care.

Design & setting: Realist appreciative inquiry, realist review, and three SWARs.

Method: We will conduct a realist appreciative inquiry facilitating patient and stakeholder input into the review scope, focus, and initial programme theory (IPT) development. This approach emphasises the identification of assets, successes, hopes, and aspirations to enable positive change. Based on these insights, we will conduct a realist review of empirical and grey literature. This project includes three elements of methodological innovation (SWARs). First, evaluation of how appreciative inquiry can inform IPT development. Two further SWARs will examine how artificial intelligence might (a) support the identification of relevant resources at title and abstract, and full-text stages; and (b) support data extraction and analysis in future realist reviews.

Conclusion: Our research aims to understand the effects of CP on general practice, supporting preparation and solutions that can inform future policies, interventions, and support systems.

Background: The memory assessment pathway (MAP) for people with subjective memory deficits (dementia, mild cognitive impairment, and other diagnoses) is under huge strain and new diagnostic technologies have been identified as a high priority for research.

Aim: To investigate the views of GPs on the MAP, and on how an artificial intelligence tool (CognoSpeak™) could be implemented.

Design & setting: Qualitative interview study in a large region of the NHS (South Yorkshire) in England.

Method: Eighteen GPs were recruited using convenience sampling to undertake semi-structured interviews, which were analysed using reflexive thematic analysis (demographic data were monitored to ensure diversity).

Results: GPs think that the MAP has system-wide problems, and that GPs are overworked yet underutilised. They highlighted assessment and referral dilemmas, and the perspectives of patients and families. When asked about implementation of CognoSpeak™, they gave their thoughts on the optimal sites of implementation. The GPs also highlighted barriers and difficulties, as well as the opportunities and benefits, and they made proposals for the future development of CognoSpeak™.

Conclusion: GPs thought effective implementation of CognoSpeak™ could save time, expedite diagnosis, free-up much needed capacity, and improve the longitudinal assessment of people with mild cognitive impairment. A major concern among GPs was the potential for unintended consequences such as creating additional unfunded work. They also felt it could exacerbate difficulties at the intersections between subjective memory deficits and other factors such as low mood, excess alcohol consumption, learning difficulties, or language and culture. They were concerned about poor access to technology among older and more economically deprived people.

Background: Infectious intestinal disease (IID) incurs substantial healthcare demands. The relationship between primary and secondary care utilisation for IID remains underexplored.

Aim: To assess patient characteristics and time trends in IID-related primary care and hospital admission episodes.

Design & setting: A population-based, linked data study using deidentified healthcare and sociodemographic data from the Discover-NOW database of 2.7 million people in North-West London between 2015-2024.

Method: IID-related episodes in primary care and hospital settings were defined using SNOMED CT and ICD10 codes. Annual episode frequencies were described. Multivariable logistic regression estimated odds ratios (ORs) and 95% confidence intervals (95% CIs) for associations of patient characteristics with 1) hospital admission during a primary care episode, and 2) primary care activity coinciding with or preceding a hospital admission episode.

Results: Between 2015-2024, annual IID-related primary care episodes decreased from 51 009 to 40,450, while hospital admission episodes increased from 8732 to 10 356. Children aged 0-4 years accounted for 23.7% of primary care and 7.8% of hospital admission episodes, compared to 16.1% and 42.7% respectively for adults aged≥60 years. During primary care episodes, compared to adults aged 18-34 years, the 0-4 years (OR 1.30, 95% CI 1.19-1.42) and≥80 years (4.77, 4.36-5.22) age groups had a higher odds of hospital admission. For hospital admission episodes, younger age and lower socioeconomic deprivation were associated with coinciding or previous primary care activity.

Conclusion: IID-related primary care activity has declined since 2015 whilst hospital admissions have increased. Young children and older adults are more likely to be admitted to hospital during an IID-related primary care episode.

Background: Reflexivity is an under-researched concept in primary care education and educators receive no formal training in reflexivity. Evidence from other disciplines suggests that reflexivity can promote patient safety and inclusivity, making it a potentially valuable tool in medical training.

Aim: To examine the use of reflexivity in GP training and how it can be used to explore experiences of exclusion.

Design & setting: A qualitative analysis of GP educators' perspectives in London and South East England.

Method: Fourteen primary care educators were recruited. Focus groups and semi-structured interviews were conducted. Participants' opinions of reflexivity were explored, focusing on their own reflexivity, and that of their learners and the medical faculty. Data were transcribed verbatim and thematically analysed.

Results: The following three key themes were identified: the value of reflexivity; revealing unfairness through reflexivity; and tokenistic reflection versus creative reflexivity.

Conclusion: This study indicates GP educators are not familiar with the concept of reflexivity but are keen to consider how it could impact their learners. Moreover, the research demonstrated how issues of diversity, inclusion, and exclusion are brought to light through reflexive practice, and how this affects international medical graduate (IMG) learners. The participants identified a lack of organisational reflexivity as an important factor affecting inclusion and differential attainment, and it was suggested there was an 'inverse education law'. The educators called for more diverse leadership, less tokenistic reflection, and more reflexive and creative learning tools to address the findings of this study.

Background: The Consultation and Relational Empathy (CARE) Measure is a widely used 10-item measure to assess patients' perceptions of physician empathy. Takahashi et al's (2022) recent study proposed a two-item version based on psychometric evaluation of survey responses, without considering patient preferences.

Aim: To apply Takahashi et al's psychometric method to UK data, and compare findings with patients' preferences on the two most important items.

Design & setting: In 2022, a cross-sectional postal survey of 6291 Scottish adults was conducted.

Method: Using Takahashi et al's method, psychometric evaluation compared correlations between all possible two-item combinations with the original 10-item CARE Measure to identify the optimal two-item combination. Patients were also asked to select the two items they considered most important. Descriptive analysis examined the proportion of patients selecting each item, and level of agreement on the most popular two-item combination.

Results: In total, 1053 (17%) of 6291 patients responded. Psychometric evaluation identified items 6 ('Showing care and compassion') and 8 ('Explaining things clearly') as the optimal two-item combination (Cronbach's alpha = 0.916, correlation = 0.953). This differed from patient preferences, with items 3 ('Really listening') and 8 receiving the highest proportion of votes (19% and 17%, respectively). Preferences also varied by age, deprivation level, and consultation complexity. The most popular two-item combination (items 3 and 8) was selected by 10% of responders, with 90% selecting other combinations.

Conclusion: The psychometrically optimal two-item combination did not align with patient preferences. Given variation in patient preferences and low agreement, reducing the CARE Measure to two-items may be inadvisable.

Background: Previous studies have shown that patients with type 2 diabetes have a higher risk of developing bladder cancer than the general population. However, little is known about how different risk factors interact to influence the risk of bladder cancer among patients with diabetes.

Aim: To explore the interaction patterns among factors associated with the risk of bladder cancer incidence among patients who received diabetes management in primary care.

Design & setting: A retrospective cohort study was performed using territory-wide electronic health records of Hong Kong. Patients who received diabetes care in general outpatient clinics between 2010 and 2019, without cancer history, were included and followed up until December 2019.

Method: The interaction patterns among factors associated with the risk of bladder cancer incidence were examined using conditional inference survival tree analysis.

Results: A total of 382 770 patients were included. During a median follow-up of 6.2 years, 644 patients developed bladder cancer. Age (≤74 years versus >74 years) and sex emerged as primary and secondary factors in differentiating the risk of bladder cancer sequentially. Among males aged 62-74 years and males aged ≤58 years, smoking (adjusted hazard ratio [aHR] for ever versus never smoking: 1.96, 95% confidence interval [CI] = 1.49 to 2.58) and chronic kidney disease (CKD; aHR for presence versus absence: 2.92, 95% CI = 1.21 to 7.02) appeared as dominant risk factors for bladder cancer, respectively.

Conclusion: This study identified the interaction patterns among age, sex, smoking, and CKD on the risk of bladder cancer incidence, providing potential targets for public health cancer prevention strategies in primary care for patients with type 2 diabetes.