BJGP Open最新文献

Background: GPs can use video when performing telephone triage in out-of-hours primary care (OOH-PC) in Denmark. Video use varies considerably among GPs; this variation could be related to GP characteristics.

Aim: To investigate associations between GP characteristics and video use in OOH-PC telephone triage.

Design & setting: A register-based study using data from the OOH-PC registration system from 1 January 2021 to 31 December 2021.

Method: Binomial regression analysis was used to measure the associations between video contacts and triage GP characteristics, thereby calculating risk ratios (RRs) and 95% confidence intervals (CI).

Results: Video was used in 10.8% of telephone triage contacts to OOH-PC. Video use was significantly associated with GPs having more shifts in OOH-PC (RR: 1.36-1.93, reference: low number of shifts) and GPs being younger (RR: 0.84-0.67, reference: age<40 years). Central Denmark Region and Region of Southern Denmark had significant higher video-user rates (RR: 1.23-1.46) than North Denmark Region, whereas Region Zealand had significant lower rates (RR = 0.57, 95% confidence interval [CI] = 0.38 to 0.87). The association between video use and GP sex was modified by number of shifts in OOH-PC. Video use was positively correlated with male sex among GPs with low, medium, and high number of shifts (RR = 1.18, 95% CI = 1.07 to 1.29) and negatively correlated with male sex among GPs with very high number of shifts (RR = 0.75, 95% CI = 0.58 to 0.98).

Conclusion: Video use was associated with the number of shifts in OOH-PC, GP sex and age, and geographical region.

Background: Urinary tract infections (UTIs) are common, representing a frequent cause of antibiotic prescription in primary care worldwide. Selection of antibiotics for antimicrobial susceptibility testing and the reporting of test results by laboratories can directly impact antibiotic prescribing and guideline adherence.

Aim: To assess the current practice of susceptibility testing by laboratories for outpatient UTIs in Germany.

Design & setting: A cross-sectional study was conducted including all laboratories identified by searching for specialists in laboratory medicine and microbiology on the websites of the 17 German associations of statutory health insurance physicians.

Method: Between January and April 2024, a survey using a standardised questionnaire was conducted across identified laboratories.

Results: Of the 396 laboratories identified, 65.2% (n = 258) replied. Of these, 106 laboratories performed susceptibility testing and on average tested for 13.1 (standard deviation [SD] 3.6) different antibiotics in a urine culture positive for Escherichia coli. The most commonly tested antibiotics were ciprofloxacin (98.1%), co-trimoxazole (97.2%), cefuroxime, and nitrofurantoin (both 91.5%). On average, laboratories tested 3.8 of the five antibiotics recommended in the German guidelines on uncomplicated UTI, with 26.4% testing for all five. Laboratories received clinical information on previous treatments and comorbidities in an estimated one-fifth (on average 21.3% and 21.5%, respectively) of the urine samples, and information on the type of the urine sample in an estimated three-fifths (63.7%) of samples.

Conclusion: Laboratories should test and report as many first-line antibiotics as possible. Further, a more detailed and standardised transfer of clinical information to laboratories could enhance the quality of antibiotic prescribing.

Background: Obesity is a common comorbidity of type 2 diabetes mellitus (T2DM), a chronic metabolic condition affecting millions worldwide. Orlistat may be used to reduce weight as an adjunct to diet and lifestyle changes.

Aim: To assess the evidence of orlistat on weight loss in adults with obesity and T2DM or a high risk of T2DM.

Design & setting: Systematic review and meta-analysis of randomised controlled trials (RCTs) in clinical settings.

Method: Articles were searched in 10 databases including MEDLINE, Embase, and PsycInfo. RCTs of orlistat in adults with T2DM or at high risk and a body mass index (BMI)≥25 kg/m², with ≥12 weeks of follow-up and reported change in weight or BMI, were included. A random effects meta-analysis model was used to pool mean differences, I ² statistics to assess heterogeneity, and a funnel plot to assess publication bias.

Results: Thirty RCTs compared orlistat with a comparator, in conjunction with a weight-loss diet. All trials showed statistically significant (P<0.05) greater weight loss for the orlistat group than controls. A meta-analysis of 22 studies (n = 5921) showed that the overall weight loss for the orlistat group was a mean 2.40 kg (95% confidence interval [CI] = 2.08 to 2.72) greater than in controls. Weight difference was statistically significant (P<0.05) between subgroups at 3 months (2.74 kg, 95% CI = 1.20 to 4.27), 6 months (2.13 kg, 95% CI = 1.61 to 2.66), and 12 months (2.49 kg, 95% CI = 1.89 to 3.09).

Conclusion: Orlistat resulted in statistically significant greater weight loss in overweight adults with T2DM or at high risk compared with controls. Orlistat can be considered an adjunct in T2DM or at high risk of T2DM for weight loss along with diet and lifestyle modifications.

Background: In the past decade, interest in researching nursing practice environments has increased considerably. Multiple studies have highlighted that substantial benefits result from enhancing these environments. A strong association has been established between the nursing practice environment and key factors such as professional satisfaction, safety climate, staff retention, and the quality and safety of care delivered.

Aim: To evaluate the effectiveness of the Positive Nursing Practice Environment Promotion Programme (PPAPEP) in improving patient safety in primary health care.

Design & setting: A randomised clinical trial will compare changes in nurses' perceptions of the safety climate and nursing practice environment in primary healthcare units. The sample will include at least 34 nurses participating in the programme and currently working in primary healthcare units. The sociodemographic and professional characteristics of the participants will be analysed, and stratified randomisation will be conducted.

Method: The intervention group will participate in the PPAPEP, consisting of six training sessions, each lasting 3 hours. The programme's goal is to empower nurses by providing knowledge about what constitutes a positive nursing practice environment and equipping them with tools to improve their practice environment. The outcomes of the intervention will be assessed both at the end of the programme and 3 months after its conclusion.

Conclusion: We anticipate that this study will provide valuable insights into the effectiveness of a capacity-building programme targeted at nurses and its impact on their perceptions regarding the safety climate and nursing practice environment.

Background: Social determinants of health (SDOH) critically influence population and individual-level outcomes, but we do not collect this information routinely in primary care.

Aim: To develop a screening tool for SDOH relevant to UK settings using systematic review and Delphi methodology to identify suitable questions.

Design & setting: A systematic review and Delphi study were undertaken.

Method: For the systematic review, five databases and grey literature were searched. Selected studies included questions or tools that screened for SDOH relevant to UK settings. Included questions and tools were measured against the eight gold standard steps for measure development. Data were thematically analysed and arranged into pre-specified domains. For the Delphi study, individuals with an interest in SDOH were invited to take part in a three-stage modified Delphi study. Ranking of 172 items in survey 1, rating of 111 items in survey 2, and ranking of 56 items in survey 3 led to one question being selected per 10 pre-specified domains. Inductive content analysis of free-text responses from the surveys was performed.

Results: Of 7889 citations, 104 studies were included in the systematic review. Screening primarily took place in clinical settings using written formats. Seven participants took part in the first Delphi survey. Prioritised questions were direct, had binary answers, had specific wording, were concerned with current situation, and had immediate impacts on health.

Conclusion: The review provides a comprehensive overview of screening questions and tools for collecting information on SDOH. We present a 10-item screening tool from the highest ranked questions that can be used to screen for SDOH in primary care settings in the UK.

Background: Complex mental health difficulties (CMHD) is an umbrella term for long-term problems with emotions and relationships, including personality disorders (PD), persistent depression, and consequences of trauma. People with CMHD often fall between NHS services that focus on either common mental disorders (anxiety, depression) or psychosis, leaving GPs as their main source of support.

Aim: To understand what is known about primary care for CMHD, from both GP and patient perspectives.

Design & setting: We conducted a scoping review of GP and patient experiences of CMHD in primary care in UK, Europe, Australasia, and North America.

Method: We searched MEDLINE, PsycInfo, and Embase for eligible studies between January 2002 and October 2023. Titles and full texts were screened by two reviewers. Thematic synthesis of qualitative studies and narrative synthesis of quantitative studies were undertaken.

Results: We screened 2209 papers and 33 met inclusion criteria. The following three key themes were found: the challenge of recognising CMHD; the work of caring for people with CMHD; and patient priorities. GPs recognised CMHD through complexity of diagnoses, of psychosocial issues, and of healthcare use. However, they were ambivalent about diagnosis and lacked the resources to make or discuss diagnoses. Working with people with CMHD involved responsibility work, relationship work, and emotional work, under pressured conditions. Patient priorities included addressing stigma, reducing fragmentation, and receiving relationship-focused care.

Conclusion: This scoping review delineates the very real challenges people with CMHD and their GPs face in providing care. It helps set an agenda for work to address gaps in provision and improve outcomes.

Background: Video use remains low in primary care telehealth consultations. Little is known about patterns of use or policy levers to promote video.

Aim: To investigate use of video telehealth in Australian general practice under permanent telehealth arrangements post-COVID-19 lockdowns, and during a policy change removing reimbursement for long telephone consultations.

Design & setting: Whole-of-population analysis of 2022 national healthcare claims linked to 2021 census data.

Method: We quantified the following: proportions of telehealth consultations by video, and of patients and GPs who used video for telehealth consultations; associations between video use and patient characteristics using Poisson regression; and video use in relation to policy changes using interrupted time-series analysis.

Results: Of 38 million GP telehealth consultations in 2022, 5.1% were by video; 8.6% of patients and 62% of GPs who used telehealth had used video. Patients most likely to use video lived remotely, were frequent GP users, or had multiple health conditions, mental health conditions or dementia. Socioeconomic disadvantage was modestly associated with lower use of video. Over 2022, use of video for telehealth decreased for consultations (from 6.5% of consultations in January to 4.1% in December), patients (from 6.7% to 4.4%), and GPs (from 40.0% to 26.0%). Time-series analyses showed downward trends before removal of reimbursement for long telephone consultations, small step increases immediately following, and shallower negative trends thereafter.

Conclusion: Use of video telehealth consultations in general practice in Australia is low and declining, more so for disadvantaged groups. Differential financial reimbursement of video and telephone consultations has not substantively increased video use in clinical practice.

Background: UK COVID-19 lockdowns significantly affected primary care access and delivery. Little is known about whether lockdowns disproportionally impacted vulnerable groups, including people who misuse substances, people who have experienced domestic violence or abuse, those with intellectual disability, and children with safeguarding concerns.

Aim: To evaluate the impact of UK COVID-19 lockdowns on primary care contact rates among vulnerable groups.

Design & setting: Natural experimental design using all registered patients in the OpenSAFELY platform.

Method: With approval from NHS England, we conducted controlled interrupted time-series analyses on records from 24 million patients in England between September 2019 and September 2021.

Results: Pre-pandemic, primary care contact rates were 110.1 per 1000 patients per week. Following the initiation of the first lockdown (23 March 2020), there was a large reduction of 29-61 contacts per 1000 patients per week among vulnerable and general population groups. For patients with alcohol misuse, those aged ≥14 years with intellectual disability, and children with safeguarding concerns, this reduction was significantly more extreme than corresponding general populations (relative rate difference -23.8 [95% confidence interval {CI} = -39.8 to -7.7, P = 0.003], -24.6 [95% CI = -38.8 to -10.5, P<0.001], and -15.4 [95% CI = -26.9 to -3.8, P = 0.009], respectively). Following the final lockdown (29 March 2021), all groups had contact rates exceeding pre-pandemic rates (with increases more marked in vulnerable populations), except those only including children.

Conclusion: Our results suggested a larger short-term impact of the first COVID-19 lockdown on primary care contact for some vulnerable groups, compared with the general population, and differential impacts persisted through subsequent lockdowns and beyond for some vulnerable groups. There is a need to examine drivers of these differences to enable more equitable primary care access and provision.

Background: Socioeconomic deprivation is associated with lower life expectancy and more complex health needs. General practices may mitigate some of these health impacts by providing holistic care to their patients. The Deep End network was established in 2009 in Scotland to support practices working in the most socioeconomically deprived communities, and the concept has since spread, with Deep End Wales (Cymru) launching in 2022.

Aim: To explore experiences of staff working within Deep End practices in Wales and understand their motivations for choosing to work in challenging practices along with their needs from a Deep End network.

Design & setting: Qualitative study with staff from Deep End eligible practices in Wales.

Method: Seventeen semi-structured interviews were undertaken. Data were analysed using thematic analysis and interpreted with reference to self-determination theory.

Results: The following four main themes were identified: (1) Treading water (experiences of providing care in Deep End practices); (2) Diving into the Deep End (motivations for working in a Deep End practice); (3) Providing a life jacket (support from the Deep End Cymru community); and (4) Swimming to shore (the search for work-based effectiveness).

Conclusion: Deep End staff reported high workload, with limited resources and time to manage complex health needs. Most participants found working in Deep End practices rewarding. However, there were concerns about staff burnout, recruitment, and retention of staff. Deep End Cymru is providing hope, validation, and a place to share ideas. Barriers to success were funding and time. Participants want Deep End Cymru to advocate for them, support recruitment, improve services for patients, and support research.