BJGP Open最新文献

Background: GPs' participation in continuous medical education (CME) is essential for patient care, GPs' wellbeing, and healthcare expenditure. However, one-quarter of Danish GPs did not use their reimbursement for CME in 2022. Knowledge of barriers for participating in CME is limited.

Aim: To analyse the barriers GPs face to participation in CME, and patterns in perceived barriers.

Design & setting: A cross-sectional questionnaire study design was used. The study population comprised all 3257 GPs in Denmark who, in May 2023, were registered as entitled to reimbursement for CME.

Method: The response rate was n = 1303/3257 (40%). Based on a question about use of CME, the responders were divided into 'frequent', 'partial', and 'seldom' users. Partial and seldom users answered questions about barriers related to CME (n = 726). The presence of barriers was quantified, and a latent class analysis (LCA) was used to stratify GPs according to their barrier patterns.

Results: The most frequent barriers were as follows: too busy (67%); fully booked courses (45%); and no substitute or locum doctor (39%). Based on the LCA, we found three distinctive patterns, clustering around the following: GPs from clinics with no tradition for CME (class 1, 17%); GPs who used time on professional work outside clinic (teaching, organisational work) (class 2, 43%); and GPs who were personally or professionally affected (class 3, 40%). Singled-handed and male GPs were slightly overrepresented among seldom users.

Conclusion: We have identified barriers for CME. We found three different profiles of GPs who perceived different patterns of barriers. Identified patterns in barriers should be considered in future CME initiatives.

Background: Owing to increasing antibiotic resistance, the worldwide efficacy of Helicobacter pylori (HP) eradication treatment has decreased.

Aim: To determine antimicrobial resistance of HP in primary care.

Design & setting: Retrospective cohort study using real-world routine healthcare data from 80 general practices in the Netherlands.

Method: Patients with International Classification of Primary Care (ICPC) codes for gastric symptoms or Anatomical Therapeutic Chemical (ATC) codes for acid inhibition in the period 2010-2020 were selected. Main outcomes were antimicrobial resistance of HP, defined as the prescription of a second eradication treatment within 12 months, and clinical remission of gastric symptoms, defined as no usage of acid inhibition 1 year following eradication therapy.

Results: We identified 138 455 patients with gastric symptoms and/or acid inhibition use (mean age 57 years [standard deviation 18.2 years], 43% male). A total of 5224 (4%) patients received an HP eradication treatment. A second treatment was prescribed to 416 (8%) of those patients. From these, 380 patients received amoxicillin-clarithromycin, 16 amoxicillin-metronidazole, and 11 clarithromycin-metronidazole as first regimen and were considered antimicrobial resistant. We observed a 0.8% increment per year of patients requiring a second eradication treatment (P = 0.003, 95% confidence interval = 0.33 to 1.22). After successful eradication, 2329/4808 (48%) patients used acid inhibition compared with 355/416 (85%) patients following treatment failure (P<0.001).

Conclusion: Antimicrobial treatment is not successful in almost one-tenth of HP infections in primary care after a first treatment containing clarithromycin and/or metronidazole. Although the treatment failure rate is not as high as reported in secondary care, the increasing trend is concerning and may require revision of the current guidelines.

Background: Smoking during pregnancy has many adverse effects for infant and mother. Despite this, many pregnant women continue smoking. Primary care is a suitable area to provide smoking cessation interventions.

Aim: To investigate available literature regarding effectiveness of smoking cessation interventions for pregnant women in primary care, the factors contributing to this effectiveness, and to provide suggestions for future research.

Design & setting: Systematic scoping literature review.

Method: The methodology followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for scoping reviews. Five electronic databases were searched. Inclusion criteria included original research studies and studies published in English. Data were extracted using a modified Joanna Briggs Institute (JBI) data-charting tool.

Results: The initial search yielded 878 articles. Following article screening, 12 studies were included. Five studies found a statistically significant increase in smoking cessation rates or reduction in tobacco consumed in the intervention group. The remaining studies showed no significant difference between the groups. However, 10 studies showed the control group received usual antenatal care involving smoking cessation promotion. An increase in smoking cessation rates was seen in intervention and control groups, demonstrating the effectiveness of these interventions. Interventions included education, counselling, self-help, and financial incentives. They were delivered by GPs, midwives, counsellors, and pregnancy advisers.

Conclusion: Primary care is suitable to offer smoking cessation interventions to pregnant women, as it is often the first point of care and more easily accessible than secondary care. Future research is needed to determine the most effective types of interventions.

Background: Evidence is sparse regarding service usage and the clinical management of people recently discharged from inpatient psychiatric care who die by suicide.

Aim: To improve understanding of how people discharged from inpatient mental health care are supported by primary care during this high-risk transition.

Design & setting: A nested case-control study, utilising interlinked primary and secondary care records in England for people who died within a year of discharge between 2001 and 2019, matched on age, sex, practice-level deprivation, and region with up to 20 living discharged people.

Method: We described patterns of consultation, prescription of psychotropic medication, and continuity of care for people who died by suicide and those who survived. Mutually adjusted relative risk estimates were generated for a range of primary care and clinical variables.

Results: More than 40% of patients who died within 2 weeks of discharge and >80% of patients who died within 1 year of discharge had at least one primary care consultation within the respective time periods. Evidence of discharge communication from hospital was infrequent. Within-practice continuity of care was relatively high. Those who died by suicide were less likely to consult within 2 weeks of discharge (adjusted odds ratio [AOR] 0.61 [95% confidence interval {CI} = 0.42 to 0.89]), more likely to consult in the week before death (AOR 1.71 [95% CI = 1.36 to 2.15]), be prescribed multiple types of psychotropic medication (AOR 1.73 [95% CI = 1.28 to 2.33]), experience readmission, and have a diagnosis outside of the 'severe mental illness' definition.

Conclusion: Primary care clinicians have opportunities to intervene and should prioritise patients experiencing transition from inpatient care. Clear communication and liaison between services is essential to provide timely support.

Background: The European guideline for the diagnosis and treatment of insomnia recommends, for all age groups, only restrictive, short-term, and periodic use of potentially addictive hypnotics. As in other European countries, in Norway, actual practice involving older patients differs substantially from this recommendation, as shown by the persistent high frequency of regular prescriptions of addictive hypnotics.

Aim: To explore experienced Norwegian GPs' views of the regular prescription of addictive hypnotics to patients aged >70 years living at home.

Design & setting: In-depth individual interviews of a purposive sample of experienced specialists in family medicine at GP offices in Southern Norway.

Method: The interviews used a semi-structured interview guide and were performed between June 2022 and January 2023. Reflexive thematic cross-case analysis was used to analyse the data.

Results: Most of the 11 GPs interviewed had more than 10 older patients who were prescribed hypnotics for daily use and the same number for intermittent prescription. Almost all prescriptions were of z-hypnotics. The GPs knew this was contrary to the guideline. Many were at ease with this fact. They emphasised the need to avoid creating new dependencies. The GPs considered these patients a selected minority within this age group with serious sleep problems, for whom few realistic alternatives were available and whose tolerance over time was better than expected. This logic of pragmatic practice reflected a patient-centred approach and respect for the patient's view in a shared decision-making process, combined with challenges of limited alternatives and resources.

Conclusion: A 'zero vision' on the prescription of addictive hypnotics to older people may neither be prudent nor realistic in the context of general practice.

Background: UK cancer deaths remain high; primary care is key for earlier cancer diagnosis as half of avoidable delays occur here. Improvement is possible through lower referral thresholds, better guideline adherence, and better safety-netting systems. Few interventions target whole practice teams. We developed a novel whole-practice team intervention to address this.

Aim: To test the feasibility and acceptability of a novel, complex behavioural intervention, 'ThinkCancer!', for assessment in a subsequent Phase III trial.

Design & setting: Pragmatic, superiority pilot randomised controlled trial (RCT) with an embedded process evaluation and feasibility economic analysis in Welsh general practices.

Method: Clinical outcome data were collected from practices (the unit of randomisation). Practice characteristics and cancer safety-netting systems were assessed. Individual practice staff completed evaluation and feedback forms and qualitative interviews. The intervention was adapted and refined.

Results: Trial recruitment and workshop deliveries took place between March 2020 and May 2021. Trial progression criteria for recruitment, intervention fidelity, and routine data collection were met. Staff-level fidelity, retention, and individual level data collection processes were reviewed and amended. Interviews highlighted positive participant views on all aspects of the intervention. All practices set out to liberalise referral thresholds appropriately, implement guidelines, and address safety-netting plans in detail.

Conclusion: 'ThinkCancer!' appears feasible and acceptable. The new iteration of the workshops was completed and the Phase III trial has been funded to assess the effectiveness and cost-effectiveness of this novel professional behaviour change intervention. Delivery at scale to multiple practices will likely improve fidelity and reach.

Background: GPs play a key role in the diagnosis and management of eating disorders (EDs).

Aim: To explore GPs' experiences of managing patients with EDs.

Design & setting: A qualitative study utilising remote semi-structured interviews in the UK.

Method: Fourteen GPs were interviewed about their experiences of supporting patients with EDs. The interviews were recorded, transcribed, and analysed using thematic analysis.

Results: The analysis described the following four themes: (i) 'Continuity of care', addressing the GP's relationship with patients and family, patient transitions across life stages and geographical areas, and patient non-attendance; (ii) 'The role of guidance', focusing on guidelines and protocols, referrals and specialist professionals as points of contact; (iii) 'Structural barriers', including waiting times, lack of resources, referral criteria, and relationships between services; (iv) 'Confidence and skills', reflecting professional and personal experience in EDs, previous training and training needs. Transcending these themes was the notion of the 'Limits to the care' GPs can provide owing to professional boundaries and the emotional impact of managing patients with EDs.

Conclusion: This study found that while GPs want to help patients with EDs many limits remain to the care they can provide owing to both internal and external factors. Funding is required for training and accessible specialist ED support, and greater clarity is needed regarding referral processes if ED management in primary care is to be optimised.

Background: Family medicine, vital for patient care but underfunded, prompts an evaluation of how family medicine journals endorse, require, and advocate for reporting guidelines (RGs), clinical trial, and systematic review registration.

Aim: Assess endorsement and requirement of RGs, and the stance on registration of clinical trials and systematic reviews in family medicine journals, impacting research quality and transparency.

Design & setting: A cross-sectional analysis of 43 'family practice' journals, identified through the 2021 Scopus CiteScore, was undertaken. Editors-in-chief were contacted to confirm article types. Data extracted from 'instructions to authors' pages focused on recommendations or requirements for use of RGs, and for trial registration.

Method: To ensure confidentiality and prevent bias, authors independently extracted data on the requirement or recommendation for use of RGs and clinical trial registration to provide an overview of research standards.

Results: From the 43 journals, the most recommended guidelines were CONSORT (69%), PRISMA (58%), and STROBE (60%). The most required were PRISMA (16%) and CONSORT (11%). Clinical trial registration was recommended or required by 67% of journals. Additionally, 40 out of the 43 (93%) journals cited at least one reporting guideline in their instructions to authors.

Conclusion: Family medicine journals exhibit a variety of endorsement and requirement patterns for RGs and clinical trial registration. While guidelines like CONSORT, PRISMA, and STROBE are acknowledged, caution is needed in presuming a direct link between mention of these RGs and enhanced research quality. A nuanced approach, promoting diverse RGs and rigorous study registration, is essential for elevating transparency and advancing research standards in family medicine.

Background: The true burden of Lyme disease in primary care in Scotland is unknown. Epidemiological data are currently based on laboratory-confirmed reports as there is no mandatory reporting of clinical cases.

Aim: To analyse data from general practice in NHS Highland (North) over a 6-year period to assess the incidence and management of Lyme disease in primary care.

Design & setting: This was a retrospective descriptive study. Study data from 2017 to 2022 were extracted from all 63 general practices within NHS Highland (North).

Method: Consultations for Lyme disease were identified via Lyme-related clinical Read codes, requests for borrelia tests , free text, 'tags' and/or Lyme disease antibiotic scripts.

Results: Using Read codes to identify patients with Lyme disease or suspected Lyme disease gave an estimated average annual incidence of 124/100 000 population, which was 2.1 times more than estimates based solely on laboratory-confirmed reports. The incidence figures increased 5.2 times (362/100 000 population) when patients with Lyme disease or suspected Lyme disease (identified via Read codes, laboratory test requests, and free text tags) who were given antibiotic treatment were taken into account. Local 'hot spots' of infection were identified. Analysis of the antibiotic data indicates that antibiotic prescribing in NHS Highland largely follows the National Institute for Health and Care Excellence (NICE) guidelines.

Conclusion: This data analysis pathway can, and should, be rolled out across the whole of Scotland to assess the incidence and management of Lyme disease in primary care and allow appropriate allocation of resources.