BJGP Open最新文献

Background: Since the COVID-19 pandemic, there has been an increase in the use of remote consultations in general practice in the UK. This leads to the displacement of the consultation outside of the physical general practice, and its 'emplacement' elsewhere, with underexplored consequences for inequities of health care in marginalised groups.

Aim: To examine the place-making demands that remote consultations make on patients, and the ways that these affect their experiences of care, with a focus on the impact on patients from marginalised groups.

Design & setting: Ethnography and interview study (n = 15) undertaken at three fieldwork sites in London: a foodbank, a community development organisation, and a drop-in advice centre for migrants. Additionally, GPs (n = 5) working at practices in deprived areas of London, Digital Health Hub staff (n = 4), and staff at fieldwork sites (n = 3) were interviewed.

Method: Ethnographic observation was undertaken for 84 hours at the fieldwork site services, and semi-structured interviews (n = 27) took place with service users and service providers. Interviews were conducted in-person and over the phone, and data were analysed through reflexive thematic analysis.

Results: The core themes emerging from the data included challenges securing privacy during remote consultations and the loss of formal healthcare spaces as important places of care. These findings were closely tied to resource access, leading to inequities in experiences of care.

Conclusion: Remote GP consultations are not 'place-less' encounters, and inequities in access to suitable spaces may lead to inequities in experiences of care. Attention should be given to ensuring that patients without appropriate spaces for remote consultations are offered in-person care, or consultation times made more specific to allow for organisation of private space.

Background: Guidelines for terminology defining chronic kidney disease (CKD) have been in use for 20 years. Age is not currently considered in the guideline definition of CKD. In previous studies, GPs have been reluctant to give older patients the label of CKD.

Aim: To determine what language GPs are using to describe or label CKD with their older patients, and to explore the reasons for their use of alternative language.

Design & setting: This was a descriptive qualitative interview study of Australian GPs.

Method: Twenty-seven GPs were recruited via email and interviewed regarding their management of CKD. GPs were asked what language and terminology they used when discussing a diagnosis of CKD with their older patients.

Results: 'Labelling of CKD', the language that GPs use when talking about CKD with their patients, emerged as a major theme from the initial GP interviews. Sub-themes emerged, including types of alternative labels and rationale for alternative labels. GPs used descriptions of 'reduced kidney function' to explain CKD to their patients, either in parallel with the diagnosis of CKD or instead of it. GPs had concerns about the words 'chronic' and 'disease', and used different terminology to explain these words to patients when diagnosing them with CKD.

Conclusion: GPs use alternative descriptions to explain mild decrease in kidney function with older patients. Alternative labels that denote level of risk to older patients, without creating unnecessary concern about normal age-related kidney function, need to be explored.

Background: Opioid and gabapentinoid prescribing has increased substantially in recent years despite having limited effectiveness in treating chronic primary pain. This is concerning, with the prescribing rates and adverse effects of these medications being higher in more socioeconomically disadvantaged groups. Guidance for prescribing and deprescribing these medications exists but the understanding of how deprescribing is operationalised, especially in areas of socioeconomic disadvantage, is limited.

Aim: To explore primary healthcare professionals' views and experiences of designing and implementing an intervention to reduce opioid and gabapentinoid prescribing.

Design & setting: A qualitative evaluation, using participant observation and semi-structured interviews with primary healthcare professionals, working in practices serving areas of substantial socioeconomic disadvantage in the North East of England.

Method: Interviewees were purposively recruited with subsequent snowballing with participant observation of the peer-support meetings. Interview transcripts and notes from the participant observation were inductively coded and thematically analysed.

Result: Thirteen healthcare professionals from five practices were interviewed. Person-centred care with shared decision-making was strived for, which was time-consuming owing to the complexity of the problem and patients. Where shared decision-making was not possible, owing to patient refusal or non-engagement, risk was used to determine the appropriate action. This work involved an emotional toll on staff and patients, but was at times conversely easier and more rewarding than expected. Ultimately, demedicalising pain with a culture change is required to ensure patients are not prescribed these medications for inappropriate reasons or doses.

Conclusion: This study demonstrates key operational aspects to consider when undertaking opioid and gabapentinoid deprescribing in primary care, such as funding dedicated time to enable deprescribing.

Background: The number of people who are living with and beyond cancer is increasing in England. Primary care delivers cancer care via structured proactive conversations which are incentivised through the Quality and Outcomes Framework (QoF): 'cancer care reviews' (CCRs). Declining workforce numbers, increasing patient demand, CCR policy changes in 2020, and the onset of the coronavirus disease 2019 (COVID-19) pandemic motivate exploration of how staff deliver CCRs.

Aim: To explore primary care staff's experiences with CCRs, their view of CCRs, how they conduct CCRs, and their perception of the value of CCRs.

Design & setting: Descriptive qualitative study in general practices in England.

Method: Semi-structured online interviews with 15 primary care staff; data analysis using reflexive thematic analysis.

Results: Four themes were identified: varied and evolving perception of cancer; the delivery and impact of CCRs; changes to CCR delivery during the COVID-19 pandemic; and ways to complement CCRs. Primary care staff felt that the way that cancer was perceived by patients, including those from ethnic minority backgrounds, impacted how CCRs were delivered. Cancer care involved acknowledging the challenge of a cancer diagnosis, helping decode jargon, and addressing unmet care needs. The pandemic resulted in remote CCR delivery for some practices. Staff suggested that community cancer teams could provide cancer care alongside existing services.

Conclusion: Staff adopted the new 3- and 12-month format CCRs despite the COVID-19 pandemic. Clinical staff may benefit from better training on cancer as a long-term condition and how cancer is perceived by people from diverse ethnic backgrounds.

Background: Early cancer recognition is key to improving patient outcomes. Diagnosis is often delayed in patients with myeloproliferative neoplasms (MPNs), putting them at risk of thromboembolic events and other complications pre-diagnosis. A clear understanding of the barriers to presentation and diagnosis is required.

Aim: To explore barriers and factors influencing delayed presentation and diagnosis of MPNs.

Design & setting: A cross-sectional study of patients with MPN within the UK and the Republic of Ireland.

Method: An online cross-sectional survey of patients with MPN was undertaken. Symptoms and factors influencing patient and GP delay were examined. Adjusted odds ratios (aORs) were calculated to explore the relationship between these factors and patient and GP delay.

Results: Most (80.2%) of the 620 patients completing the survey reported symptomatic presentation. The most common symptoms associated with patient delay were pruritus (aOR 1.89, 95% confidence interval [CI] = 1.19 to 3.01), headaches (aOR 1.86, 95% CI = 1.13 to 2.82), and concentration difficulties (aOR 1.75, 95% CI = 1.12 to 2.76). Attributing symptoms to ageing (aOR 1.92, 95% CI = 1.19 to 3.11) and not wanting to burden the GP (2.04, 95% CI = 1.24 to 3.39) were significantly associated with patient delay. Those reporting >3 blood cancer warning signs were more likely to experience GP delay than those experiencing fewer (aOR 3.26, 95% CI = 1.75 to 6.29), and lack of relational continuity of GP care was significantly associated with GP delay (aOR 3.41, 95% CI = 1.65 to 7.28).

Conclusion: Debunking misconceptions around ageing, encouraging timely communication with GPs, and improving relational continuity of GP care could assist in reducing diagnostic delays, prevent potentially fatal disease complications, and ultimately improve outcomes for patients with MPN.

Background: Video consultations (VC) disrupt how general practice provides care and how patients receive it. A step towards understanding the use of VC is to study the association between user-status and general practitioner and practice characteristics.

Aim: To study the association between general practitioner and general practice characteristics and VC user-status (users, never users, and former users).

Design & setting: An anonymous, web-based, cross-sectional survey was distributed to all 1674 Danish general practices (singlehanded, collaborative, and partnership forms) contracting with and working on a collective agreement with the public funder.

Method: Multinomial logistic regression was used to correlate VC user-status and (1) general practice characteristics, and general practitioners' (2a) objective characteristics and (2b) subjective attitudes towards VC and organizational change.

Results: The study sample included 416 general practitioners. Users of VC compared to never-users: partnership practices (RRR=0.22; 95% CI 0.06-0.85) and practices with six or more practice staff (RRR=0.05; 95% CI 0.01-0.28) were significantly more likely to be users. The same was found for general practitioners with a high degree of tech savviness (RRR=0.02; 95% CI 0.001-0.17) and openness to organisational change (RRR=0.26; 95% CI 0.08-0.85).

Conclusion: Characteristics of general practice and general practitioners are associated with VC user-status (being a user, never user or former user). Future research should use a Difference-in-Difference study design and register data to make causality claims.

Background: Although increasing numbers of appointments are being provided, public satisfaction with access to UK general practice is declining. Previous attempts to improve access have not been systematically collated.

Aim: We aimed to identify interventions to improve access to general practice in the UK, to organise these interventions into thematic categories, and to identify which aspects of access are targeted.

Design & setting: Narrative systematic review.

Method: A three-stage search was conducted to identify interventions used to improve access to NHS general practice. Using an iterative process, we generated thematic categories to classify interventions according to how they are intended to work. We assessed which aspects of access they addressed using the seven-feature Candidacy Framework.

Results: The search identified 449 relevant sources reporting on interventions to improve access to general practice over the period 1984-2023. We generated six overarching thematic categories into which we organised these interventions: appointment innovations; direct patient access to services; increasing the number and range of professionals available in general practice; offering contacts beyond core hours, core settings and core services; supporting patient engagement; and supporting the wider structures of general practice. We assessed which features of Candidacy were addressed, with "permeability" (the ease with which people can use) services emerging as the most frequent feature.

Conclusion: Multiple and diverse attempts have been made to improve access in general practice over a 40-year period. This curated, thematised catalogue offers an important resource for future efforts to improve access.

Background: Strengthening primary care is a priority globally and for the South African health system. The current measurement tools in South Africa do not measure the core functions of primary care: access, comprehensiveness, coordination, continuity and person-centredness. A new regional version of the Primary Care Assessment Tool (PCAT) has just been validated and can measure these core functions.

Aim: To field test the regional PCAT and measure the core functions of primary care performance.

Design & setting: A descriptive cross-sectional survey in Amathole District, South Africa.

Method: Data were collected from 386 randomly selected patients from 40 clinics and six subdistricts. Data was collected using the REDCap mobile App and analysed in the Statistical Package for Social Sciences version 27.

Results: The median primary care score was 3.3 (IQR 3.2-3.5) where a score>3 was seen as acceptable performance and>3.5 as good. Person-centredness, coordination and utilisation were all scored as good (4.0 (IQR 4.0-4.0). Comprehensiveness (3.3 (IQR 2.9-3.6) and continuity (3.2 (IQR 3.1-3.6) were scored as acceptable. Access to care was scored as poor (1.7 (IQR 1.0-2.9). There were significant differences in primary care scores between subdistricts. Those with a worse health status or chronic condition gave lower scores. The most affluent and the poorest groups also gave lower scores.

Conclusion: The district needs to focus on improving access to care as well as some aspects of comprehensiveness, continuity, and coordination. The newly validated regional PCAT provided the district with novel information for performance management and improvement.

Background: Practices with higher two-week-wait (2WW) referral-rates demonstrate higher survival for several cancers. Yet, there is little up-to-date evidence exploring factors influencing 2WW-referral-rates and whether health inequalities exist, particularly after COVID-19.

Aim: To establish which patient-factors (eg, age, sex, ethnicity, deprivation) and practice-factors (eg, remote consultations, frequency of seeing a preferred-GP) independently predict 2WW-referral-rates.

Design & setting: A cross-sectional, observational study was performed using data from English general practices for 2021-2022.

Method: Multivariable linear regression was used to identify the strongest, independent predictors of 2WW-referral-rates for all-cancers (primary outcome) and for breast, lower-gastrointestinal, lung and skin cancers separately (secondary outcome).

Results: The analysis included 6307 practices. Practices with more females, patients aged 75+and with a greater burden of long-term conditions were associated with higher 2WW-referrals for all-cancers, as were practices in Northwest England and those with higher scores for patients feeling involved in care decisions. Conversely, practices with a higher frequency of seeing a preferred-GP were predictive of fewer all-cancer 2WW-referrals. Whilst practices with a higher proportion of current smokers and Asian and Black ethnicity patients predicted fewer all-cancer 2WW-referrals, these associations were strongest for skin cancer, and for breast cancer (except for Black ethnicity). Higher socioeconomic deprivation predicted lower 2WW-referrals for lung cancer only.

Conclusion: This study analyses factors influencing 2WW-referral-rates and highlights potential inequalities. This work identifies priority populations, including smokers and Asian and Black ethnicity patients, who may benefit from interventions to increase primary care access. Shared-decision-making may be an underexplored resource for increasing all-cancer 2WW-referral-rates.