BJGP Open最新文献

Background: Organisations providing secondary care in the NHS in England have historically not also provided primary health care, but this is changing. Data on where this kind of 'vertical integration' is happening are lacking, making it difficult to evaluate its impact.

Aim: To compile a comprehensive list of instances of secondary care trusts running general practices in England, to enable evaluation of the impact of such arrangements.

Design & setting: This service mapping study comprises review, collation, synthesis, and analysis of published information describing secondary and primary care provision in the NHS in England in March 2021.

Method: Desk-based collection, including hand-searching, of secondary care organisations' statutory annual reports. Triangulation via comparison with national data on general practices, the general practice workforce and practice contracts.

Results: It was possible to construct a database of all instances of trusts running general practices in England as of 31 March 2021. We have identified 26 trusts running a total of 85 general practices, operating across a total of 116 practice sites. These practices have on average fewer patients and fewer GP full-time equivalents than other general practices, and before becoming vertically integrated were performing less well in the Quality and Outcomes Framework.

Conclusion: We recommend that national statistics recording the details of general practices contracting with the NHS should include whether each practice is owned by another organisation and whether that is an NHS trust, another public body, or a private organisation. Such data are required to enable evaluation of the impacts of this kind of vertical integration.

Background: The English NHS data opt-out allows people to prevent use of their health data for purposes other than direct care. In 2021, the number of opt-outs increased in response to government-led proposals to create a centralised pseudonymised primary care record database.

Aim: To describe the potential impact of NHS national data opt-outs in 2021 on health data research.

Design & setting: We conducted a descriptive analysis of opt-outs using publicly available data and the potential consequences on research are discussed.

Method: Trends in opt-outs in England were described by age, sex, and region. Using a hypothetical study, we explored statistical and epidemiological implications of opt-outs.

Results: During the lead up to a key government-led deadline for registering opt-outs (from 31 May 2021-30 June 2021), 1 339 862 national data opt-outs were recorded; increasing the percentage of opt-outs in England from 2.77% to 4.97% of the population. Among females, percentage opt-outs increased by 83% (from 3.02% to 5.53%) compared with 76% in males (from 2.51% to 4.41%). Across age groups, the highest relative increase was among people aged 40-49 years, which rose from 2.89% to 6.04%. Considerable geographical variation was not clearly related to deprivation. Key research consequences of opt-outs include reductions in sample size and unpredictable distortion of observed measures of the frequency of health events or associations between these events.

Conclusion: Opt-out rates varied by age, sex, and place. The impact of this and variation by other characteristics on research is not quantifiable. Potential effects of opt-outs on research and consequences for health policies based on this research must be considered when creating future opt-out solutions.

Background: GPs and mental health nurse practitioners (MHNPs) often feel ill equipped to provide mental health (MH) care to people with mild intellectual disabilities (MID). This is worrying, as insufficient primary MH care may lead to more severe or chronic problems. To improve primary MH care for this patient group, account must be taken of the experiences and needs of GPs and MHNPs providing the care.

Aim: To explore GPs' and MHNPs' experiences, needs, and recommendations for improvement regarding primary MH care for adults with MID.

Design & setting: A qualitative study was undertaken using focus groups with GPs and MHNPs in the Netherlands.

Method: The focus groups were guided by topics based on an interview study with adults with MID receiving primary MH care. Transcripts were analysed by thematic analysis.

Results: Four focus groups, with 19 GPs and nine MHNPs, revealed four themes describing the needs and perceived complexity involved in providing MH care to patients with both MID and MH problems: (1) GPs' and MHNPs' struggles with adapting to challenging patient characteristics; (2) importance and difficulties of establishing a good doctor-patient relationship; (3) facilitating and hampering roles of the patient's network; and (4) GPs' and MHNPs' challenges to provide care in the healthcare chain.

Conclusion: GPs and MHNPs often experience providing care and support to this patient group as burdensome. It is important to consider the MID throughout the MH trajectory, to invest in a strong doctor-patient relationship, and to establish a stable, sustainable network and coordinated collaborative care around the patient.

Background: Acute abdominal pain is a common complaint, caused by a variety of conditions, ranging from acutely life-threatening to benign and self-limiting, with symptom overlap complicating diagnosis. Signs and symptoms may be valuable when assessing a patient to guide clinical work.

Aim: Summarising evidence on the accuracy of signs and symptoms for diagnosing serious illness in adults with acute abdominal pain in an ambulatory care setting.

Design & setting: We performed a systematic review, searching for prospective diagnostic accuracy studies that included adults presenting with acute abdominal pain to an ambulatory care setting.

Method: Six databases and guideline registers were searched, using a comprehensive search strategy. We assessed the risk of bias, and calculated descriptive statistics and measures of diagnostic accuracy. Results were pooled when at least four studies were available.

Results: Out of 18 923 unique studies, 16 studies with moderate to high-risk bias were included. Fourteen clinical features met our criteria, including systolic blood pressure <100 mmHg (positive likelihood ratio [LR+]7.01), shock index >0.85, uterine cervical motion tenderness (LR+5.62 and negative likelihood ratio [LR-]8.60), and a self-assessment questionnaire score >70 (LR+12.20) or <25 (LR-0.19). Clinical diagnosis made by the clinician had the best rule-in ability (LR+24.6).

Conclusions: We identified 14 signs and symptoms that can influence the likelihood of a serious illness, including pain characteristics, systemic signs, gynaecological signs, and clinician's overall assessment. The risk of bias was moderate to high, leading to uncertainty and preventing us from making firm conclusions. This highlights the need for better research in this setting.

Background: To be effective, interventions aimed at increasing the appropriateness of antibiotic use in primary care should consider the perspectives of prescribing physicians.

Aim: To explore the decision making of general practitioners (GPs) when managing uncomplicated urinary tract infections (uUTIs) in women.

Design & setting: A qualitative study using semi-structured interviews with 22 GPs in Bavaria and Baden-Württemberg (southern Germany).

Method: Verbatim transcripts were analysed through inductive qualitative content analysis.

Results: We generated the following three main themes: factors facilitating the decision making; factors complicating the decision making; and consultation modalities. According to participants, following evidence-based recommendations makes the prescription decision smoother. GPs' and patients' prior experiences and beliefs guides decisions towards certain antibiotics, even if those experiences and beliefs contradict evidence-based recommendations. Patient expectations and demands also condition antibiotic prescribing, favouring it. Organisational constraints, such as time pressure, the day of the week (for example, before weekends), and a lower cost of antibiotics for patients than alternative treatments favour the decision to prescribe antibiotics. Diagnostic and prognostic uncertainty complicates decision making, as does scepticism towards evidence-based recommendations. Discordance within the patient-doctor relationship contributed to this complexity. Regarding consultation modalities, a more in-depth consultation and shared decision making were seen as helpful in this process.

Conclusion: We identified different factors as intervening against or for a straightforward management decision when dealing with women with uUTIs. They reveal the complexity behind the GPs' decision making. Providing GPs with easy-to-apply guidance while removing economic constraints to allocate sufficient consultation time, and supporting shared decision making may help GPs appropriately manage uUTIs in women.

Background: Research examining general practice supervisor wellbeing has often been conducted within the context of trainee wellbeing and educational outcomes.

Aim: To consolidate the current literature regarding the wellbeing of GP supervisors through a 'supervisor-wellbeing' lens.

Design & setting: Literature review of original research studies on Embase, Ovid MEDLINE, and Ovid PsycINFO from inception to December 2022.

Method: The Embase, Ovid MEDLINE, and Ovid PsycINFO databases were systematically searched from inception to December 2022. Original research studies were eligible if they explored any aspect of wellbeing or burnout (that is, construct conceptualisations, risk and protective factors, implications, or interventions) among GPs involved in educating GP trainees. Reporting quality of included studies was assessed using the QualSyst tool. Results from included studies were narratively synthesised.

Results: Data from 26 independent samples were reviewed. Burnout was generally conceptualised using the Leiter and Maslach model. Wellbeing was poorly defined in the literature, largely being conceptualised in personal psychological terms and, to a lesser extent, professional satisfaction. Risk and protective factors were identified and grouped as individual (for example, satisfaction with capacity to teach) and external (for example, autonomy, collegial relationships, resource availability) factors. GP supervisors' wellbeing appeared to affect their job performance and retention. This review identified only two studies evaluating interventions to support GP supervisors' wellbeing.

Conclusion: The present review highlights a lack of conceptual clarity and research examining interventions for GP supervisor wellbeing. It provides guidance for future research designed to maximise the wellbeing of GP supervisors and support the wellbeing of trainees.

Background: Deep vein thrombosis (DVT), a formation of blood clots within deep veins, mostly of the proximal lower limb, has an annual incidence of 1-2 per 1000. Patients who are affected by multiple chronic health conditions and who experience limited mobility are at high risk of developing DVT. Traditional DVT diagnosis involves probabilistic assessment in primary care, followed by specialised ultrasound scans (USS), mainly conducted in hospitals. The emergence of point-of-care ultrasound (POCUS), coupled with artificial intelligence (AI) applications, has the potential to expand primary care diagnostic capabilities.

Aim: To assess the accuracy and acceptability of AI-guided POCUS for DVT diagnosis when performed by non-specialists in primary care.

Design & setting: Diagnostic cross-sectional study coupled with a qualitative evaluation conducted at primary care DVT clinics.

Method: First, a diagnostic test accuracy (DTA) study will investigate the accuracy of AI-guided POCUS in 500 individuals with suspected DVT, performed by healthcare assistants (HCAs). The reference standard is the standard of care of USS conducted by sonographers. Second, after receiving both scans, participants will be invited to complete a patient satisfaction survey (PSS). Finally, semi-structured interviews with 20 participants and four HCAs, and three sonographers will explore the acceptability of AI-guided POCUS DVT diagnosis.

Conclusion: This study will rigorously evaluate the accuracy and acceptability of AI-guided POCUS DVT diagnosis conducted by non-specialists in primary care.

Background: Despite programmatic protocolised care and structured support, considerable variation is observed in completeness of registration and achieving targets of cardiovascular risk management (CVRM) between individual GPs in the Netherlands.

Aim: To determine whether completeness of registration and achieved targets of cardiovascular risk factors improves with practice visitation.

Design & setting: Observational study utilising the care group's database (2016-2019), comparing changes in registration and achieved targets in non-visited practices and visited practices.

Method: We compared completeness scores of registration and scores of targets achieved before visitation and 1 year after visitation. Data were analysed on patient level and GP level. Separate analyses were performed among GPs who were ranked in the lower 25% of score distributions.

Results: We observed no clinically relevant improvements in completeness of registration and targets achieved in 2017, 2018, and 2019 that could be attributed to visitations in the previous year, both on individual patient level and on aggregated level per general practice. In practices ranked in the lower 25% of the distribution, improvements over time were clinically relevant and larger than the overall changes. Yet, these findings were irrespective of the number of practice visitations.

Conclusion: Practice visitations in our setting did not seem to lead to improvements in practice performance, nor in completeness of registration of risk factors or in reaching predefined target goals for cardiovascular risk factors.

Background: Research suggests that in both France and the UK, between 5% and 10% of appointments with GPs are unattended. A comprehensive Irish study linked missed appointments with an increased short-term risk of mortality, prompting further investigation into the reasons behind absenteeism.

Aim: To delve into the underlying causes of missed appointments, within the context of an urban health centre.

Design & setting: Using a mixed-method approach, this study combines qualitative telephone interviews with quantitative analysis of medical records. The study focuses on patients who failed to attend appointments at an urban health centre in France over a 15-day period.

Method: The interview guide collected data on circumstances leading to missed appointments and explored patients' social determinants of health. Additionally, quantitative data, including patients' socioeconomic backgrounds, were extracted from medical records.

Results: Among 53 missed appointments (4.9% of all scheduled), 22 patients were interviewed. State health coverage (SHC) beneficiaries (68.2% of the sample) cited socioeconomic instability, including precarious work hours, social isolation, and multiple commitments, as reasons for non-attendance. For non-SHC beneficiaries, forgetting the appointment or failing to cancel it after self-resolution of the health issue was one of the main causes. Remarkably, 36.4% disclosed that they had experienced domestic violence. During the qualitative interview, patients were offered the opportunity to reschedule appointments, and a retrospective analysis by physicians found that over a quarter of the missed appointments were classified as 'capital appointments', meaning their absence could have significantly harmed the patient's health.

Conclusion: The findings indicate that missed appointments can highlight social inequality, emphasising the need to align health care with patients' temporal realities. The identification of patients who have experienced violence and the use of missed appointments as triggers for follow-up calls seem to be promising strategies to enhance care and mitigate health inequalities.