BJGP Open最新文献

Background: Cardiovascular disease (CVD) is the main cause of mortality in type 2 diabetes (T2DM) and detection of CVD risk is a key part of routine care. Slow walking speed is strongly correlated with CVD events in the general population.

Aim: To see if this applies in people with Type 2 diabetes.

Design & setting: Systematic review of studies of people with Type 2 diabetes METHOD: We searched studies in which usual walking speed was recorded, and participants were followed up for subsequent fatal and non-fatal cardiovascular events. (PROSPERO CRD42024578164) PubMed Central, Web of Science, Cochrane Register of Controlled Trials and Google Scholar were searched in December 2024. Studies were screened by two independent reviewers. Studies reporting walking speed or comparable indices and CVD outcomes in T2DM were included. Study quality was assessed using the Newcastle-Ottowa Scale. Heterogeneity of study populations prevented meta-analysis.

Results: Out of 1281 studies identified, 53 full-texts were retrieved and four were included, all of good quality. These involved 132 967 individuals with diabetes from USA, UK and Japan. Mean study follow-up was 3-14 years. All four studies assessed walking speed by self-reported questionnaire and reported significant associations between reduced walking speed and increased CVD risk with risk/hazard ratios ranging from 1.18-5.88.

Conclusions: This is the first systematic review to indicate an association between reduced walking speed and increased CVD incidence in T2DM. This association is seen across diverse populations and settings. Further research in T2DM could explore whether increasing walking speed reduces CVD risk.

Background: Asthma is frequently misdiagnosed because clinic-based tests miss its natural variability.

Aim: As part of early stakeholder engagement, we examined primary-care healthcare professionals (HCP)' views on using handheld spirometer and fractional exhaled nitric oxide (FeNO) for home-based diagnostic testing.

Design & setting: This is a two-phase mixed-method study. Phase 1 involved two focus groups with primary care HCPs in North-West England. Phase 2 involved a national electronic survey distributed to primary-care HCPs across the UK.

Method: We used Nominal Group Technique in focus groups to identify key priorities for home-based asthma strategy, which informed the development of the national survey in Phase 2.

Results: Twenty-one primary care HCPs took part in focus groups. Advantages, challenges and facilitators for implementing home-based asthma diagnostics were identified. A total of 104 primary care HCPs completed all survey questions. Respondents represented a wide demographic and practices across all levels of socioeconomic deprivation. Only 3% considered home-based diagnostics strategy is unlikely to be feasible. The most frequently cited barrier was high device cost, while patient engagement and device accessibility were identified as the most important enablers. Most respondents highlighted more accurate asthma diagnosis as key potential benefits.

Conclusion: Home-based asthma diagnosis using handheld spirometry and FeNO is generally viewed favourably by primary care professionals based on survey findings, though implementation challenges are multifaceted. Success will require system-level changes in how home-based testing is delivered and supported. The subsequent phase involves evaluation of test feasibility and accuracy, followed by assessment of clinical and cost-effectiveness.

Background: People experiencing homelessness (PEH) are disproportionately affected by frailty, yet few interventions have targeted this syndrome in this population.

Aim: To assess the feasibility, and potential impact of a combined exercise and nutritional intervention for PEH living with frailty.

Design & setting: A single-arm feasibility trial in a GP clinic for PEH in Ireland.

Method: A two-month exercise and nutritional intervention tailored for PEH was offered to potential participants. Pre-frail and frail individuals attending a GP clinic for PEH in Ireland were invited to participate. The primary outcomes was feasibility, assessed using Bowen's framework. Secondary outcomes were based on potential impact and included frailty scores (Clinical Frailty Scale [CFS] and SHARE-Frailty Index [SHARE-FI]) and weight. A process evaluation explored participant experience.

Results: Of 124 eligible individuals, 108 (87.1%) enrolled, and 75 (69.4%) completed follow-up. Among those followed up, 70 (93.3%) engaged with at least one component of the intervention, with the majority finding the intervention easy to follow. CFS and SHARE-FI scores improved following the intervention in those followed-up.

Conclusions: This study supports the feasibility of a primary care-based exercise and nutritional intervention for PEH living with frailty. The intervention appeared to be safe and to improve frailty status of participants and can inform the design of a definitive trial.

Background: The memory assessment pathway 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 memory assessment pathway, and on how an artificial intelligence tool (CognoSpeak^TM) could be implemented.

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

Method: Recruitment of 18 GPs using convenience sampling to undertake semi-structured interviews, analysed using reflexive thematic analysis (demographic data was monitored to ensure diversity).

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

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

Background: Prescribing of pressurised metered-dose inhalers (pMDIs) is a key NHS carbon hotspot and reducing the number of these devices prescribed will help achieve NHS net zero targets.

Aim: To explore primary healthcare professionals' perspectives on reducing the prescribing of pMDIs for people with asthma to reduce associated carbon emissions.

Design & setting: Qualitative study of healthcare professionals (GPs, practice nurses [PNs], and clinical pharmacists [CPs]) working in general practice in England.

Method: Eighteen semi-structured interviews were conducted with healthcare professionals. Participants were recruited through professional networks and using snowball sampling. Topic guides were developed to explore participant perspectives, concerns, and motivations.

Results: Eight GPs, six PNs, and four CPs were interviewed. Results are presented over two topics. The first explores factors influencing inhaler device choice and discusses the following themes: patient-centred care; bias and assumptions; clinician confidence and knowledge; and status quo of asthma care. The second topic identifies facilitators and barriers for prescribing fewer pMDIs through the following themes: understanding; attitudes to change; confidence in dry powder inhalers (DPIs); attitudes to change; engagement with sustainable prescribing; and system drivers.

Conclusion: Interlinking personal, consultation, and external factors influence which inhaler device is prescribed for patients with asthma. There are considerable actionable barriers to implementing carbon-conscious prescribing, many of which would improve the quality of asthma care.

Background: Around 2.5 million people in the UK are absent from work due to ill health, yet, for many, accessing work-orientated vocational support (VS) to facilitate return to work (RTW) is challenging. The majority of fit notes are issued in primary care, making this an ideal setting to provide VS.

Aim: As part of the Work And Vocational advicE (WAVE) randomised controlled trial (RCT), we explored the delivery of VS by trained vocational support workers (VSWs), from the perspectives of patients, VSWs, employers, and GPs.

Design & setting: In the WAVE RCT, patients from 10 UK general practices were randomised to the offer of usual care or usual care plus VS. This qualitative study explored stakeholder perspectives of the VS intervention.

Method: Semi-structured interviews were conducted with participants in the intervention arm (n = 10), employers, VSWs, and GPs (n = 5). Interviews were audio-recorded, transcribed, and analysed using thematic analysis. Public and patient involvement and engagement was embedded throughout.

Results: Taking a person-centred, individualised approach to VS enabled VSWs to identify and mitigate RTW obstacles and support participants' self-efficacy to proactively negotiate RTW. The perceived independence of the VSWs from employers and health care was considered important and facilitated more open discussions about capabilities and RTW planning.

Conclusion: Findings indicated that individualised and independent VS offered to patients referred from primary care was perceived by all stakeholders to be valuable to patients absent from work due to illness and supported their RTW planning. These insights can inform future models of VS.

Background: The COVID-19 pandemic led to a rapid transformation of the operating model for GP practices in England, with a switch towards the use of remote rather than face-to-face appointments.

Aim: To assess changes in the quality of general practice in England over the course of the COVID-19 pandemic based on patients' views of their experiences.

Design & setting: Analysis of practice-level multicategory response data on patient-reported experience measures (PREMs) from annual GP Patient Surveys from 2018-2023.

Method: Healthcare quality changes (HQC) at both practice and national levels were assessed. An index sensitive to changes in the distribution of patient responses was used across the full set of PREM response categories, not just in the proportion meeting a binary quality threshold.

Results: Patients' reported experience of general practice improved nationally between the 2020 and 2021 surveys, in spite of the restrictions on the operation of GP practices. The reported experiences then fell sharply between 2021 and 2022 before resuming the pre-pandemic downward trend. Variation in HQCs at the practice level was considerable between all consecutive years.

Conclusion: Changes in patients' reports of their experiences of general practice over the course of the pandemic reflected broader shifts in public attitudes towards the NHS as well as real changes in the nature and quality of service delivery.

Background: There is limited evidence that anti-vertigo drugs (AVDs) are effective in patients with vestibular symptoms. Still, betahistine is one of the most frequently prescribed off-label drugs. GPs are likely to contribute substantially to these potentially inappropriate prescriptions.

Aim: To evaluate the frequency of (long-term) AVD prescriptions in primary care and characteristics associated with long-term prescriptions.

Design & setting: We conducted a retrospective observational cohort study using anonymised routine primary care data from ≥1.2 million patients registered at 269 general practices throughout the Netherlands, covering the period 2018-2021.

Method: We included adult patients with vestibular symptoms and/or AVD prescriptions. Outcomes were the prevalence and incidence of (long-term) AVD prescriptions. We used a multivariable logistic regression analysis to identify characteristics associated with long-term prescriptions.

Results: Among 66718 patients with vestibular symptoms, 6172 patients (9%) received AVD prescriptions of which 32% were long term. The majority of patients with prescriptions and long-term prescriptions (88% and 77%, respectively) had any other vestibular disorder than Ménière's disease. Still, Ménière's disease was associated with long-term prescriptions as well as increasing age. Patients with benign paroxysmal positional vertigo (BPPV) and a symptom diagnosis of lightheadedness were less likely to receive long-term prescriptions, in addition to patients registered at practices in extremely urbanised areas.

Conclusion: AVD prescriptions, including long-term prescriptions, are common among patients with a wide array of vestibular symptoms and disorders, despite limited evidence. Management of vestibular symptoms by GPs can be improved by reducing these potentially inappropriate prescriptions.

Background: Decontextualised risk information (DRI) is any information pertaining to diagnosis, which is introduced into a clinical consultation, or a diagnostic thought process, without being requested by the clinician. It can be risk scores, computerised warnings, or laboratory tests or diagnostic imaging requests ordered by other clinicians. It is an increasing, and yet under-researched phenomena in UK primary care.

Aim: To investigate how GPs integrate DRI into their clinical decision making and how might they communicate this to patients.

Design & setting: Clinical vignettes of cases that involve DRI, designed to increase the diagnostic uncertainty of the case, were presented to UK trained GPs. 'Think-aloud' techniques and qualitative interviews were used to explore clinical thinking.

Method: Nine GPs were interviewed. After a warmup vignette, clinicians were shown and asked to talk through three clinical vignettes, which involved DRI. Semi-structured interview questions, exploring diagnostic thinking and uncertainty, followed each vignette. Thematic analysis was used to explore the research question.

Results: DRI tends to dominate a consultation when introduced. It can produce cognitive dissonance, defensive medicine, and more complex consultations. DRI explicitly presents differential diagnoses that clinicians may have considered but not discussed, compelling them to act, or justify their inaction, at several levels. Clinicians needed to recognise the complexity of clinical reasoning, and balance this against over-reliance on individual test or risk scores.

Conclusion: When DRI conflicts with a clinician's judgement, it can produce cognitive dissonance leading to complex consultations and predisposes towards defensive medical practices.