BJGP Open最新文献

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.

Background: In chronic care, patient-GP collaboration is essential, but might be challenging if patients have complex health problems due to multimorbidity, psychosocial predicaments and addiction problems. To understand and manage these challenges, it is important to explore how patients' and GPs' attempt to collaborate, to maintain and achieve an alliance in order to gain good quality of care.

Aim: To explore how dyads of GPs and patients that GPs deem have complex health problems and difficulties following treatment perceive and manage challenges in their chronic care partnership.

Design & setting: A qualitative study from Danish general practice in deprived, rural areas.

Method: Semi-structured interviews with 12 dyads of GPs and patients with doctor-assessed complex chronic conditions and difficulties following treatment. The principles of Systematic Text Condensation were used in the analysis.

Results: Overall, the patient-GP collaboration could be characterized as either stuck or unstable. In both types, the challenges were identified as pointless consultations, conflicts about lifestyle, resignation, concealment of information, and hopelessness. These challenges could be managed by solving conflicts, adjusting to the patient's needs, accommodating the challenges in the relationship, and offering continued emotional support even with unsolved medical problems.

Conclusion: Care of patients with complex health problems may possess several challenges. In this study, patients and GPs experienced the relational dimension as crucial for collaboration. A robust therapeutic alliance, incorporating the patient's agenda, offers an essential foundation for enhancing care in individuals with complex health problems.

Background: Frailty increases vulnerability to major health changes because of seemingly small health problems. It affects around 10% of people aged over 65.Older adults with frailty frequently have multiple long-term conditions, personal challenges, and social problems. Personalised Care Planning (PCP) based on 'goal-setting' and 'action planning' is a promising way to address the needs of older adults living with frailty.

Aim: To identify and explore factors that influence the implementation of personalised care planning style interventions for older adults.

Design & setting: We conducted a scoping review and identified a small number of interventions that explicitly employed 'goal setting' and 'action planning'.

Method: We used a range of sources to identify relevant material. We included all interventions inclusive of patients aged 65 and over and reported in English. We excluded end-of-life care interventions, group education and/or, those that did not involve one-to-one engagement. We explored all related papers which described, examined, or discussed implementation. We constructed a thematic framework in NVivo 11. Findings were narratively synthesised.

Results: We identified 18 potentially relevant PCP-style interventions. Within these, were seven main categories of potentially modifiable influences relevant to older adults with frailty related to: Primary care engagement; Delivery staff characteristics; Training; Client engagement; Collaborative working; Organisation and management; Systems.

Conclusions: Many modifiable factors can influence the implementation of PCP. We identified several influences which have informed the development and implementation of a novel intervention for older adults with frailty, PROSPER.

Background: Knowledge about healthcare users' evaluation of general practice is relatively limited.

Aim: We aimed to investigate evaluations in Danish men of general practice healthcare and of different aspects of general practitioners' (GPs) communication with patients.

Design & setting: Secondary analyses of data from a web-based survey in 6756 Danish men aged 45-70 years (30% response rate) using municipality-level information from registries, self-reported sociodemographic data, personality characteristics, and five-point Likert scale evaluations of healthcare and communication in general practice.

Results: A large majority of participants agreed (n=4420, 65%) or strongly agreed (n=1653, 24%) that their GP treatment had been "almost perfect", with slightly fewer (n=4205, 63%) responding that their GP was good at showing consideration for them. The latter item was, however, reversed, making comparisons more difficult and all differences were small. Older healthcare users evaluated healthcare higher (P<0.01) and higher scores on the extraversion, agreeableness, and conscientiousness personality dimensions generally were associated with higher evaluation scores (P<0.01) while the opposite tended to be true for respondents with higher neuroticism scores (P=0.002). When not controlling for multiplicity, participants in rural area tended to evaluate the explanation of medical procedures with lower scores (P=0.014) and participants with cerebrovascular disease (P=0.003) and those residing in higher tax income area (P=0.001) tended to generally evaluate GP care less positively.

Conclusion: Despite an overall high evaluation of GP care, evaluations may vary, including among different groups of healthcare users.

Background: The incidence of different types of hand and wrist disorders in primary care is unknown since there are no specific encodings for it.

Aim: To determine the overall incidence and the incidence of specific types of hand and wrist disorders in primary care.

Design & setting: A retrospective cohort study was undertaken, using a healthcare registration database from Dutch general practice, which contains medical records of more than 200 000 patients, and included approximately 25% of the population of the area of Rotterdam in The Netherlands.

Method: Patients aged ≥18 years with a new diagnosis of hand or wrist disorder from 1 January 2015-31 December 2019 were extracted using a search algorithm based on International Classification of Primary Care (ICPC) coding and search terms in free text.

Results: The mean incidence over the study period of a hand disorder was 5.9 per 1000 persons-years and of a wrist disorder 0.3 per 1000 persons-years. The incidence of trigger finger or thumb, hand or finger fracture, tendon or ligament tendinopathy, mallet finger, and hand or finger ligament injury were 3 (95% confidence interval [CI] = 2.69 to 3.15), 1 (95% CI = 1.03 to 1.33), 1 (95% CI = 0.98 to 1.28), 0.6 (95% CI = 0.48 to 0.69), and 0.1 (95% CI = 0.06 to 0.14) per 1000 persons-years, respectively. The incidence of a wrist fracture and ligament injury were 0.2 (95% CI = 0.13 to 0.25) and 0.1 (95% CI = 0.04 to 0.12) per 1000 persons-years, respectively.

Conclusion: There is a large difference between the number of patients presenting to the GP with hand and wrist complaints and the number of hand and wrist diagnoses reported in the medical files. Introducing specific ICPC codes for different types of hand and wrist disorders could (potentially) lead to a more accurate registration of a diagnosis and determination of the incidence figures.

Background: Globally, almost one-third of adults with chronic non-cancer pain (CNCP) are prescribed opioids. Prevention of opioid dependence among these patients is a public health priority.

Aim: To synthesise the evidence on the effectiveness of primary care-based interventions for secondary prevention of opioid dependence in patients with CNCP who are taking pharmaceutical opioids.

Design & setting: Systematic review of randomised controlled trials (RCTs) and comparative non-randomised studies of interventions from high-income countries.

Method: We searched five databases for studies on non-tapering secondary prevention interventions, such as tools for predicting dependence, screening tools for early recognition of dependence, monitoring of prescribing or medication, and specialist support. We examined multiple outcomes, including reduction in opioid dosage. Primary analyses were restricted to RCTs with data synthesised using an effect direction plot. Risk of bias was assessed using the Cochrane risk of bias (RoB2) tool.

Results: Of 7102 identified reports, 18 studies were eligible (eight of which were RCTs). Most used multiple interventions or components. Of the seven RCTs at low risk of bias or with 'some concerns', five showed a positive intervention effect on at least one relevant outcome, four of which included a nurse care manager and/or other specialist support. The remaining two RCTs showed no positive effect of automated symptom monitoring and optimised analgesic management by a nurse care manager or a physician pain specialist team, or of a mobile opioid management app.

Conclusion: We identify a clear need for further adequately powered high-quality studies. The conclusions that can be drawn on the effectiveness of interventions are limited by the sparsity and inconsistency of available data.

Background: Persistent physical symptoms (PPS) are consistently prevalent among primary care patients. PPS can negatively affect quality of life, healthcare costs, and work participation. In a previous study, we found substantially improved outcomes and reduced sick leave for patients treated by a work-focused communication tool, known as the Individual Challenge Inventory Tool (ICIT), compared with a control group.

Aim: To examine predictors of treatment outcome in patients who received treatment by ICIT, delivered by the patient's GP.

Design & setting: This study is based on the findings of our previous cluster randomised controlled trial undertaken in Norway.

Method: Regression analyses of the intervention group were used to identify predictors (all measured at baseline) of improvements in Patient Global Impression of Change (PGIC) and sick leave after 11 weeks follow-up.

Results: Living alone predicted improvement in the adjusted model (odds ratio [OR] 4.03, 95% confidence interval [CI] = 1.33 to 12.25, P = 0.014). Receiving long-term benefits predicted improved PGIC in both the unadjusted (OR 2.30, 95% CI = 1.21 to 4.39, P = 0.011) and adjusted models (OR 2.46, 95% CI = 1.04 to 5.83, P = 0.040). In addition, living alone predicted reduced sick leave in the adjusted model (OR 3.23, 95%CI = 1.11 to 9.42, P = 0.032).

Conclusion: In general, there were few factors to predict the outcome of the work-focused communication tool. We therefore suggest that this work-focused communication tool is applicable to most patients with PPS. GPs may consider using the ICIT for all primary care patients who exhibit ineffective coping strategies in their daily lives and work, especially those who live alone.

Background: Social isolation is associated with increased all-cause and premature mortality, poor chronic disease management, and mental health concerns. Limited research exists on interventions addressing social isolation among individuals under 65 despite its increasing prevalence among young and middle-aged adults.

Aim: To identify interventions from the extant literature that address social isolation and loneliness in ambulatory healthcare settings in adults aged 18-64 and to identify elements of successful studies for future intervention design.

Design & setting: Systematic review of interventions targeting social isolation in community-dwelling adults aged 18-64 within ambulatory healthcare settings.

Method: A search strategy was developed to identify relevant articles in the following databases: Ovid MEDLINE, Embase, EBM Reviews, Scopus, CINAHL, and PsychInfo. Data were extracted on study design and setting, intervention type, outcome related to social isolation/loneliness, and scale of measure used.

Results: 25 078 citations were identified and underwent title and abstract screening. 75 articles met our inclusion criteria and were synthesised, including an assessment of bias. Effective interventions were delivered in community health settings, incorporated a group component, and used digital technologies. They also addressed the association between mental health and social isolation using cognitive-behavioural therapy (CBT) approaches and enhanced self-management and coping strategies for chronic conditions through psycho-educational interventions.

Conclusion: Future research should prioritise adults living in low-income and middle-income countries, racialised individuals, as well as those with fewer educational opportunities. There is also a need to advance research in primary care settings, where longitudinal patient-provider relationships would facilitate the success of interventions.

Background: Danish hospital physicians are obliged to mark discharge summaries addressing whether the GP is recommended to follow up the patient, as well as stating suggested follow-up actions in a recommendation text box.

Aim: To investigate GPs' experiences with the recommendation text box in discharge summaries.

Design & setting: A questionnaire was sent to a representative sample of GPs in Denmark in January 2021.

Method: A questionnaire was prepared for GPs based on background material, focus group interviews, and discussions with GPs and hospital physicians. It was subsequently pilot-tested by fellow researchers and GPs, and revised before the survey.

Results: Seventy-two per cent of the GPs surveyed 'totally agree' or 'partly agree' that the recommendation text box is easy to find. In addition, our results show significant differences on how difficult the recommendation box is to find on different software. Sixty-three per cent 'totally agree' or 'partly agree' that the recommendation text box provides brief and precise information about the recommended follow-up.

Conclusion: GPs generally find that the recommendation text box provides them with brief and precise information about the recommended follow-up. In addition, the software used by the GPs has a significant influence on how the recommendation text box is to find.

Background: Despite advances in glaucoma management, topical eyedrop treatment has been paramount, with prostaglandin analogues (PGAs) being first-line agents. While late presentation is linked with deprivation, there is no recent research examining associations between deprivation and prescribing within primary care.

Aim: To explore PGA prescribing in general practice over a 6-year timeline, assessing associations with deprivation.

Design & setting: Analysis of NHS Business Services Authority (NHSBSA) data for general practice prescribing in England from April 2016-March 2022.

Method: Glaucoma treatments by GP prescribers were extracted, identifying ~9.11-9.58 million prescriptions/annum. Data were linked to Index of Multiple Deprivation (IMD) quintiles of GP practices. Crude rates per 1000 population were calculated using population data from NHS Digital. Time-series analyses facilitated comparison in prescribing nationally and in deprived areas. Autoregressive Integrated Moving Average (ARIMA) modelling facilitated measurement of synchrony between time series using cross correlation.

Results: PGAs and fixed combination eyedrops accounted for approximately two-thirds of glaucoma-related prescribing. Prescriptions per month increased slightly over a 6-year timeline, but rates per 1000 population reduced in 2020-2021 during the COVID-19 pandemic. The number of PGA prescriptions dispensed in deprived areas was lower than all other quintiles. Cross-correlation analysis indicates a lag of ~12 months between average PGA prescribing nationally versus more deprived areas.

Conclusion: The rate of PGA prescribing in primary care was substantially lower in deprived versus affluent areas, with delayed uptake of PGAs in more deprived areas of ~12 months. Further research is needed to explore reasons for this discrepancy, permitting strategies to be developed to reduce unwarranted variation.