BJGP Open最新文献

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: The term 'non-utilised appointments' emerged in 2019 but lacks a clear definition. We focus on multiple non-utilised appointments owing to recent advances in understanding 'missingness' in UK health care. Studies on missed appointments show conflicting results regarding interventions such as text messaging owing to oversight of occasional versus repeated missed appointments. Understanding patient and healthcare-related factors in multiple non-utilised appointments is crucial for improving interventions and patient engagement.

Aim: To identify factors influencing multiple non-utilised appointments from patients' and healthcare providers' perspectives.

Design & setting: A systematic review of qualitative research identifying factors that influence multiple non-utilised appointments across diverse global healthcare settings.

Method: The review employed a qualitative systematic approach, encompassing diverse papers from multiple databases, irrespective of patient or healthcare provider age, location, or setting. Data analysis followed Thomas and Harden's thematic synthesis method. Themes are presented in alignment with both the health service and patient perspective aspects of the Levesque access model.

Results: Ten thousand and eighty-six records were retrieved. Five studies met the inclusion criteria and were analysed. Six key themes influenced appointment utilisation. Healthcare system determinants highlighted provider-patient relationship and professionalism, and healthcare organisation factors role in appointment utilisation. Patient experience and decision making explored personal factors. Additionally, communication, support, and engagement delved into challenges with communication and language, family and social support, and socio-familial barriers to appointment utilisation. Health and wellbeing factors encompassed medical conditions, mental and emotional factors, and psychosocial determinants affecting appointment utilisation. Moreover, financial constraints and socioeconomic factors were identified as significant contributors. Lastly, healthcare access and barriers addressed transportation challenges, accessibility issues, and geographical barriers impacting healthcare access.

Conclusion: The analysis reveals complex factors influencing multiple non-utilised appointments. Strong provider-patient relationships improve care accessibility. Flexible scheduling and patient-centred approaches are pivotal, alongside addressing workplace discrimination. Tailored healthcare services and overcoming geographical barriers are essential. Ensuring safety, accessibility, and communication, while supporting vulnerable groups and mental health needs, are necessary. Equitable access to services and alternative transportation solutions are essential for comprehensive healthcare delivery.

Background: Advance care planning (ACP) was encouraged by policymakers throughout the COVID-19 pandemic. Little is known about use of ACP during this time.

Aim: To compare use of ACP before and during the COVID-19 pandemic.

Design & setting: Retrospective, observational cohort study comparing the creation, use, and content of Electronic Palliative Care Coordination System (EPaCCS) records in London. Individuals aged ≥18 years with a Coordinate My Care record, created and published in the pre-pandemic period (1 January 2018-31 December 2019), wave 1 (W1; 20 March 2020-4 July 2020), interwave (IW; 5 July 2020-30 September 2020), and wave 2 (W2; 1 October 2020-5 March 2021).

Method: Patient demographics and components of ACP were compared using descriptive and comparative statistics.

Results: In total, 73 675 records were included; 35 108 pre-pandemic, 21 235 W1, 6323 IW, and 9925 W2 (n = 1084 records not stratified as created and published in different periods). Most records were created in primary care (55.6% pre-pandemic, 75.5% W1, and 47.7% W2). Compared with the pre-pandemic period, the average weekly number of records created increased by 296.9% W1 (P<0.005), 35.1% IW, and 29.1% W2 (P<0.005). Patients with records created during the pandemic were younger (60.8% aged ≥80 years W1, 57.5% IW, 59.3% W2, 64.9% pre-pandemic [P<0.005]). Patients with records created in W1 had longer estimated prognoses at record creation (73.3% had an estimated prognosis of ≥1 year W1 versus 53.3% pre-pandemic [P<0.005]) and were more likely to be 'for resuscitation' (38.2% W1 versus 29.8% pre-pandemic [P<0.005]).

Conclusion: During the COVID-19 pandemic increased ACP activity was observed, especially in primary care, for younger people and those not imminently dying. Further research is needed to identify training and planning requirements as well as organisational and system changes to support sustained high-quality ACP within primary care.

Background: Nasopharyngitis is a common viral infection that has led to an overuse of prescription drugs, in particular antibiotics, which are not indicated for this condition.

Aim: The purpose of this study was to describe drug prescriptions for patients with a diagnosis of acute rhinopharyngitis in general practices in France.

Design & setting: Retrospective study of 1 067 403 prescriptions for a diagnosis of nasopharyngitis issued by 2637 physicians to 754 476 patients living in metropolitan France.

Method: The data were sourced from the prescription software, Cegedim, for the period 1 January 2018 to 31 December 2021 and analysed according to patients' and physicians' ages.

Results: A total of 2 591 584 medications were prescribed by GPs, with a median of three medications per patient. A total of 171 540 courses of antibiotics were prescribed (16% prescription rates), with amoxicillin being the most frequently prescribed (102 089 prescriptions; 59.5% of antibiotic prescriptions). Amoxicillin prescription increased in extreme age groups (18.2% of visits in those aged 9 years and under, and 10.0% of visits in those aged over 80 years, while patients aged 20-29-years were prescribed amoxicillin in just 2.9% of visits), and more prescriptions are issued by older doctors (GPs older than 70 years prescribed antibiotics in 26.4% of visits versus 3.2% of visits by GPs aged under 29 years).

Conclusion: Nasopharyngitis is frequently a cause of therapeutic over-prescriptions including antibiotics, with an antibiotic prescription rate of 16%. Additional research is required to enhance our understanding of factors linked to drug prescriptions.

Background: Continuity of care is important for patients with chronic conditions. Assigning patients to a named GP may increase continuity.

Aim: To examine whether patients who were registered with a named GP at the onset of their first chronic disease had higher continuity of care at subsequent visits than patients who were only registered at a practice.

Design & setting: Registry-based observational study in Skåne County, Sweden. The study population included 66 063 patients registered at the same practice at least 1 year before the onset of their first chronic condition between 2009 and 2015.

Method: We compared patients registered with a named GP with patients only registered at a practice over a 4-year follow-up period. The primary outcome was the usual provider of care (UPC) index for all visits and for visits related to the chronic disease. Secondary outcomes were the number of GP, nurse, and out-of-hours visits; emergency department visits; hospital admissions; and mortality. We used linear regression models, adjusted for patient characteristics (using entropy balancing weights) and for practice-level fixed effects, to compare the UPC between those registered with a named GP and those who were not.

Results: Patients with a named GP at onset of their condition had a UPC that was 3-4 percentage points higher than patients who did not have a named GP, but the difference decreased and was not statistically significant after adjusting for patient and practice characteristics. Patients with a named GP made more visits, although not specifically for the chronic condition. There were no statistically significant differences for the other outcomes.

Conclusion: Patient registration with a GP at diagnosis of their first chronic condition does not demonstrate higher continuity of care at subsequent GP visits and is not linked to other relevant outcomes for patients.

Background: Influenza contributes to the surge in winter infections and the consequent winter pressures on the health service. Molecular point-of-care testing (POCT) for influenza may improve patient management by providing rapid and accurate clinical diagnosis to inform the timely initiation of antiviral therapy and reduce unnecessary admissions and antibiotics use.

Aim: To explore factors that influence the adoption or non-adoption of POCT in English general practices and provide insights to enable its integration into routine practice workflows.

Design & setting: A qualitative implementation evaluation was conducted in 10 general practices within the English national sentinel network (Oxford RCGP Research and Surveillance Centre), from April-July 2023.

Method: Using the Non-adoption, Abandonment, Scale-up, Spread, and Sustainability (NASSS) framework, data collection and analysis were conducted across 10 practices. We made ethnographic observations of the POCT workflow and surveyed the practice staff for their perspectives on POCT implementation. Data were analysed using a mix of descriptive statistics, graphical modelling techniques, and framework analysis.

Results: Ethnographic observations identified the following two modes of POCT integration into practice workflow: (1) clinician POCT workflow, which typically involved batch testing owing to time constraints; and (2) research nurse or healthcare assistant POCT workflow, which was characterised by immediate testing of individual patients. Survey data indicated that most primary care staff considered the POCT training offered was sufficient and these practices were ready for change. Some participants agreed that there was the capacity and resources to integrate POCT into workflows. It was uncertain as to whether POCT required changes to organisational routines and processes.

Conclusion: General practices should demonstrate flexibility in the workflow and workforce they deploy to integrate POCT into routine clinical workflow.

Background: In the UK, epilepsy care involves both specialists (for example, neurologists) and generalists (for example, GPs). Policymakers typically consider that epilepsy care should be integrated and involve both specialists and generalists. However, few understand exactly how patients view and compare specialist and generalist care.

Aim: To explore patient perspectives of specialist care and generalist care for epilepsy in a qualitative evidence synthesis.

Design & setting: A systematic review of patient perspectives of epilepsy care. A qualitative evidence synthesis was conducted using an identified framework.

Method: Systematic searches in five databases retrieved 17 eligible studies. Data were extracted and synthesised using framework analysis informed by the 'United Model of Generalism'.

Results: The following three themes were developed: 'Epilepsy care can be burdensome' (for example, through care fragmentation); 'Patients' experiences of care is that care is not always accessible' (for example, lack of a continuum between standardised and interpretive care); and 'How care could change for people with epilepsy' (for example, clinicians currently have insufficient time to deviate from protocol-driven care to address psychosocial needs). People with epilepsy frequently observe that generalists lack expertise in epilepsy management.

Conclusion: This synthesis of patient experiences indicates recommendations should focus on improving communication and integration between specialists and generalists for epilepsy care. Patient experiences indicate specialist care risks being burdensome and generalist knowledge insufficient, requiring enhanced primary care clinician skills and improved awareness of patient psychosocial needs. The findings argue in favour of healthcare policies, materials, and tools to continually support patient perspectives in developing epilepsy services.