BJGP Open最新文献

Background: Antibiotic overuse is associated with antimicrobial resistance (AMR). It is unclear whether community AMR is driven by overall antibiotic use or by high levels of repeated (intense) use by individual patients.

Aim: To determine the association between high antibiotic prescribing intensity (all antibiotic prescriptions; any indication), and rates of UTI resistance among patients within small communities.

Design & setting: Repeated cross-sectional ecological analysis of geographical areas (population averaging 1500) from 2012-2015 using anonymised primary care data and urine cultures.

Method: For each area, we compared the percentage of antibiotic-prescribed patients who received≥5 prescriptions/3 years or≥4 prescriptions/year, with subsequent or same year UTI resistance rates. We also compared 'Average Daily Quantities' of all antibiotics prescribed, with UTI resistance rates, per year, per area. Results were adjusted for co-variates and analysed at area level using mixed effects logistic regression.

Results: Of 196,513 patients prescribed antibiotics in 69 areas, 16% were prescribed intensively (≥5 prescriptions in 3 years), receiving almost 30% of prescriptions. Of 12 308 confirmed UTI specimens (80% Escherichia Coli), 65% were resistant to at least one antibiotic (amoxicillin; cefalexin; ciprofloxacin; trimethoprim; nitrofurantoin). We found no significant association between high intensity 'any' antibiotic prescribing (same year/two preceding years) or overall 'any' antibiotic prescribing (same year) and UTI resistance.

Conclusion: We found no relationship between concurrent high intensity 'any' antibiotic prescribing, and UTI resistance rates in small urban communities, pre-covid. Individual patient use of multiple antibiotics, even at high intensity, may not be an independent risk factor for community UTI resistance.

Background: Asthma is the most common chronic disease in children, resulting in considerable morbidity and healthcare utilisation, especially in geographical areas with high deprivation. Parents play a pivotal role in children's asthma management.

Aim: To explore the views of parents whose children have asthma, regarding barriers and facilitators to receiving adequate asthma care.

Design & setting: A qualitative study conducted in an urban, multi-ethnic setting with high socioeconomic deprivation and paediatric asthma-related hospital admissions.

Method: The study used a pragmatic approach underpinned by a perspective of critical realism. Parents of children with asthma were recruited through purposive and convenience sampling, and data were collected through semi-structured interviews. Transcripts were analysed using thematic analysis, facilitated by NVivo12 software.

Results: Ten parents participated in nine interviews. Six themes were identified relating to the following: (1) the establishment of a new life dynamic following a diagnosis of asthma; (2) the turbulent and drawn-out process of asthma diagnosis; (3) the roles and expectations of the partnership established between parents and healthcare services; (4) the importance of schools in asthma management; (5) sources and access to relevant information; and (6) the importance of social support networks. Parents frequently felt unsupported and misunderstood, particularly during the diagnostic process.

Conclusion: Unmet parental educational and emotional needs, particularly around the time of diagnosis, were identified as a key barrier to adequate asthma management. Deeper understanding of gaps in support can instruct asthma care delivery and inform co-produced interventions, thus improving asthma outcomes in children.

Background: Since 2020, the General Medical Services contract requires GP practices in England to offer women a GP appointment 6-8 weeks after birth: the '6-8 week postnatal check' or 'consultation'. Historically, provision of checks was variable, and women still frequently report poor experiences.

Aim: To explore GPs' and women's perspectives of the 6-8 week postnatal check, including key components and timing.

Design & setting: Mixed methods study: focus groups of GPs and women, and an online survey of GPs in England.

Method: Focus groups explored GPs' and women's experiences of postnatal consultations. An online survey explored GPs' clinical approach, organisation, and improvement potential. Quantitative analysis examined associations between demographics and clinical approach. Thematic framework analysis was used for qualitative data.

Results: 18 women and 14 GPs participated in focus groups. 671 GPs completed the survey. Mental wellbeing and contraception were reported as important topics, although some women were not asked about mental health. GP survey responses indicated most recommendations from national guidance were 'always' or 'very often' covered by most, but not all GPs. Clinical coverage was higher for GPs who used clinical templates, had awareness of guidance, were female or a parent. Many GPs (n=326, 49%) needed more time than was allocated for the consultation: (n=524, 78% allocated<15 minutes; n=351, 52% completed in<15 minutes).

Conclusion: This study suggests GPs are allocated insufficient time for postnatal consultations, with substantial variation in practice. Specifying consultation duration and consideration of template usage in policy may improve care and outcomes for women.

Background: The use and advantages of point-of-care tests (POCTs) for C-reactive protein (CRP) in general practice, especially for upper respiratory tract infections (uRTIs), have been studied extensively. However, there is limited knowledge about test indications, prerequisites, and integration of these tests into everyday practice.

Aim: This study aims to investigate the attitudes and experiences of general practitioners (GPs) in Germany regarding the use of semi-quantitative CRP-POCTs. The study places special emphasis on implementation in routine care, including testing procedures, feasibility, opportunities and barriers for specific consultation scenarios, as well as test indications and their impact on GP-patient communication.

Design & setting: Qualitative interview study with 10 GPs (May/2023 to Aug/2023) METHOD: Ten German GPs who participated in an observational study on CRP-POCT use in general practices were interviewed using semi-structured interviews. Audio recordings were transcribed and content analysis was performed.

Results: Interviewed GPs stated that CRP-POCTs offer several advantages for various treatment cases. They improve diagnostic confidence and certainty of GPs' therapeutic decisions, and offer a broad spectrum of indications and application scenarios. Additionally, they have a positive impact on GP-patient communication, and their ease of use enables rapid implementation into existing workflows. On the other hand, CRP-POCT increase the time required for test performance and patient consultation.

Conclusion: Due to the numerous benefits of semi-quantitative CRP-POCTs, interviewed GPs have a favourable attitude towards their regular integration into everyday practice. Implementation barriers include increased time and personnel expenses for testing and inadequate reimbursement by German statutory health insurance.

Background: Demand for palliative care is rising. Recent UK policy approaches promote integrated care models - collaborations between generalist practitioners and multidisciplinary specialists - and remote and digital practices. The extent to which different forms of continuity are supported within this evolving context is currently unclear.

Aim: To explore the experience of continuity and impact of remote and digital practices within an integrated palliative care model.

Design & setting: A qualitative interview study of patients and bereaved relatives recruited from a GP practice list and healthcare professionals delivering the integrated palliative care service for that population.

Method: 20 narrative and semi-structured interviews were conducted with 22 patients, relatives, and professionals between May 2022 and November 2023. They explored how care was delivered or received, focusing on coherency and the use of remote and digital practices. Data were theorized using a novel framework that considered psychodynamic, biomedical, sociotechnical, and sociopolitical domains of continuity.

Results: The need for human care and connection were of primary importance and affected by intersubjective, biomedical, sociotechnical, and sociopolitical factors that influenced continuity of care. Despite the logistical ease of remote and digital practices, professionals had to work harder or around technologies to provide a 'caring' service. This was exacerbated by a lack of co-localisation, loss of longitudinal relationships, and reduction in tacit knowledge.

Conclusion: Numerous complex factors and the exacerbating effects of remote and digital practices influence continuity and coherency within an integrated palliative care model.

Background: Proton pump inhibitors (PPIs) the most frequently prescribed drug class globally, are often overused.

Aim: To assess PPI prescribing practice in England.

Design & setting: Electronic medical record (EMR) evaluation from 62 primary care GP practices.

Method: Adult patients on continuous PPI treatment (repeat prescription or≥4 acute prescriptions 6 months before data extraction) were included (August 2021-June 2022) to compare PPI prescribing practices vs National Institute for Health and Care Excellence (GORD and dyspepsia management) and Medicines and Healthcare products Regulatory Agency (clopidogrel-PPI interaction) guidelines.

Results: We identified 77,356 patients on continuous PPI treatment. The most common (68%) diagnosis recorded in patients' EMRs and indicated for PPI use was gastroprotection, although 62% had no recorded indication. Of these 62% patients, 40% had no medication review in the preceding year. Among those with diagnoses indicated for≤3 months of PPI therapy (34%), 99% received their first PPI prescription≥3 months previously. Of patients with diagnoses indicated for long-term treatment (4%), 41% had no medication review in the preceding year. Furthermore, 18% of patients using omeprazole or esomeprazole were also prescribed clopidogrel, and 19% of those prescribed treatments associated with gastrointestinal risk (N=14,826) were not prescribed PPIs.

Conclusion: This study shows that PPI prescribing in England is not in alignment with existing clinical guidelines and highlights the need for appropriate measures to increase awareness of overuse and support deprescribing where appropriate.

Background: Chronic Kidney Disease (CKD) is a common health problem, associated with increased risk of cardiovascular disease (CVD), end stage kidney disease (ESKD), and premature death. A third of people aged≥70 years have CKD, many of whom are undiagnosed, but little is known about the value of screening.

Aim: To compare the risk of adverse health outcomes between people with an existing diagnosis of CKD and those identified on screening. To identify factors associated with mortality in CKD.

Design & setting: Prospective cohort study of 892 primary care patients aged≥60 years with CKD (existing and screening detected) in Oxfordshire, with data linkage to civil death registry and secondary care.

Method: Hazard Ratios (HR) and 95% Confidence Intervals (CI) were estimated using Cox proportional-hazard models to compare the risk of all-cause mortality, hospitalisation, CVD, ESKD separately, and as a composite between CKD groups, as well as to identify factors associated with mortality.

Results: After a median follow-up of 3-5 years, 49 people died, 493 were hospitalised, 57 had an incident CVD event, and 0 had an ESKD event. There was no difference in the composite outcome between those existing CKD and those identified on screening (HR 0.94, CI 0.67-1.33). Older age (HR 1.10, CI 1.06-1.15), male sex (HR 2.31, CI 1.26-4.24), and heart failure (HR 5.18, CI 2.45-10.97) were associated with increased risk of death.

Conclusion: Screening older people for CKD may be of value, as their risk of short-term mortality, hospitalisation, and CVD is comparable to people routinely diagnosed. Larger studies with longer follow-up in more diverse and representative populations of older adults are needed to corroborate these findings.

Background: Family medicine, often known as general practice, is the foundation of sustainable and universal healthcare worldwide. As a new specialty in the Eastern Mediterranean Region (EMR), it must recruit doctors and gain public acceptability, which has traditionally favored specialists.

Aim: This research examined studies on Arab populations' attitudes toward family medicine and the specialty to discover barriers to creating and embracing this vital specialty.

Design & setting: This review was based on the PRISMA guidelines and encompassed peer-reviewed articles from reputable sources such as PsychNet, Web of Science, PubMed, Embase, Scopus, and grey literature.

Method: A comprehensive search was conducted across databases for peer-reviewed studies that explored Arabs' awareness, perceptions, and attitudes toward family medicine and physicians.

Results: After a rigorous selection process, nineteen studies were deemed suitable for analysis. These studies encompassed diverse participants, including medical students, physicians, patients, and the general public. The overall perception of family medicine was positive, but it was noted that few had direct exposure to family physicians during their medical education or in the clinical setting.

Conclusion: Our review suggests five significant efforts: 1) an education campaign for the general public about the role of Family Medicine; 2) increasing training capacity for family physicians; 3) early exposure to family physicians during medical school; 4) developing a process for continually improving the education and quality of family physician, 5) Further research on the challenges to FM practice in Arab countries are required to understand the situation better and work toward its improvement.

Background: GPs are often required to make decisions about the management of acute illness in people living with dementia. These decisions are often complex and involve multiple informants.

Aim: We aimed to explore how GPs made decisions about acute illness in people with dementia using a micropolitics approach.

Design & setting: Qualitative, semi-structured interviews with 13 GPs with a range of years of experience working in South Yorkshire, UK.

Method: Interviews were conducted by phone. Interviews focused on GPs' accounts to reflect their own perceptions and choices as portrayed to the interviewer. The analysis used the lens of micro-politics in the analysis and interpretation of the themes, with a focus on decisions between GP, patient, family and carers, other health and social care providers about the management of acute illness in a person with dementia.

Results: The results showed that GPs act as street-level bureaucrats while carrying out their role, using discretion during decision-making in an environment characterised by uncertainties and work pressures. In addition, GPs use the "soft power" skills of diplomacy such as negotiation, persuasion and engagement in navigating through difficult decision-making situations, while building relationships and partnerships with various actors in the health system.

Conclusion: GPs possess and express power and influence decision-making in people living with dementia when navigating biomedical, social, economic and psychological factors. This power comes in the form of soft power (street level diplomacy) and the more formal power of street level bureaucracy.

Background: Preschool children (aged≤5 years old) have the highest antibiotic prescribing rate in general practice, mostly for self-limiting acute respiratory tract infections (RTIs). Research from over 250 000 UK children suggests that a child's antibiotic history for RTI may be a good predictor for re-consulting a health professional for the same illness episode and increase clinical workload.

Aim: To develop a data-enabled nudge intervention to optimise antibiotic prescribing for acute RTI based on a child's antibiotic history in general practice DESIGN & SETTING: Two phase qualitative study with parents/carers of preschool children and primary care clinicians METHOD: In phase 1, through an initial focus group with eight parents/carers and 'think aloud' interviews with 11 clinicians, we co-designed the intervention (computer screen prompt and personalised consultation leaflet). In phase 2, 13 clinicians used the intervention, integrated into the GP computer software, and share their feedback through 'think aloud' interviews. Interviews were audio-recorded, transcribed, and analysed thematically.

Results: We co-created a data-driven intervention that automatically integrates a child's antibiotic history for acute RTI and personalised leaflet into the electronic medical records. We found that parents and clinicians found this intervention, in principle, acceptable and feasible to use in primary care consultations.

Conclusion: Delivering such interventions, integrated into practice workflow, could be efficiently scaled up to promote effective antimicrobial stewardship and reduce unnecessary antibiotic use in primary care. Further research will test this intervention in a future trial.