BJGP Open最新文献

Background: Collaborative working between GPs and community pharmacists (CPs) has led to improvements in management of long-term conditions, and has strong policy backing, yet such joint working remains patchy and underdeveloped. Understanding the perspectives of GPs and CPs regarding collaboration provides insights for more sustainable collaborative practices.

Aim: To understand the perspectives of GPs and CPs concerning collaborative care practices, and to develop a framework of factors that influence this collaborative working relationship.

Design & setting: A systematic review of qualitative studies.

Method: Five databases were searched from inception to the 22 April 2023 for qualitative studies exploring GP and CP views on collaborative care services. Articles were independently screened by two reviewers at title, abstract, and full-text levels. Data extracted from eligible studies were analysed and synthesised thematically.

Results: Thirty-six studies met the inclusion criteria. The following four main themes were identified: (1) how pre-existing relationships influence mutual understanding of roles; (2) the impact of co-location and communication on relationship building; (3) analysis of perceived costs and benefits of collaborative care; and (4) unequal motivation to collaborate.

Conclusion: A complex interplay of factors influences GP and CP collaborative working, including pre-existing relationships, communication and mutual understanding, and the balance of costs and benefits to further develop these relationships. When planning future collaborative care practices, stakeholders must take the time and initiative to elucidate and understand these factors within their own unique healthcare setting to form lasting working relationships.

Background: Age-related vision impairment (ARVI) is associated with an increased risk of dementia and depression and can affect older patients' overall health and ability to manage everyday tasks. ARVI is often asymptomatic making it difficult to detect. The World Health Organization (WHO) recommends primary care settings for identification of ARVI, underscoring the importance of general practice.

Aim: To synthesise recent knowledge on identifying ARVI in general practice within countries with well-established primary healthcare systems.

Design & setting: A systematic literature review searching for published research focused on identification of ARVI and chronic eye diseases in general practice.

Method: The search was conducted in June 2024 across PubMed, Web of Science, and Scopus. Inclusion criteria included empirical, peer-reviewed studies focused on ARVI or eye diseases in adults in general practice, conducted in countries with well-established primary healthcare systems, and published in English or three Scandinavian languages (Danish, Swedish, and Norwegian). Acute eye diseases were excluded. Twenty articles were included. A thematic qualitative synthesis of included articles was conducted.

Results: The following three themes were identified: (1) general practice screenings and referrals, highlighting a limited knowledge of eye health, but a high focus on diabetic retinopathy (DR); (2) collaboration between general practices and other health professions, implied the importance of cross-sectorial collaboration; and (3) potentials in general practice for detecting ARVI, through initiatives such as continued professional development, systematic DR screening, and more focus on other eye diseases than DR.

Conclusion: This review highlights the need for more research in detection of ARVI and prevalent chronic eye diseases in general practice.

Background: There are two models of urgent care telephone triage in the UK: one-step triage that is conducted by a clinician, and two-step triage involving an initial triage by a non-clinical call adviser followed by a secondary clinician triage. Both models may involve digital triage (computerised decision support). Little is known about patient experiences of receiving two-step triage.

Aim: To explore patients' and carers' experiences of two-step triage in relation to experiences of one-step triage.

Design & setting: Semi-structured interviews were conducted between July 2021 and February 2022 with patients and carers who had undergone one-step or two-step urgent care triage in England or Northern Ireland.

Method: Data were thematically analysed; Oben's conceptual framework of patient experience was used to interpret findings. Findings were reported in line with the Standards for Reporting Qualitative Research framework.

Results: In total, 25 patients or carers were interviewed. Complexity, delays, and frustration were described in relation to two-step triage. Communication with non-clinicians was often experienced as scripted and inflexible, while communication with clinicians was described as more natural and empathetic. Reassurance experienced during triage enabled some patients to stay home without seeking further care.

Conclusion: Minimising the complexity experienced by patients should be factored into planning two-step triage services. Further research should explore how digital triage can be adapted to promote more natural flow of communication and how empathetic communication during triage may enable self-care. Training for clinicians should emphasise such communication and the importance of giving sufficient time to patients during triage.

Background: Primary care is in urgent need of more effective and efficient ways of managing the care of people living with multiple long-term conditions (MLTCs; multimorbidity). Personalised care organised around an individual's needs and conditions, taking account of individual context and priorities and supporting self-management, may offer an improved approach.

Aim: To explore the impact of a computerised template to support personalised care for patients with MLTCs within the context of routinely applied general practice.

Design & setting: A convergent mixed-methods evaluation design. General practices were recruited from three areas of England: Bristol, Southampton, and Staffordshire.

Method: A computerised template for the review of MLTCs was made available to all general practices subscribing to a commercial template supplier. Implementation practices were supported to conduct personalised multimorbidity reviews. We used routine clinical data from implementation and control practices, a before-and-after patient questionnaire, and qualitative interviews with general practice staff and patients to evaluate the impact of the intervention.

Results: Thirty-two general practices were recruited, of which half were implementation practices. Using the multimorbidity template has potential to improve quality of care and patient benefit with no increase in consultation numbers. Patients received a more complete assessment of their needs with a clearer focus on the problems that matter most to them. Conducting multimorbidity reviews can increase burden on nursing staff and consideration is required as to the organisation of reviews and appropriate training for nursing staff.

Conclusion: Use of the multimorbidity template needs to be supported by staff training, adequate practice capacity, support for system reorganisation, and attention to incentives to facilitate its benefits.

Background: Clinically coded long COVID cases in electronic health records (EHRs) are incomplete, despite reports of rising cases of long COVID.

Aim: To determine patient characteristics associated with clinically coded long COVID.

Design & setting: With the approval of NHS England, we conducted a cohort study using EHRs within the OpenSAFELY-TPP platform in England, to study patient characteristics associated with clinically coded long COVID from 29 January 2020 to 31 March 2022.

Method: We summarised the distribution of characteristics for people with clinically coded long COVID. We estimated age-sex adjusted hazard ratios (aHRs) and fully aHRs for coded long COVID. Patient characteristics included demographic factors, and health behavioural and clinical factors.

Results: Among 17 986 419 adults, 36 886 (0.21%) were clinically coded with long COVID. Patient characteristics associated with coded long COVID included female sex, younger age (aged <60 years), obesity, living in less deprived areas, ever smoking, greater consultation frequency, and history of diagnosed asthma, mental health conditions, pre-pandemic post-viral fatigue, or psoriasis. These associations were attenuated following two doses of COVID-19 vaccines compared with before vaccination. Differences in the predictors of coded long COVID between the pre-vaccination and post-vaccination cohorts may reflect the different patient characteristics in these two cohorts rather than the vaccination status. Incidence of coded long COVID was higher in those with hospitalised COVID-19 than with those with non-hospitalised COVID-19.

Conclusion: We identified variation in coded long COVID by patient characteristic. Results should be interpreted with caution as long COVID was likely under-recorded in EHRs.

Background: Diabetic foot ulcers (DFUs) significantly impair health-related quality of life (HRQoL). While clinical predictors are well established, the contribution of psychological factors, particularly in primary care, remains underexplored.

Aim: To examine the sociodemographic, clinical, and psychological determinants of HRQoL in individuals with DFUs to inform development of psychologically informed interventions.

Design & setting: Cross-sectional study conducted between April and October 2022 in primary care settings in Singapore.

Method: A total of 186 patients with DFUs completed validated measures, including psychological variables (for example, the Diabetes Distress Scale and Brief Illness Perception Questionnaire) and Wound-QoL, which uses a questionnaire to assess quality of life in body, psyche, and everyday life domains. Hierarchical multiple regression analyses evaluated the contribution of psychological variables to HRQoL.

Results: Psychological burden dominated, with psyche HRQoL impaired in 57% of participants (mean = 2.0), outpacing everyday life (38%; mean = 1.3) and body domains (24%; mean = 0.8). In hierarchical models, psychological variables - together with sociodemographic and clinical factors - explained 29.8% of the variance in body HRQoL, with interpersonal distress and threat perceptions emerging as significant predictors. A similar model accounted for 31.8% of the variance in psyche HRQoL, with female sex, emotional burden, and threat perceptions as key predictors. Everyday life HRQoL was significantly associated with HbA1c, independence in daily activities, emotional burden, and threat perceptions, with the full model explaining 33.7% of the variance.

Conclusion: Psychological factors significantly contributed to reduced HRQoL in primary care patients with DFUs. Routine screening and targeted, psychologically informed support - particularly for females, those with poor glycaemic control, or limited functional independence - are essential to improve outcomes.

Background: Declining continuity of care in England could disproportionately affect some patient groups.

Aim: To examine patients' perceptions of continuity of primary care, identify factors associated with continuity, and measure changes in continuity of care for different patient groups, following primary care network (PCN) implementations.

Design & setting: Cross-sectional surveys were undertaken of patients from three groups (older adults with polypharmacy, patients with mild or moderate anxiety or depression, and working-age adults [18-45 years]), attending 19 practices in five PCNs in England, at two timepoints (November 2021-April 2022 and November 2022-April 2023).

Method: Relational continuity was measured using the Nijmegen Continuity Questionnaire (NCQ) score. Differences between patient groups and two timepoints were tested using multiple linear regression.

Results: Survey response rates were n = 362/1547 (23%) and n = 350/1528 (23%). Adults with polypharmacy experienced significantly better continuity than adults with anxiety or depression and younger working-age adults after adjusting for PCN, practice, and population-level characteristics (P< 0.05). Those who always or sometimes saw their preferred GP experienced significantly better continuity than those who never did (P< 0.01). PCNs with pre-existing inter-practice collaborations were not associated with differences in relational continuity.

Conclusion: We found differences in experienced continuity of care between patient groups. Relational continuity depends on seeing a preferred GP, not a non-preferred GP or other healthcare professional (HCP). Better continuity was associated with larger practice networks.

Background: The UK healthcare system has a growing workforce crisis, which is felt especially acutely in primary care. A prospective solution is the use of physician associates (PAs). In recent times, this has generated some controversy. There is a sparsity of synthesised evidence around the use of PAs in the UK, particularly their implementation in primary care.

Aim: To look at the impact PAs have on workload, safety, efficacy, and cost-effectiveness in delivering UK primary care.

Design & setting: Systematic review of peer-reviewed literature, including qualitative and quantitative studies of PAs, in UK primary care.

Method: Cochrane and Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines were followed. PubMed, Embase, the Cochrane Library, Web of Science, and CINAHL were searched from 2011-2024. Covidence was used for data management. Narrative synthesis was performed based on the four primary aims.

Results: Sixteen studies were deemed to meet the inclusion criteria for data extraction and synthesis. Thirteen commented on workload, eight commented on safety, 13 on efficacy, and eight studies discussed cost-effectiveness. Results showed that PAs were considered clinically safe but impacts on workload and efficacy were less clear. Cost-effectiveness assessment was limited by inability to calculate full costs or benefits.

Conclusion: This review found that there is limited evidence available in the published literature to demonstrate the impact of PAs in primary care. While there were some positive studies, a clear need for further research was demonstrated. An additional pathway to explore, comparing PAs with the non-GP primary care workforce, was also noted.

Background: Scabies cases are rising in several high-income European countries, but its true incidence remains unclear owing to its non-notifiable status. GPs play a key role in managing scabies, yet the impact on primary care is unknown.

Aim: To assess the epidemiology and care burden of scabies-related episodes in general practice.

Design & setting: A retrospective longitudinal study using pseudonymised data from Dutch GPs.

Method: Data from five general practices, covering nearly 40 000 patients from 2014-2023, were analysed. Scabies-related episode incidence, time between scabies-related symptoms and first GP encounter (patient's delay), time between first GP encounter and scabies diagnosis (doctor's delay), and care burden were compared between two periods: 2014-2020 (low incidence) and 2021-2023 (high incidence).

Results: In total, 1525 scabies-related episodes, including 4555 recorded encounters, were included. Between 2014 and 2023, the incidence increased from 99 to 1341 episodes per 100 000 patient-years, with encounters rising from 614 to 2438 per 100 000 patient-years between the two periods. The largest increase in encounters occurred in those aged 17-25 years (P<0.001) and in females (P = 0.002). Patient delays >28 days decreased from 26.4% to 14.3%. Scabies diagnoses during initial consultations improved from 84.9% to 92.3%. Encounters without interventions declined from 36.9% to 14.4%. Medical prescriptions and referrals per 100 000 patient-years increased.

Conclusion: Our findings highlight an exponential increase in scabies-related episodes, significantly increasing the burden on general practices. Regions experiencing rising scabies incidence rates should prioritise public health interventions to curb transmission, which require a coordinated clinical and public health response.

Background: Guidelines recommend measuring blood pressure (BP) in both arms and using the higher reading.

Aim: To determine interarm pressure difference (IAD) distribution and associated factors, and BP and atherosclerotic cardiovascular disease (ASCVD) risk classification using the higher and lower readings.

Design & setting: This cohort study used a representative cross-sectional sample of community-dwelling residents aged ≥40 years on four Caribbean islands (Barbados, Puerto Rico, US Virgin Islands, and Trinidad).

Method: BP was measured simultaneously in both arms. Mixed effects logistic and linear regression tested associations with an IAD. BP and ASCVD risk were classified using the higher and lower BP.

Results: Of 2912 participants (mean age 57.2 years), 10.7% (95% confidence interval [CI] = 9.6 to 11.8) and 3.3% (95% CI = 2.6 to 3.9) had systolic IADs ≥10 mmHg and ≥15 mmHg, respectively, and 5.0% (95% CI = 4.2 to 5.8) and 1.8% (95% CI = 1.3 to 2.3) diastolic IADs ≥10 mmHg and ≥15 mmHg, respectively. Independent associations with systolic and diastolic IADs ≥10 mmHg and/or continuous outcomes, included increasing body mass index (BMI), systolic and diastolic pressures and hypertension (P<0.05). Higher versus lower arm BP reclassified 10.3% (95% CI = 7.8 to 12.8) and 8.3% (95% CI = 5.9 to 10.7) from below to above the 130-mmHg and 140-mmHg systolic thresholds, respectively, 10.8% (95% CI = 8.2 to 13.3) and 6.9% (95% CI = 4.9 to 8.9) at the 80-mmHg and 90-mmHg diastolic thresholds, respectively, and 9.2% (95% CI = 0.0 to 18.4) of those with an IAD of ≥10 mmHg at the ≥10% 10-year ASCVD risk threshold.

Conclusion: Assessing both arms detects an IAD ≥10 mmHg and reclassifies BP in about 1 in 10 people. Increasing BMI and BP increase the risk of an IAD ≥10 mmHg or 15 mmHg.