BJGP Open最新文献

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.

Background: Access to interpreters for refugee and migrant patients that do not share the same language and culture as their GPs is considered a critical healthcare adaptation. However, interpreters are not routinely available in many healthcare settings and artificial intelligence (AI) is increasingly used as a pragmatic alternative. The patient-safety implications of relying on AI for this purpose are under-researched.

Aim: To identify and map available evidence on AI-facilitated synchronous communication between refugee or migrant patients and their healthcare provider, focusing on the patient-safety implications.

Design & setting: A six-stage scoping review was undertaken, examining the international literature.

Method: A literature search of five relevant electronic databases and grey literature from July 2017 to October 2024 was conducted. Data were extracted and synthesised accordingly.

Results: A total of 220 articles spanning various healthcare contexts were screened, with five articles meeting inclusion criteria. These studies report use of the AI-tool Google Translate to address language barriers across diverse clinical settings, despite Google Translate not being designed to support synchronous communication or communication in medical contexts. Negative experiences of using these tools were reported more than positive experiences. Clinicians discussed specific concerns about reliability of Google Translate for medical terms, patient consent, and complex consultations.

Conclusion: There is no evidence that using Google Translate to synchronously communicate medical information to refugees and migrants has been tested for patient safety, highlighting potential for translation inaccuracies impacting patient safety. In clinical settings, where the high stakes of failure are ever-present, such inaccuracies can result in misdiagnosis, inappropriate treatment, and serious harm.

Background: Social determinants of health (SDOH) critically influence population and individual-level outcomes, but we do not collect this information routinely in primary care.

Aim: To develop a screening tool for SDOH relevant to UK settings using systematic review and Delphi methodology to identify suitable questions.

Design & setting: A systematic review and Delphi study were undertaken.

Method: For the systematic review, five databases and grey literature were searched. Selected studies included questions or tools that screened for SDOH relevant to UK settings. Included questions and tools were measured against the eight gold standard steps for measure development. Data were thematically analysed and arranged into pre-specified domains. For the Delphi study, individuals with an interest in SDOH were invited to take part in a three-stage modified Delphi study. Ranking of 172 items in survey 1, rating of 111 items in survey 2, and ranking of 56 items in survey 3 led to one question being selected per 10 pre-specified domains. Inductive content analysis of free-text responses from the surveys was performed.

Results: Of 7889 citations, 104 studies were included in the systematic review. Screening primarily took place in clinical settings using written formats. Seven participants took part in the first Delphi survey. Prioritised questions were direct, had binary answers, had specific wording, were concerned with current situation, and had immediate impacts on health.

Conclusion: The review provides a comprehensive overview of screening questions and tools for collecting information on SDOH. We present a 10-item screening tool from the highest ranked questions that can be used to screen for SDOH in primary care settings in the UK.

Background: Urinary tract infections (UTIs) are common, representing a frequent cause of antibiotic prescription in primary care worldwide. Selection of antibiotics for antimicrobial susceptibility testing and the reporting of test results by laboratories can directly impact antibiotic prescribing and guideline adherence.

Aim: To assess the current practice of susceptibility testing by laboratories for outpatient UTIs in Germany.

Design & setting: A cross-sectional study was conducted including all laboratories identified by searching for specialists in laboratory medicine and microbiology on the websites of the 17 German associations of statutory health insurance physicians.

Method: Between January and April 2024, a survey using a standardised questionnaire was conducted across identified laboratories.

Results: Of the 396 laboratories identified, 65.2% (n = 258) replied. Of these, 106 laboratories performed susceptibility testing and on average tested for 13.1 (standard deviation [SD] 3.6) different antibiotics in a urine culture positive for Escherichia coli. The most commonly tested antibiotics were ciprofloxacin (98.1%), co-trimoxazole (97.2%), cefuroxime, and nitrofurantoin (both 91.5%). On average, laboratories tested 3.8 of the five antibiotics recommended in the German guidelines on uncomplicated UTI, with 26.4% testing for all five. Laboratories received clinical information on previous treatments and comorbidities in an estimated one-fifth (on average 21.3% and 21.5%, respectively) of the urine samples, and information on the type of the urine sample in an estimated three-fifths (63.7%) of samples.

Conclusion: Laboratories should test and report as many first-line antibiotics as possible. Further, a more detailed and standardised transfer of clinical information to laboratories could enhance the quality of antibiotic prescribing.

Background: In the past decade, interest in researching nursing practice environments has increased considerably. Multiple studies have highlighted that substantial benefits result from enhancing these environments. A strong association has been established between the nursing practice environment and key factors such as professional satisfaction, safety climate, staff retention, and the quality and safety of care delivered.

Aim: To evaluate the effectiveness of the Positive Nursing Practice Environment Promotion Programme (PPAPEP) in improving patient safety in primary health care.

Design & setting: A randomised clinical trial will compare changes in nurses' perceptions of the safety climate and nursing practice environment in primary healthcare units. The sample will include at least 34 nurses participating in the programme and currently working in primary healthcare units. The sociodemographic and professional characteristics of the participants will be analysed, and stratified randomisation will be conducted.

Method: The intervention group will participate in the PPAPEP, consisting of six training sessions, each lasting 3 hours. The programme's goal is to empower nurses by providing knowledge about what constitutes a positive nursing practice environment and equipping them with tools to improve their practice environment. The outcomes of the intervention will be assessed both at the end of the programme and 3 months after its conclusion.

Conclusion: We anticipate that this study will provide valuable insights into the effectiveness of a capacity-building programme targeted at nurses and its impact on their perceptions regarding the safety climate and nursing practice environment.