BJGP Open最新文献

Background: Adherence to statins for the primary prevention of cardiovascular disease (CVD) is low. There is evidence that some facets of the initiation consultation, or the initiating clinician, are associated with adherence. CVD risk estimation is fundamental to statin initiation and shared decision making (SDM), because the benefits of statins are proportional to CVD risk. Absence of a recorded CVD score before statin initiation therefore indicates SDM is unlikely.

Aim: To investigate whether SDM, using CVD risk score as a proxy measure, is associated with adherence to statins and CVD outcomes.

Design & setting: A retrospective cohort study using a database of English primary care records.

Method: The cohort will include statin naïve patients aged 40-84 years initiated on statins for primary prevention between 2017 and 2020, categorised by the presence or absence of a CVD risk score at statin initiation. Statin adherence and persistence will be determined from subsequent statin prescriptions. Multivariable modelling, accounting for potential confounders, will determine the association between a recorded CVD risk score and subsequent statin adherence and with statin persistence. A secondary analysis will investigate the relationship to subsequent CVD outcomes and death.

Conclusion: This research uses a record of CVD risk score as a proxy for SDM, to investigate the link between SDM and medication adherence. It will shed light on relationship between how the initiation consultation is performed and subsequent adherence and persistence with treatment.

Background: Point-of-care tests (POCT) can support diagnosis of patients with community acquired acute respiratory tract infections (CA-RTI) in primary care and thereby reduce uncertainty whether antibiotics may benefit patients. However, successful roll out of POCTs need to be built on a deep understanding of patients' perspectives on the place of POCTs in patient centred care.

Aim: To explore patients' perceptions of the value of POCTs during consultations for CA-RTI.

Design & setting: A qualitative study using semi- structured interviews in Belgium, Ireland, Georgia, Germany, Greece, and UK with patients who consulted for CA-RTI in primary care.

Method: Interviews were audio recorded, transcribed, and analysed using reflexive thematic analysis.

Results: Interviews with 56 participants revealed that in the process of a GP making a diagnosis and treatment decision, patients valued several components such as a physical examination, their GP enquiring about and listening to concerns, and a POCT. Yet, the visibility and relative importance of each of these components varied in the four main ways in which patients perceived the value of POCTs including i) test as objective evidence compared to "subjective" clinical judgement; ii) test as providing more precision; iii) test as inferior to clinical judgment; iv) test as one of the tools in GP's toolbox.

Implications: The wide variation in patient perceptions about POCT for CA RTI underscores the importance of recognising patient preferences regarding the diagnostic process. This understanding is important to ensure that POCT results optimally influence treatment decision-making, patient satisfaction, and acceptance of their care plan.

Background: Chronic Obstructive Pulmonary Disease (COPD) exacerbations are clinically significant events that affect millions globally.

Aim: To explore patients' and carers' experiences, understandings and responses to exacerbations.

Design & setting: Semi-structured interviews with COPD patients and carers.

Method: Interviews were conducted with a purposive sample of COPD patients and carers from four centers in England. Interviews were analysed using reflexive thematic analysis, theoretically informed by the Breathing Space concept. This research is reported in line with the Standards for Reporting Qualitative Research.

Results: Forty patient-participants were recruited: 21 female, 28 white, mean age 69 years [SD 8.1], mean COPD duration 11.3 years [SD 8.3], median 1.5 exacerbations in past year [range 0-9]. Seven carer-participants were recruited: 6 female, 6 white.Three themes were identified: 1) The language clinicians use in COPD is important; 2) Episodes of symptom worsening have profound patient and carer impact and 3) Patients' early experiences, including the responses of clinicians to their help-seeking, have a lasting effect on their behaviour. How patients respond to symptom worsening can be considered holistically in the context of the Breathing Space framework. Breathlessness affected all patient-participants and was a key symptom that precipitated action.

Conclusions: Our novel findings show how early help-seeking experiences shape later behaviour. Early emphasis on symptom management, preparation for exacerbations and post-exacerbation reviews are practical ways that clinicians can support patients and carers to manage these events better. The Breathing Space concept provides a useful framework to identify needs and tailor COPD management appropriately.

Background: The recommendation to consider prescribing inhalation corticosteroids to a subgroup of vulnerable COVID-19 patients was added to the Dutch medical guideline on November 11, 2021, and was also adopted by other countries during the pandemic.

Aim: To evaluate the adherence of general practitioners to this guideline, and whether real-world data quality is sufficient to study the effect of revised guidelines on prescribing behaviour.

Design & setting: A retrospective cohort study using Dutch primary care data from the Extramural LUMC Academic Network database, containing patient data of 129 general practices in the Leiden - The Hague area.

Method: We performed an interrupted time series analysis to measure the effect of the new guideline on the prescription rate of ICS, accounting for general trend and seasonal fluctuations.

Results: Between July 1, 2020 to August 1, 2022, 131,482 patients had 164,098 COVID-19 consultations. During this period, 1,709 patients received 2094 ICS prescriptions for COVID-19. After the guideline update, there was an instantaneous decrease in prescription rate (IRR 0.47, 95% CI 0.32-0.69). Prescription rate in the subgroup of vulnerable patients did not change significantly (IRR 0.93, 95% CI 0.66-1.32), while less vulnerable patients were significantly prescribed less (IRR 0.29, 95% CI 0.14-0.59).

Conclusion: The revision to COVID-19 guidelines had significant impact on general practitioners' prescription behaviour soon after publication: prescription rate remained constant for vulnerable patients, while less vulnerable patient were significantly prescribed less often. Using electronic health records it is feasible to assess changes in guideline adherence using interrupted time series.

Background: The UK National Institute for Health and Care (NICE) recommends that GPs inform patients referred onto the Urgent Suspected Cancer (USC) pathway about what to expect from the service. However, there is a lack of evidence on patient experience and information needs at the point of referral. It is a challenge for GPs to communicate the reasons for referral and provide reassurance.

Aim: This study aimed to examine how GPs communicate a potential cancer diagnosis and USC referral in practice.

Design & setting: This is a secondary analysis of a dataset of 23 audio-recorded GP-patient consultations, selected from a larger dataset of 200 consultations collected in Surrey and London, UK in 2017-2018. The consultations were selected based on inclusion criteria related to cancer discussions.

Method: This is a qualitative analysis of video recordings of face to face patient consultations.

Results: We found that most GPs informed patients that they might have cancer and engaged in reassurance using personalised risk statements. Some GPs avoided all mention of cancer, using symptom-led language instead. GPs focused on communicating practical rather than support-based information. While most GPs informed patients that they would be seen by a specialist within two weeks, few discussed patients' support needs during the referral period.

Conclusion: Clear communication about cancer in primary care is promoted in UK policy, and has an important role driving patient investigations attendance. The study highlights the need for further research on communication practices around cancer referral to improve patient understanding and experience. Our recommendations for enhanced communication may improve patient outcomes by optimising routes to diagnosis via primary care.

Background: The Quality and Outcomes Framework (QOF), a pay-for-performance programme, has been the most widespread quality initiative in National Health Service (NHS) general practice since 2004. It has contributed between 25% and 8% of practices' income during this time, but concerns about its effect on equity have been raised.

Aim: Understand which practice characteristics are associated with QOF performance.

Design and setting: Systematic review, NHS general practice.

Method: MEDLINE, Embase, CINAHL+, Web-of-Science and grey literature were searched for studies examining the association between general practice characteristics and QOF performance.

Results: Twenty-two studies, published between 2006 and 2022, exploring the relationship between six population and 15 organisational characteristics and QOF measures were found. Most studies were cross-sectional, of English general practices, and used data from the early years of QOF. A negative association was frequently found between overall QOF performance and socioeconomic deprivation; proportion of registered patients>65; list size; mean general practitioner (GP) age; and Alternative Provider Medical Services contracts. Group practices (versus single-handed); more full-time-equivalent GPs; and being a training practice were frequently associated with better overall QOF performance. The associations of most other characteristics with performance were inconsistent.

Conclusion: Associations with characteristics both within and outside practices' control were identified. Pay-for-performance instruments may systematically disadvantage practices serving those at greatest risk of ill-health, such as older and more deprived populations. Given the cross-sectional design of many studies and focus on the early years of QOF, more up-to-date evidence is needed to understand if and why these relationships persist.

Background: Work-related asthma (WRA) is prevalent yet under-recognized in UK primary care.

Aim: We aimed to identify behaviour change interventions (BCI) intended for use in primary care to identify WRA, or any other chronic disease (that could be adapted for use in WRA).

Design & setting: Systematic review METHOD: We searched CCRCT, Embase, PsychINFO and Ovid-MEDLINE databases (1946-2023) for studies describing development and/or evaluation of BCIs for case finding any chronic disease in primary care settings, aimed at either healthcare professionals and/or patients. Two blinded, independent reviewers screened abstracts and assessed full text articles. We undertook narrative synthesis for outcomes of usability and effectiveness, and for BCI development processes.

Results: We included 14 studies from n=768 retrieved citations, comprising 3 randomised control trials, 1 uncontrolled experimental study, and 10 studies employing recognized multi-step BC methodologies. None of the studies were concerned with identification of asthma. BCIs had been developed for facilitating screening programmes (5), implementing guidelines (3) and individual case finding (6). Five studies measured effectiveness, in terms of screening adherence rates, pre-/post-intervention competency, satisfaction and usability, for clinicians, though none measured diagnostic rates.

Conclusion: No single or multi-component BCIs has been developed specifically to aid identification of asthma or WRA, though other chronic diseases have been targeted. Development has used BC methodologies that involved gathering data from a range of sources, and developing content specific to defined at-risk populations, so are not immediately transferable. Such methodologies could be used similarly to develop a primary acre-based BCI for WRA.

Background: Electronic Risk Assessment Tools (eRATs) are intended to improve early primary care cancer diagnosis. eRATs which interrupt a consultation to suggest a possibility of a cancer diagnosis, could impact clinical appraisal and the experience of the consultation. This study explores this issue using data collected within the context of the ERICA trial.

Aim: To explore experiences of General Practitioners (GPs) who used the ERICA eRATs, and how the tool impacted their perception of risk and diagnostic thinking, and communication of this to patients.

Design & setting: Qualitative interviews with GPs from English General Practices undertaking the ERICA trial.

Method: Participants were purposefully sampled from practices participating in the intervention arm of the ERICA trial. 18 GPs undertook semi-structured interviews via MS Teams. Thematic Analysis was used to explore their perspectives the impact of eRATs on consultations, diagnostic thinking related to cancer and other conditions, and how this information is communicated to patients.

Results: Three themes were developed: 1) eRATs were perceived as "Additional Armour", offering a layer of protection against missing a cancer diagnosis, the defence coming at a cost of anxiety and complexity of consultation; 2) eRATs were seen as another actor in the consultation, separate from clinician and patient, and challenging GP autonomy; and 3) GPs were conflicted about whether the numerical eRAT outputs were helpful when communicating with patients.

Conclusion: eRATs are appreciated as a defence against missing a cancer diagnosis. This defence comes at a cost and challenges GP's freedom in communication and decision making.

Background: Poverty can have significant impacts on health and wellbeing. However, asking patients about their broader socio-economic circumstances is not routine within primary care consultations.

Aim: To understand healthcare professionals' experiences of communicating with patients about their socio-economic circumstances and how a bespoke training programme supported these conversations in routine consultations.

Design & setting: Healthcare professionals from 30 GP practices across England received training to improve understanding and communication with patients about the ways that poverty impacted their mental health.

Method: Semi-structured interviews were undertaken with 49 GPs and allied health professionals to understand barriers and enablers to communication around poverty and the impact of the training on their consultation practice.

Results: Health professionals often lacked confidence in discussing socio-economic issues and welcomed information on how to do this sensitively. Asking questions relating to poverty-related stresses was felt to lead to better understanding around the causes of mental distress, avoidance of problematic assumptions and inappropriate antidepressant prescribing and to enable more coordinated and appropriate support from practice teams.

Conclusion: Asking patients about their socio-economic circumstances can facilitate provision of appropriate support.

Background: The career decisions of medical students are pivotal in shaping the future healthcare workforce. In many countries, the number of medical students who choose general practice (GP) as their career is insufficient to meet the needs of the healthcare system.

Aim: The aim of this study was to describe the factors influencing medical students' career intentions and their preference for a career in GP.

Design & setting: A cross-sectional study involving medical students from Flanders (Belgium), Estonia and Hungary.

Method: An online questionnaire was used to gather data. Multivariable logistic regression was conducted.

Results: Altogether 1601 medical students participated in this study. 18.5% of the participants were interested in GP. Factors related to medical students and the curriculum which predicted the interest in GP were being a woman, being a medical student from Flanders, being a 6th year medical student, coming from a rural area and having GP role models. Students preferring GP named the following factors as important: short and low intensity training program, having long-term and close relationship with patients, continuity of care, regular and flexible working hours and opportunities to achieve work-life balance.

Conclusion: This study adds further evidence which characteristics and factors can predict medical students' interest in GP, having GP role models being the most important predictor. Further research into which qualities medical students value in their role models could give us better understanding on how we can support GPs to be better advocates for their specialty and thereby help increase interest in GP.