BJGP Open最新文献

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.

Background: Rapid, cost-effective diagnosis of acute respiratory infections is now possible using multi-viral rapid-antigen point-of-care-tests (MVRA-POCTs) with high sensitivity/specificity. These offer a realistic alternative to polymerase chain reaction tests in primary care. However, evidence of acceptability and clinical utility in this setting is limited.

Aim: To pilot feasibility of integrating MVRA-POCTs into routine primary care and investigate patient/clinician attitudes and behaviours.

Design & setting: A prospective mixed-methods pilot study in seven New Zealand primary care clinics during winter 2023.

Method: Patients with acute respiratory symptoms received a MVRA-POCT (instead of COVID-19-only). Outcomes and acceptability were assessed via audits of electronic medical records, clinician/patient surveys, and interviews/focus groups with patients/clinic staff.

Results: Swab results were recorded from a demographically diverse cohort of 1754 patients; 14% tested positive for any virus (246/1754). All clinicians and most patients surveyed positively evaluated the test. All clinicians incorporated the MVRA-POCT into practice and found it useful. 66% of prescribers (27/41) reported results influenced antibiotic prescribing; 12% (5/41) avoided referrals to secondary care. All patient respondents who tested positive (n=39) and most testing negative (172/180, 96%) would like the MVRA-POCT in future. Patients testing positive self-reported as more likely to follow non-pharmaceutical interventions to reduce transmission compared to those testing negative.

Conclusion: MVRA-POCTs were well-accepted and readily incorporated into practice. Routine integration into primary care could potentially improve management of common respiratory illnesses and promote patient behaviour change to reduce transmission.

Background: The overuse and misuse of antibiotics significantly contributes to antimicrobial resistance (AMR). Adverse reactions to antibiotics are well documented, but their impact on patients' behaviours requires further exploration.

Aim: To explore how side effects and allergies influence patients' behaviours to prescribed antibiotic use.

Design & setting: A mixed-methods explanatory sequential study in England.

Method: A survey of 1059 adults with prior experience of antibiotic side effects was conducted. Descriptive statistics identified common side effects and behavioural responses, while chi-squared tests explored demographic differences. Focus groups were held with 21 participants, recruited through a research panel. Thematic analysis captured deeper insight into participants' personal experiences.

Results: Many antibiotic side effects were identified, presenting shortly after consumption and affecting several aspects of patients' lives. One-third of respondents (31%, n=325; 95% CI: 28-34%) were unaware of potential side effects beforehand, citing inaccessible patient information leaflets and limited communication from healthcare professionals as barriers. Almost half (42%, n=440; 95% CI: 37-47%) did not complete their antibiotic course following the side effects, with 32% (n=142; 95% CI: 28-37%) stopping without medical advice. Many allergy diagnoses were made in childhood without follow-up assessments.

Conclusion: Antibiotic side effects can significantly disrupt patients' lives and discourage appropriate use of antibiotics. Providing accessible information before prescribing may help manage expectations and support self-management of side effects. Patients with longstanding allergy labels should be encouraged to undergo reassessment to ensure that they are not contributing to AMR by unnecessarily avoiding the use of first-line antibiotics.

Background: Urinary tract infection (UTI) recurrence rates are high for certain patient groups, affecting physical and mental health, and leading to repeated antibiotic usage. Behavioural measures and non-antibiotic products can prevent recurrences, reducing the need for antibiotics. However, these preventive strategies are often not addressed, despite being advocated in UTI guidelines.

Aim: To identify barriers to and facilitators of discussing UTI prevention in primary care and to identify strategies to overcome these barriers.

Design & setting: Qualitative study in primary care setting.

Method: Semi-structured interviews were performed with general practitioners, doctor's assistants, and patients with a history of UTI to identify barriers to and facilitators of discussing UTI prevention. Deductive content analysis was employed, using the Theoretical Domains Framework to structure the interview guide and analyse the data. Subsequent focus groups were performed to identify strategies to overcome the barriers.

Results: Main barriers for all stakeholders included incomplete knowledge, prioritization of treatment over prevention, and time pressure at the general practice. Additionally, general practices lacked protocols on when, which, and by whom preventive measures should be discussed. Healthcare professionals also assumed patients already held preventive knowledge and solely sought care to obtain antibiotics. The main facilitator was patient-initiated conversations about UTI. Strategies included enhancing knowledge, inviting patients to initiate conversations about UTI, and optimizing the timing of preventive information dissemination.

Conclusion: Barriers exist across behavioural, interpersonal, and organizational domains, but provide clear starting points for tailored interventions. The strategies offer promising directions for improving UTI prevention and reducing antimicrobial consumption.

Background: In the six weeks between the announcement of the 2024 UK General Election (22 May) and election day (4 July), national newspapers published numerous articles depicting a "crisis" in general practice. These portrayals varied across publications and may have influenced public discourse and political pledges.

Aim: To explore how UK national newspapers depicted access to general practice during the six weeks preceding the 2024 General Election.

Design & setting: Thematic analysis of UK national newspaper articles published in the pre-election period.

Method: Articles were retrieved from the LexisNexis® Academic database using predefined search terms and inclusion/exclusion criteria. After screening, 194 articles were included and analysed thematically. Key themes identified were the crisis itself, regional disparities, access challenges for the elderly, consequences of poor access, and political promises.

Results: All newspapers articulated a "GP crisis", though with distinct emphases. Inequalities featured prominently, with coverage highlighting rural GP shortages and difficulties for elderly patients. Articles frequently linked poor access with adverse outcomes, such as delayed or missed diagnoses, as well as wider system pressures, including strain on emergency services. Coverage was overwhelmingly negative, and political promises mirrored the crisis narrative presented in the press.

Conclusion: In the run-up to the 2024 General Election, UK print media consistently portrayed general practice as being in crisis, often through sensationalised accounts of waiting times and limited access. These framings likely shaped public perception and influenced election pledges. Editorial choices played a key role in constructing dominant narratives around general practice and health policy discourse.

Background: Perinatal mental health (PMH) problems affect 10-20% of women during pregnancy and the postnatal year, costing the UK an estimated £8.1 billion annually. Underserved groups-including women from ethnic minorities, deprived areas, and those facing multiple disadvantages-experience the greatest inequalities in access and outcomes. Despite national investment, many fall between primary care (general practice, NHS Talking Therapies) and specialist PMH services, with limited guidance on bridging this gap.

Aim: To co-design an experience-based intervention to address unmet PMH needs among underserved women, and to explore barriers to accessing care and gaps across PMH pathways.

Design & setting: A mixed-methods study using the MRC framework and an adapted Accelerated Experience-Based Co-Design (AEBCD) approach.

Method: Work Package 1 will survey and interview professionals nationally across diverse roles and organisational contexts. Work Package 2 will involve focus groups and interviews with underserved women in Sheffield and Doncaster (South Yorkshire, UK), supported by bilingual community link workers. Findings will be synthesised and used in co-design workshops (Work Package 3) to develop an accessible, evidence-informed intervention tailored to the needs of an underserved group.

Conclusion: The PRAMS study will generate clinically relevant insights into improving access to and management of PMH care for underserved women and birthing people. By working collaboratively with practitioners, women with lived experience, and community partners, PRAMS will deliver a co-designed intervention with potential to reduce inequalities. Findings will inform local service delivery and contribute national learning on user-led redesign of PMH services across primary and secondary care.

Background: Housebound patients are an under-researched group who face challenges accessing primary healthcare and have complex needs. There is no consensus definition of housebound, hindering research.

Aim: To develop a definition of housebound.

Design & setting: Consensus methodology, United Kingdom (UK).

Method: The study had parts: (i) a systematic review to examine how housebound was defined within UK literature; (ii) interviews to explore views of housebound people and carers (n=12); (iii) a consensus exercise with health and social care professionals (n=14) to agree a definition. An evidence summary was developed for each definition, combining review and interview data. A two-stage RAND/UCLA Appropriateness Method was used, with consensus defined as a median score≥7/9 for clarity and appropriateness.

Results: 847 titles and abstracts were screened, and 413 articles underwent full text review. Fifty-two definitions were identified, grouped under five themes: unable to attend the surgery; unable to leave the house; unable to leave house without assistance; self-report of housebound; and recorded as housebound on healthcare records. Subcategories of housebound included fully/semi, temporarily/permanently, and blockbound/housebound/chairbound/bedbound. Six definitions met the top scoring criteria, and a final definition was agreed: "Someone who is unable to leave their home or who requires significant assistance to do so. This may be due to illness, frailty, disability, surgery, mental ill health or nearing the end of life."

Conclusion: Our consensus definition can be used in UK research and may help policymakers and providers - within and outside the UK - evaluate and develop healthcare services for housebound patients.

Background: The global ecological crisis is impacting vulnerable African communities and their primary care services. Family physicians and primary care providers need to be better prepared to respond to the effects on services and communities.

Aim: To evaluate what members of the Primary Care and Family Medicine (PRIMAFAMED) network in sub-Saharan Africa need to know about planetary health, and how to address their learning needs.

Design & setting: A descriptive cross-sectional survey of 40 institutions in the PRIMAFAMED network.

Method: Two members from each institution were purposively invited to complete a questionnaire, developed from a qualitative study.

Results: Eighty respondents, came from 38 institutions and 24 countries. The majority were not familiar with planetary health (58.2%) and never attended related education (60.8%). Main barriers were lack of clinical relevance, institutional or government support and educational resources. The top five clinical topics were: respiratory problems, infectious diseases, gastroenteritis, malnutrition, and cardiovascular disease together with diabetes. The top five broader topics were: how climate change impacts health, addressing environmental determinants through community-orientated primary care, how to make services more climate resilient and environmentally sustainable, and the effects of heat. Respondents reported that videos (49.4%), PowerPoint (48.1%), links to expert speakers (36.7%), and continuing professional development (CPD) articles (35.4%), would be most useful.

Conclusion: Family physicians are interested in CPD on planetary health. Educational resources should enable clinical CPD to integrate specific information and should also include broader planetary health topics. These resources will be developed within the context of the PRIMAFAMED network.

Background: Total hip or knee replacement (arthroplasty) is common in aging populations as are prescribed opioids for osteoarthritis pain while awaiting such surgeries. Opioid-related harm can be minimised through pre-surgery tapering of opioids yet, the practice is uncommon.

Aim: This research sought to understand general practitioners (GPs) understandings, beliefs and support needs for managing pain while waiting surgery, use of opioids and pre-surgery tapering.

Design & setting: A qualitative study with GPs in Australia.

Method: Semi-structured interviews were conducted. Data were transcribed, deidentified and reflectively analysed inductively and thematically.

Results: Analysis of transcript data from GP interviews (n=17) revealed little knowledge of, yet support for, pre-arthroplasty opioid tapering as a further way to minimise opioid harm. Three themes described were: 1. feeling challenged by pre-surgery pain management and opioid prescribing; 2. optimal pain management and tapering prevented by patient-related and system-level barriers; and 3. sharing workload and perceived risk - pharmacists could provide opioid management support.

Conclusion: Realisation of potential opioid tapering benefits will require addressing some personal, patient and system level barriers revealed by this study. GPs view support from pharmacists as valuable and welcomed yet the required collaborative models appear, currently, underdeveloped between these primary care professions. Implementation research is a crucial next area of inquiry.

Background: Suicidal ideation is associated with chronic pain.

Aim: To measure the association of clinical empathy with suicidal ideation among patients with chronic low back pain.

Design & setting: A target trial emulation was performed using adult patients selected from a national pain research registry in the United States from May 2018 to December 2023.

Method: Patients having a physician who provided primary health care for their pain were followed for 12 months. Clinical empathy was assessed using the Consultation and Relational Empathy measure. Propensity-score matching of 936 registry patients without suicidal ideation at baseline yielded 185 patients each in greater and lesser clinical empathy groups. Suicidal ideation and helplessness were measured with the Pain Catastrophizing Scale.

Results: The median (IQR) age of patients was 55 (42-64) years and 281 (75.9%) were female. Twenty-seven (14.6%) patients in the greater clinical empathy group and 45 (24.3%) patients in the lesser clinical empathy group expressed suicidal ideation (RR, 0.60; 95% CI, 0.39-0.92; P=0.02). Correspondingly, 140 (75.7%) patients in the greater clinical empathy group and 164 (88.6%) patients in the lesser clinical empathy group expressed helplessness (RR, 0.85; 95% CI, 0.78-0.94; P=0.001).

Conclusion: The decreased risk of suicidal ideation in the greater clinical empathy group has potentially important implications for the delivery of primary health care for chronic pain. Research is needed to replicate these findings and determine the effects of clinical empathy on suicide attempts and completed suicides.