BJGP Open最新文献

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.

Background: Obesity is a common comorbidity of type 2 diabetes mellitus (T2DM), a chronic metabolic condition affecting millions worldwide. Orlistat may be used to reduce weight as an adjunct to diet and lifestyle changes.

Aim: To assess the evidence of orlistat on weight loss in adults with obesity and T2DM or a high risk of T2DM.

Design & setting: Systematic review and meta-analysis of randomised controlled trials (RCTs) in clinical settings.

Method: Articles were searched in 10 databases including MEDLINE, Embase, and PsycInfo. RCTs of orlistat in adults with T2DM or at high risk and a body mass index (BMI)≥25 kg/m², with ≥12 weeks of follow-up and reported change in weight or BMI, were included. A random effects meta-analysis model was used to pool mean differences, I ² statistics to assess heterogeneity, and a funnel plot to assess publication bias.

Results: Thirty RCTs compared orlistat with a comparator, in conjunction with a weight-loss diet. All trials showed statistically significant (P<0.05) greater weight loss for the orlistat group than controls. A meta-analysis of 22 studies (n = 5921) showed that the overall weight loss for the orlistat group was a mean 2.40 kg (95% confidence interval [CI] = 2.08 to 2.72) greater than in controls. Weight difference was statistically significant (P<0.05) between subgroups at 3 months (2.74 kg, 95% CI = 1.20 to 4.27), 6 months (2.13 kg, 95% CI = 1.61 to 2.66), and 12 months (2.49 kg, 95% CI = 1.89 to 3.09).

Conclusion: Orlistat resulted in statistically significant greater weight loss in overweight adults with T2DM or at high risk compared with controls. Orlistat can be considered an adjunct in T2DM or at high risk of T2DM for weight loss along with diet and lifestyle modifications.

Background: GPs can use video when performing telephone triage in out-of-hours primary care (OOH-PC) in Denmark. Video use varies considerably among GPs; this variation could be related to GP characteristics.

Aim: To investigate associations between GP characteristics and video use in OOH-PC telephone triage.

Design & setting: A register-based study using data from the OOH-PC registration system from 1 January 2021 to 31 December 2021.

Method: Binomial regression analysis was used to measure the associations between video contacts and triage GP characteristics, thereby calculating risk ratios (RRs) and 95% confidence intervals (CI).

Results: Video was used in 10.8% of telephone triage contacts to OOH-PC. Video use was significantly associated with GPs having more shifts in OOH-PC (RR: 1.36-1.93, reference: low number of shifts) and GPs being younger (RR: 0.84-0.67, reference: age<40 years). Central Denmark Region and Region of Southern Denmark had significant higher video-user rates (RR: 1.23-1.46) than North Denmark Region, whereas Region Zealand had significant lower rates (RR = 0.57, 95% confidence interval [CI] = 0.38 to 0.87). The association between video use and GP sex was modified by number of shifts in OOH-PC. Video use was positively correlated with male sex among GPs with low, medium, and high number of shifts (RR = 1.18, 95% CI = 1.07 to 1.29) and negatively correlated with male sex among GPs with very high number of shifts (RR = 0.75, 95% CI = 0.58 to 0.98).

Conclusion: Video use was associated with the number of shifts in OOH-PC, GP sex and age, and geographical region.

Background: Complex mental health difficulties (CMHD) is an umbrella term for long-term problems with emotions and relationships, including personality disorders (PD), persistent depression, and consequences of trauma. People with CMHD often fall between NHS services that focus on either common mental disorders (anxiety, depression) or psychosis, leaving GPs as their main source of support.

Aim: To understand what is known about primary care for CMHD, from both GP and patient perspectives.

Design & setting: We conducted a scoping review of GP and patient experiences of CMHD in primary care in UK, Europe, Australasia, and North America.

Method: We searched MEDLINE, PsycInfo, and Embase for eligible studies between January 2002 and October 2023. Titles and full texts were screened by two reviewers. Thematic synthesis of qualitative studies and narrative synthesis of quantitative studies were undertaken.

Results: We screened 2209 papers and 33 met inclusion criteria. The following three key themes were found: the challenge of recognising CMHD; the work of caring for people with CMHD; and patient priorities. GPs recognised CMHD through complexity of diagnoses, of psychosocial issues, and of healthcare use. However, they were ambivalent about diagnosis and lacked the resources to make or discuss diagnoses. Working with people with CMHD involved responsibility work, relationship work, and emotional work, under pressured conditions. Patient priorities included addressing stigma, reducing fragmentation, and receiving relationship-focused care.

Conclusion: This scoping review delineates the very real challenges people with CMHD and their GPs face in providing care. It helps set an agenda for work to address gaps in provision and improve outcomes.

Background: Video use remains low in primary care telehealth consultations. Little is known about patterns of use or policy levers to promote video.

Aim: To investigate use of video telehealth in Australian general practice under permanent telehealth arrangements post-COVID-19 lockdowns, and during a policy change removing reimbursement for long telephone consultations.

Design & setting: Whole-of-population analysis of 2022 national healthcare claims linked to 2021 census data.

Method: We quantified the following: proportions of telehealth consultations by video, and of patients and GPs who used video for telehealth consultations; associations between video use and patient characteristics using Poisson regression; and video use in relation to policy changes using interrupted time-series analysis.

Results: Of 38 million GP telehealth consultations in 2022, 5.1% were by video; 8.6% of patients and 62% of GPs who used telehealth had used video. Patients most likely to use video lived remotely, were frequent GP users, or had multiple health conditions, mental health conditions or dementia. Socioeconomic disadvantage was modestly associated with lower use of video. Over 2022, use of video for telehealth decreased for consultations (from 6.5% of consultations in January to 4.1% in December), patients (from 6.7% to 4.4%), and GPs (from 40.0% to 26.0%). Time-series analyses showed downward trends before removal of reimbursement for long telephone consultations, small step increases immediately following, and shallower negative trends thereafter.

Conclusion: Use of video telehealth consultations in general practice in Australia is low and declining, more so for disadvantaged groups. Differential financial reimbursement of video and telephone consultations has not substantively increased video use in clinical practice.

Background: Hypertension disproportionately affects individuals identifying as Black African, Black Caribbean, and Black other with higher rates of uncontrolled hypertension and related organ damage including stroke and kidney disease. Improved understanding of ethnic and cultural views about hypertension is needed to support medication adherence.

Aim: To explore the adherence barriers and facilitators to taking antihypertensive medication in people of Black African or Black Caribbean heritage.

Design & setting: Qualitative study with an electronic survey followed by semi-structured interviews in South East London.

Method: 11 participants were recruited with the support of public health and a community interest company; nine who completed an online survey and six who completed online interviews, regarding their experiences and thoughts around medical management of hypertension. Data were analysed using thematic analysis and then mapped to Capacity, Opportunity, and Motivation Behaviour (COM-B) model components.

Results: Substantial barriers exist to the adherence to antihypertensive medication for Black African and Black Caribbean patients in South East London owing to mistrust on both system and interpersonal levels. People felt uninvolved in treatment decisions and that there was a lack of discussion about non-medical management. Adherence was facilitated by an understanding of the consequences of not taking antihypertensive medication, although this was also associated with fear and mistrust.

Conclusion: These barriers add new findings to existing studies on hypertension management and are congruent with current literature describing mistrust stemming from longstanding racial discrimination. Mapping to a COM-B model allows clinicians, and wider systems, to translate these findings into opportunities for interventions. Recommendations include patient-centred consultations to improve health literacy and shared decision making, trust-based engagement with communities and cultural awareness training.

Background: Musculoskeletal pain, often affecting multiple sites - including neck, hip, and knee - is common, with limited treatment options. Novel treatments are needed to support self-management, preferably addressing multiple pain sites.

Aim: To develop and explore the acceptability of a short, mixed course of individual (one-to-one) and group lessons in the Alexander Technique (AT), which addresses dysfunctional use of the musculoskeletal system.

Design & setting: A single-centre, mixed-methods study of patients with chronic or recurrent neck, hip, or knee pain from four general practices.

Method: Preliminary development of a course of 10 AT lessons (six group, four individual) took place with a group of AT teachers. Semi-structured interviews of participants were undertaken, which were analysed using inductive thematic analysis. Descriptive pre-post analysis of quantitative scales were used to assess improvement (Numerical pain scale [NRS]; modified Roland-Morris Disability Questionnaire (RMDQ); enablement (modified Patient Enablement Instrument used in the ATEAM trial); and global improvement (Health Transition scale).

Results: Twenty-three participants were included; 18 were interviewed. Commonly, participants found the mixture of group and individual lessons helpful, including helping multiple pain sites, and the mix of different problems enhanced learning. There was moderate improvement in standard quantitative measures over 12 weeks (NRS from 5.15 to 3.85; modified RMDQ 8.26 to 5.7) but with more substantial improvement in enablement and global improvement. Those who perceived underlying structural damage to the knee reported little benefit.

Conclusion: People with chronic or recurrent neck, hip, or knee pain found a course of mixed group and individual lessons in AT helpful in managing their pain, but not those with severe knee problems. Whether standard quantitative measures provide the best measures of effectiveness requires exploration.

Background: Hidradenitis suppurativa (HS) is a painful, chronic, inflammatory skin condition affecting the skin folds. It is frequently misdiagnosed, leading to delays in care and the progression of the disease to permanent scarring.

Aim: To understand the level of knowledge and confidence of healthcare professionals (HCPs) in primary care managing patients with HS. To establish their ability to recognise the early signs of HS, awareness of associated comorbidities, and recognition of treatment options available in primary care.

Design & setting: A survey was distributed to HCPs working in primary care in the UK.

Method: The survey was disseminated via weekly GP bulletins distributed by local integrated care boards, the Primary Care Dermatology Society (PCDS) mailing lists, and at professional events.

Results: Of 183 responders, most (93%) did not have a specialist role in dermatology or a postgraduate qualification in dermatology (69%), 36 (20%) were not doctors, and there was a good geographical spread over the UK. Of the responders, 74% felt confident diagnosing HS, but only 39% were confident in managing the pain associated with the disease. Perceived confidence did not correlate with understanding the importance of early referral to secondary care where multiple skin sites were affected.

Conclusion: Further education in diagnosing and managing HS in primary care is needed. Future research could focus on developing a tool to support the diagnosis of HS in primary care and a clear, primary care-focused management guideline for identified patients.

Background: The year 2022 saw the largest number of human immunodeficiency virus (HIV) cases diagnosed in the Republic of Ireland on record, with a 122% increase on 2021 and a 68% increase compared with the pre-pandemic year of 2019. Late-stage diagnoses and difficulties accessing testing are more common outside of Dublin.

Aim: To assess practices and attitudes to testing in general practice in the West of Ireland.

Design & setting: This cross-sectional mixed-methods study was carried out through University Hospital Galway, which provides all HIV care for the West and North-West of Ireland.

Method: A postal survey was sent to GPs. The survey was based on a study in 2013.

Results: There was a 21.4% response rate (n = 136) to the survey, which found 79.4% reported a registered patient living with HIV. Sexual history and patient request were the most common indications for testing and 19.1% used guidelines for testing. More responders had patients living with HIV in 2023 than in 2013 (79.4% versus 59.2%). In 2013, urban GPs were significantly more likely to have sent a test compared with their rural colleagues (P = 0.005). This difference was not observed in 2023. Qualitative themes identified included low perceived impact of HIV on daily practice. A key theme was a desire for national guidelines.

Conclusion: GPs report a positive attitude to HIV testing but have concerns regarding undertesting. Urban and rural GPs reported different testing practices but this may be lessening over time. Guideline usage was low. We believe this study highlights areas to improve testing in this region.