BJGP Open最新文献

Background: Emergency admissions are costly, increasingly numerous, and associated with adverse patient outcomes. Policy responses have included the widespread introduction of emergency admission risk stratification (EARS) tools in primary care. These tools generate scores that predict patients' risk of emergency hospital admission and can be used to support targeted approaches to improve care and reduce admissions. However, the impact of EARS is poorly understood and there may be unintended consequences.

Aim: To assess effects, mechanisms, costs, and patient and healthcare professionals' views related to the introduction of EARS tools in England.

Design & setting: Quasi-experimental mixed methods design using anonymised routine data and qualitative methods.

Method: We will apply multiple interrupted time series analysis to data, aggregated at former Clinical Commissioning Group level, to look at changes in emergency admission and other healthcare use following EARS introduction across England. We will investigate GP decision-making at practice level using linked general practice and secondary care data to compare case-mix, demographics, indicators of condition severity and frailty associated with emergency admissions before and after EARS introduction. We will undertake interviews (n~48) with GPs and healthcare staff to understand how patient care may have changed. We will conduct focus groups (n=2) and interviews (n~16) with patients to explore how they perceive that communication of individual risk scores might affect their experiences and health seeking behaviours.

Conclusion: Findings will provide policymakers, healthcare professionals, and patients, with a better understanding of the effects, costs and stakeholder perspectives related to the introduction of EARS tools.

Background: Natriuretic peptides (NPs) are released by increased ventricular wall stress, most often caused by heart failure (HF). NP level measurement helps select patients clinically suspected of HF who need echocardiography. Yet, the diagnostic actions following NP testing in daily primary care are poorly studied.

Aim: To assess the diagnostic actions taken by general practitioners (GPs) in patients with an elevated NP level.

Design & setting: Retrospective observational study in general practices in the Netherlands.

Method: In patients with an elevated NP level between July 2017 and July 2022 diagnostic actions were gathered during three months following NP testing. We compared patients with an elevated NP level referred for echocardiography to those not referred by univariable analyses.

Results: Among 902 patients, 394 (43.7%) had an elevated NP level. Median age was 75.0 (IQR 18.0) years, 68.8% were female. In total, 166 (42.1%) were referred for echocardiography and 114 (28.9%) underwent additional ECG recording. 30/166 (18.1%) referred patients were labelled HF by the cardiologist within three months after NP testing compared to 29/228 (12.7%) not referred. Referred patients were compared to those not referred younger (69.7 vs. 74.1 years, P<.001), less already known to a cardiologist (46.3% vs. 62.3%, P=.002), and had less marginally increased BNP levels (35-50 pg/mL) (19.9% vs. 37.5%, P<.001).

Conclusions: Three out of five patients with an elevated NP level are not referred for echocardiography by GPs. Restraint to refer patients were older age, a marginally elevated BNP value, and already being under control of a cardiologist.

Background: Treatment targets for cardiovascular risk management make no distinction between women and men.

Aim: To explore sex differences in achieving treatment targets in patients that participated in a nurse-led, integrated CVRM care programme in primary care between 2013 and 2019.

Design & setting: We conducted a dynamic cohort study in the Eindhoven region, south-east of The Netherlands METHOD: We assessed outcomes of three biological risk factors (systolic blood pressure, low density lipoprotein-cholesterol and estimated glomerular filtration rate) and four lifestyle factors (smoking, physical activity, alcohol intake and body mass index). Points (1=on target; 0=not on target) were assigned for biological risk factors, lifestyle factors and an overall score. Using the annual results, we applied, multivariable regression models to study trends over time and differences in trends between women and men.

Results: The number of participants increased from 24 889 to 38,067, mean age increased from 67.3 to 71.5 years, with around 52% women each year. The average of seven risk factors on target increased significantly from 4.6 to 4.9 in women, and from 4.7 to 5.0 in men, with no statistical difference between women and men. Differences between women and men in 2013 in the number of both biological and lifestyle factors on target did not materially change over time.

Conclusion: Integrated cardiovascular management care led to improvements in cardiovascular risk factors on target, equally well in women than in men. Differences in risk factors on target between women and men in 2013 were still present in 2019.

Background: How continuity of general practitioner care (GP-CoC) affects mortality in patients with type 2 diabetes (T2D) is unclear.

Aim: The aim of this study was to examine the effect of having no continuity of care (CoC) and GP-CoC on mortality in primary health care (PHC) patients with T2D.

Design & setting: Cohort study in patients aged 60 years or older with T2D within the public PHC of the city of Vantaa, Finland.

Method: Inclusion period was between 2002-2011 and follow-up period between 2011-2018. Six groups were formed (no appointments, one appointment and Modified, Modified Continuity Index [MMCI] quartiles). Mortality was measured with standardized mortality ratio (SMR) and adjusted hazard ratio (aHR). GP-CoC was measured with MMCI. Comorbidity status was determined with Charlson comorbidity index (CCI).

Results: In total 11,020 patients were included. Mean follow-up time was 7.3 years. SMRs for the six groups (no appointments, one appointment, MMCI quartiles) were 2.46 (95%CI: 2.24-2.71), 3.55 (3.05-4.14), 1.15 (1.06-1.25), 0.97 (0.89-1.06), 0.92 (0.84-1.01) and 1.21 (1.11-1.31), respectively. With continuous MMCI, mortality formed a u-curve. The inflection point was at a MMCI value of 0.65 with corresponding SMR of 0.86. Age and CCI adjusted HR for death between men and women was 1.45 (1.35-1.58).

Conclusions: Patients with no CoC had the highest mortality. In patients having care over time, the effect of GP-CoC on mortality was minor and mortality turned to rise with high GP-CoC.

Background: The COVID-19 pandemic led to a rapid transition to telehealth particularly in general practice (GP) where continuous care for chronic conditions such as musculoskeletal (MSK) is provided.

Aim: To determine the appropriateness of telehealth for MSK by identifying whether in-person tasks can be supported remotely via telehealth.

Design & setting: This study is a secondary analysis of the HaRI dataset. This dataset comprises of 281 videos of recorded GP consultations. The data set includes 10 general practitioners, across 8 separate clinics and was collected during 2017 in the United Kingdom.

Method: Content analysis was conducted to identify the clinical tasks, physical examinations and physical artefacts used during the consultations. A scoring method applying two key metrics was developed to assess the translatability of clinical tasks to telehealth.

Results: Across the 31 MSK consultations analysed, 12 clinical tasks, five physical examinations and 12 physical artefacts were observed. Of clinical tasks, 17% (2/12) were deemed to be 'easily translatable over telehealth' and 50% (5/12) were deemed 'relatively easy to be translated over telehealth'. Only 17% (2/12) of tasks were rated 'moderately translatable over telehealth', and 17% (2/12) were deemed 'potentially translatable over telehealth'. No clinical tasks in this study were categorised as untranslatable to telehealth. The average telehealth translatability score was 7.1/10.

Conclusion: Most clinical tasks observed during in-person GP consultations with MSK patients are translatable to telehealth. Further research is necessary to investigate the long-term efficacy and safety of telehealth utilisation for MSK in primary care.

Background: The number of people who are living with and beyond cancer is increasing in England. Primary care delivers cancer care via structured proactive conversations which are incentivised through the Quality and Outcomes Framework (QoF): 'cancer care reviews' (CCRs). Declining workforce numbers, increasing patient demand, CCR policy changes in 2020 and the onset of the coronavirus disease 2019 (COVID-19) pandemic, highlight a need to explore how staff deliver CCRs.

Aim: To explore primary care staff experiences with CCRs, identify their view of CCRs, how they conduct CCRs and their perceived value of CCRs.

Design & setting: Descriptive qualitative study in general practices in England.

Method: Semi-structured online interviews with 15 primary care staff; data analysis using reflexive thematic analysis.

Results: Four themes were identified: varied and evolving perception of cancer, the delivery and impact of CCRs, changes to CCR delivery during the COVID-19 pandemic, ways to complement CCRs. Primary care staff felt that the way that cancer was perceived by patients, including those from ethnic minority backgrounds, impacted how CCRs were delivered. Cancer care involved acknowledging the challenge of a cancer diagnosis, helping decode jargon, and addressing unmet care needs. The pandemic resulted in remote CCR delivery for some practices. Staff suggested community cancer teams to provide cancer care alongside existing services.

Conclusion: Staff adopted the new 3- and 12-month format CCRs despite the COVID-19 pandemic. Clinical staff may benefit from better training on cancer as a long-term condition and how cancer is perceived by people from diverse ethnic backgrounds.

Background: Remote and digital consulting in primary care has rapidly expanded since March 2020. It is important to understand patient experiences, particularly for those living with complex long-term conditions, to identify how care can best be delivered, including within the remote space.

Aim: To explore the experiences of people living with Chronic Fatigue Syndrome/Myalgic Encephalomyelitis [CFS/ME] and Fibromyalgia when consulting remotely in primary care.

Design & setting: Semi-structured interviews with patients living with CFS/ME and fibromyalgia in general practice in England METHOD: Semi-structured interviews were carried out with 13 participants. The interviews were transcribed and analysed thematically according to a Foucauldian theoretical framework.

Results: All participants highlighted needing to feel believed by clinicians. Many reported difficulties with telephone and online consulting due to the lack of physical communication. Positive outcomes were reported when there was a good relationship with a clinician. Continuity in care and recognising the complexity of these conditions were also considered important.

Conclusion: This study allowed people living with CFS/ME and Fibromyalgia to describe their experiences when consulting remotely. Participants highlighted needing to feel listened to and felt they benefited from an ongoing relationship with a clinician although this was difficult to achieve when consulting remotely. Some advantages of remoted consulting were reported, particularly when symptoms were troublesome. Flexible access systems with a range of consultation modalities or preferred clinician(s) availability could improve healthcare encounters, particularly given the increased use of remote consulting, in primary care.

Background: Dementia diagnostics can often be performed in primary care, yet older persons with memory complaints are frequently referred to memory clinics (MCs).

Aim: To compare diagnostic information in general practitioner (GP) referral letters of patients with and without an eventual dementia diagnosis.

Design & setting: Retrospective cohort study in a Dutch academic geriatric MC.

Method: We collected electronic health record (EHR) data of consecutive patients aged≥65 referred by their GP between 2016-2020. EHR data included patient characteristics, diagnostic information in referral letters, ancillary investigations performed at the MC, and established diagnoses. Chi-square tests were applied to compare groups.

Results: Of 651 patients included, the average age was 78.0 (SD: 6.8), and 348 (53.5%) were diagnosed with dementia. Most people with dementia were diagnosed without ancillary investigations (235/348, 67.5%). In GP referral letters of people with dementia compared with people without dementia, a collateral history, any physical examination, a differential diagnosis including dementia, an MMSE score, interference with daily functioning, and decline from previous levels of functioning were mentioned more often. Furthermore, the more diagnostic criteria mentioned in the referral letter, the more often dementia was diagnosed at the MC (no criteria: 35.4%, one criterion: 47.3%, two criteria: 53.4%, three criteria: 69.9%, four or five criteria: 83.3%).

Conclusion: GPs often correctly mention diagnostic information and dementia criteria in referral letters of people with dementia, and they are often diagnosed without ancillary investigations. This suggests that referral is often unnecessary, and GPs can be empowered to diagnose dementia themselves.

Background: Women who use drugs face specific challenges compared to men, such as higher rates of HIV infection, unsafe injecting practices and intimate partner violence. However, this population's access to drug dependence treatment and gender-sensitive interventions remains limited, leading to unmet needs and increased vulnerability.

Aim: To investigate the characteristics of and associations with retention in care among women on opioid substitution therapy (OST) in a community based primary care setting.

Design & setting: A descriptive observational study within the Community Orientated Substance Use Programme in Tshwane, South Africa.

Method: Data from 199 women (>18 years) on OST was extracted from an electronic database and paper-based files. Data was analysed descriptively, and inferential analysis looked for association of variables with retention on OST for≥6 months.

Results: Majority of participants were unemployed, with 44.3% falling within the 20-29 years age range. During the initiation and course of OST, 39.2% of women experienced intimate partner violence, and 19.0% were pregnant. Retention on OST was significantly associated with increasing age at initiation (p=0.047), knowledge of HIV status (p=0.029), an increase in the ASSIST score (p=0.023), and methadone dose (p<0.001). Factors such as race, employment status, health system level, pregnancy, intimate partner using substances, intimate partner violence, route of administering opioids, and having tuberculosis and/or hepatitis C exposure did not show a significant relationship with retention on OST (p>0.05).

Conclusion: This study reveals specific vulnerabilities in women receiving OST, emphasising the need for the integration of interventions to address reproductive health, violence mitigation, infectious disease and polydrug use into care.

Background: GPs can detect cognitive impairment at a very early stage, allowing early support for people and their caregivers. The early onset of cognitive impairment is between 50 and 60 years. Currently, in France, the Mini Mental State Examination remains the most used screening test, though it has a lower sensitivity and specificity than the Montreal Cognitive Assessment (MoCA) for detecting mild cognitive impairment, taking an average of 15 minutes to complete.

Aim: To investigate the feasibility of the MoCA during routine consultations in general practice for the early detection of cognitive impairment and to determine prevalence of cognitive impairment in a primary care setting.

Design & setting: A quantitative, prospective feasibility study was carried out in real-life working condition during routine consultation.

Method: GPs performed MoCA on adults aged 50 years and older, without suspected or confirmed cognitive impairment.

Results and conclusion: 61 GPs performed 221 MoCA with a mean duration of 8 minutes and detected mild neurocognitive impairment in 62% of patients. The MoCA is feasible and easy to perform during routine consultations in general practice by trained and experienced physicians.