European Journal of General Practice最新文献

Background: Prescribing epidemiology in general practice shows gabapentinoid drugs to be independently associated with unexpected, drug-related death. There is an increasing trend of gabapentinoid deaths throughout Europe and North America.

Objectives: The overall aim of this study was to assess how patient, practice and health system factors might be associated with gabapentinoid prescribing in primary care.

Methods: Case series following a critical incident of an unexpected death in a patient prescribed a gabapentinoid drug in a single general practice. Unexpected and expected deaths in patients prescribed a gabapentinoid drug deaths over an 11-year period in a single general practice. We examined patient, prescriber and health system factors. Toxicology and post-mortem data were provided by the Coroner.

Results: There were 36 deaths (four unexpected and 32 expected deaths) during the study period. Of the four patients who suffered an unexpected death, one of these patients' cause of death could be attributed to drug and alcohol toxicity. Over half of gabapentinoid prescribing (n = 19,53%) was hospital initiated, often 'off-label' (n = 6, 17%) and commonly co-prescribed with opiates (n = 15, 42%) and benzodiazepines (n = 11, 31%) to patients with high multi-morbidity.

Conclusions: Gabapentinoids are often initiated in the outpatient setting in clinically complex patients, often for 'off label' indications, with high polypharmacy. Patient, practice and health-system related factors need to be addressed in relation to gabapentinoid associated deaths and reflected in clinical practice guidelines. There is critical value in using toxicology reports from Coroner's offices in cases of unexplained gabapentinoid death in general practice.

Background: While several risk scores for the diagnosis of community-acquired pneumonia (CAP) have been developed, they require prospective external validation.

Objectives: To externally validate existing prediction models, risk scores, and heuristics for the diagnosis of CAP in adults.

Methods: The Enhancing Antibiotic Stewardship in Primary Care (EAST-PC) study recorded signs, symptoms, demographics, and vitals in 718 adults presenting to primary or urgent care clinics with acute lower respiratory tract infection between 2019 and 2023. C-reactive protein (CRP) was available for 575. The diagnosis of CAP was based on the clinician diagnosis and/or chest radiograph. Literature was searched for previous risk scores. Using the EAST-PC population, the area under the receiver operating characteristic curve (AUROCC), calibration curves, and percentage with CAP in each risk group were calculated for each risk score.

Results: We identified 11 studies describing 4 risk scores, 9 multivariate models, and 5 simple heuristics. The Genomics to Combat Resistance Against Antibiotics in Community-acquired LRTI in Europe (GRACE) risk score using the absence of a runny nose, the presence of breathlessness, crackles, diminished vesicular breathing, heart rate > 100/min, temperature >37.8 °C, and CRP > 30 mg/L was the most accurate (AUROCC 0.81). It classified 280 patients as low (0.7% CAP), 265 as moderate (5.7%) and 30 as high risk (33.3%) for CAP. The GRACE score without CRP performed similarly. Other risk scores had poor calibration or failed to accurately classify patients as low or high risk.

Conclusions: The previously derived GRACE risk scores were successfully externally validated in a contemporary US outpatient population.

Background: Ageing, multimorbidity, and workforce shortages increasingly limit access to primary healthcare, especially in rural and underserved areas.

Objectives: To document impact of nurse practitioners (NPs) in primary care on patients with chronic diseases.

Methods: Searches were conducted in Medline, EMBASE, CINAHL, and CENTRAL (March 1978-October 2023). This systematic review followed MECIR and PRISMA guidelines (PRISMA 2020 checklist: EQUATOR Network) with SWiM used as a PRISMA extension due to the lack of meta-analysis. The focus was on NPs' roles in chronic disease management and primary care in underserved or remote areas, excluding mental health, cancer, and dental care.

Results: Among 3,684 citations, 25 studies were selected, including 10 RCT. NPs may improve access to primary care and chronic disease management, particularly in underserved areas. Although not all studies directly compared NPs to traditional models, they were most often assessed against General Practitioners (GPs) alone. Seven studies also evaluated collaborative NP-GP models versus GP-only care. Patient satisfaction was generally higher with NPs, possibly due to longer consultations and greater patient education. Clinical and biological outcomes were often comparable between NPs and GPs, with the best results in collaborative models, which were also associated with higher costs.

Conclusion: NPs may enhance access to care, particularly for vulnerable populations. Higher patient satisfaction may be linked to longer consultations and patient education. While clinical outcomes were comparable to those of GPs, collaborative models yielded the best results, though potentially at a higher cost.

Background: General practitioners (GPs) frequently refer patients for abdominal ultrasound. Depending on the clinical context, a 'triage ultrasound' can assess multiple potential causes of abdominal symptoms, while a 'targeted ultrasound' (point-of-care ultrasound, POCUS) focuses on specific indications (e.g. cholelithiasis).

Objective: To assess whether medical questions posed by GPs in abdominal ultrasound referral letters are adequate for radiologists to perform their examination, and to identify indications for POCUS by GPs based on exclusion rates and alternative findings in radiological reports.

Methods: Retrospective study analysing GP referral letters with corresponding radiology reports referred for abdominal ultrasound. Key variables: GP's medical question, indication type and the radiologist's final interpretation, following established diagnostic guidelines.

Results: A total of 1,196 referral letters with corresponding reports were reviewed. Of these, 143 (12%) were excluded, primarily due to missing clinical information from the GP (102; 8.5%). The final sample comprised 1053 referral letters with reports (mean age 59.2 years; 60% female). Sixteen percent of referral letters lacked a medical question, and 33% included exclusively guideline-based indications. The most common guideline-based indications were urolithiasis (43%) and cholelithiasis (39%). For guideline-based requests, radiologists excluded the indicated condition in 75% of cases, and an alternative diagnosis was identified in fewer than 10%.

Conclusion: GPs frequently provide insufficient clinically relevant information in abdominal ultrasound referral letters. Simple cases with well-defined clinical queries like cholelithiasis, urolithiasis, hydronephrosis and abdominal aortic aneurysm seem suitable for POCUS evaluation, as these are often excluded conditions for which the risk of overlooking serious diagnoses is low.

Background: In Flanders, Belgium, the 3-year specialised training in General Practice includes a specialty training rotation, for which trainees may choose their training site. After graduation, General Practitioners (GPs) decide where to establish their practice.

Objective: This study explored the factors influencing GP trainees' choice of training location, reasons for settling in a specific region after graduation, and motivations for remaining in or leaving a practice.

Methods: In May 2024, the Interuniversity Centre for Education of General Practitioners distributed an anonymous online survey with closed- and open-ended questions to all GP alumni graduating between 2014 and 2023. Quantitative data were analysed using linear regression; qualitative data underwent content analysis.

Results: Of 772 alumni respondents (26.7% response rate), 93.4% were still practising as a GP. Most were female (70.9%), and 37.2% engaged in additional professional roles. Key influences on training location choice and practice settlement included colleague connections, proximity to home, and opportunities to work in group practices. Decisions to stay in or leave a practice were shaped by interpersonal relationships, practice organisation, and work-life balance. Working as a substitute GP was a frequent reason for changing practices, especially among recent graduates, to explore varied working environments.

Conclusion: Both interpersonal and logistical factors strongly influence training practice choice and later GP practice settlement. High-quality training practices and supportive work environments are essential to promote sustainable GP careers and achieve a more balanced geographical distribution of GPs.

Background: The close link between mental health and physical health is evident in patients with severe psychiatric disorders (SPD), such as schizophrenia and bipolar disorder. SPD is associated with a reduction in life expectancy, due to excess mortality from cardiovascular disease and cancer. In patients with SPD, reduced access to cancer screening programs, due to cognitive, organisational and social barriers, leads to late detection and worse prognosis.

Objectives: The objective was to identify the barriers and facilitators to systematic cancer screening in patients with SPD, with a focus on the role of general practitioners (GPs) in improving access to preventive care.

Method: This study was conducted in the Finistère department, France. A qualitative study based on semi-structured interviews with GPs, recorded, anonymised, transcribed verbatim, and analysed using a grounded theory approach.

Results: From October 2023 to February 2024, 25 GPs were interviewed. The analysis highlighted 3 areas for improving access to cancer screening: logistic support, active involvement of the family and professional support networks and coordination among the healthcare providers. Barriers included the patients' lack of autonomy, difficulties in accessing transport, precariousness and complexity of the screening process, particularly for at-home screening tests. Family and friends play a key role, but remain vulnerable to caregiver burnout.

Conclusion: These results confirm the importance of a multi-professional and integrative approach, with GPs playing a central role in addressing the specific vulnerabilities of this population. More research, involving patients, caregivers and psychiatric teams, is needed to co-construct appropriate, sustainable and ethically sound solutions.

Background: General practitioners (GPs) frequently prescribe anti-vertigo drugs (AVDs), even though there is limited evidence for their effectiveness. Meanwhile, they rarely apply vestibular rehabilitation, a treatment for various vestibular disorders with a strong evidence base.

Objectives: This study aimed to identify barriers and facilitators to appropriate vestibular care in general practice.

Methods: We conducted a qualitative study in Dutch general practice using semi-structured interviews with GPs and patients with vestibular symptoms. We used purposive sampling to select participants. Interviews were audio-recorded, transcribed verbatim, and thematically analysed following the Template Analysis approach using MAXQDA 2022 software.

Results: We interviewed 11 GPs and 15 patients. We assessed barriers and facilitators to appropriate vestibular care for GPs (i.e. not prescribing AVDs, advising vestibular exercises) and patients (i.e. not using AVDs, doing vestibular exercises). We identified four themes: competence, mindset, relational determinants, and accessibility to care. Facilitators included adequate knowledge about vestibular disorders, GPs valuing delivering high-value care, positive experiences with physiotherapy, patients' coping skills, personal continuity, close collaboration between GP and colleagues, social support, and sufficient time and availability of providers. Barriers included diagnosis and treatment insecurity among GPs, patients doubting the GPs' competence, patients' desperation for treatment and GPs accommodating these wishes, positive experiences with AVDs, prescriptions by other providers, and insurance not covering physiotherapy.

Conclusion: Multiple barriers and facilitators shape appropriate vestibular care in general practice. Interventions should strengthen GPs' and patients' knowledge of vestibular management. Internet-based vestibular rehabilitation may address key barriers, particularly logistic and financial ones.

Background: COVID-19 pandemic caused a significant impact on healthcare workers' mental health and burnout, which continues after the pandemic.

Objectives: To assess the levels of burnout in general practitioners (GP) in Catalonia at three different times.

Methods: Cross-sectional study involving members of the GPs' Catalan Society (n = 4700). A self-administered survey was sent via institutional email in June-July 2021 (T1), in March-April 2022 (T2), and in May-June 2023 (T3). Probable burnout was assessed through Maslach Burnout Inventory (MBI) test, with three independent dimensions: emotional exhaustion, depersonalisation, and personal achievement. A descriptive analysis was performed, as well as a comparison between T1, T2, and T3 results.

Results: 500 GPs responded in T1, 454 in T2, and 386 in T3. Samples were similar in demographic variables. Regarding burnout dimensions, the level of emotional exhaustion was 67.5% in T1, with a statistically significant decrease in T2 and T3 (56.4 and 58.1%, respectively, p = 0.001); levels of depersonalisation were 42.7% in T1, 37.0% in T2 and 36.7% in T3 (p = 0.091); levels of personal achievement were 29.9% in T1, 30.4% in T2 and 24.2% in T3 (p = 0.086).  Starting at high levels of emotional exhaustion and depersonalisation, the prevalence decreased significantly over time in two groups: women and GPs who worked <10 years at the same workplace.

Conclusion: Catalan GPs experienced significant burnout during the COVID-19 pandemic with emotional exhaustion being particularly high. Although the prevalence of burnout decreased slightly over time, over half of the participants consistently reported high levels of emotional exhaustion.