European Journal of General Practice最新文献

Background: A general practitioner (GP) standardly provides contraceptive counselling and care in the Netherlands. Recent years have seen the rise of mobile health technologies that aim to prevent pregnancy based on fertility awareness-based methods (FABMs). We lack high-quality evidence of these methods' effectiveness and clarity on how healthcare professionals include them in contraceptive counselling.

Objectives: To analyse how Dutch healthcare professionals include pregnancy-prevention mobile health technologies (mHealth contraception) in contraceptive counselling and to propose practice recommendations based on our findings.

Methods: We used ethnographic methods, including semi-structured interviews with nine professionals who were recruited using purposive sampling, 10 observations of contraceptive counselling by four professionals, six observations of teaching sessions in medical training on contraception and reproductive health, one national clinical guideline, and seven Dutch patient decision aids. Data were collected between 2018 and 2021 and analysed inductively using praxiographic and thematic analysis.

Results: In contraceptive counselling and care, professionals tended to blend two approaches: 1) individual patient-tailored treatment and 2) risk minimisation. When interviewed about mHealth contraception, most professionals prioritised risk minimisation and forewent tailored treatment. Some did not consider mHealth contraception or FABMs as contraceptives or deemed them inferior methods.

Conclusion: To minimise risk of unintended pregnancy, professionals hesitated to include mHealth contraception or other FABMs in contraceptive consultations. This may hamper adequate patient-centred counselling for patients with preference for mHealth contraception.Based on these results, we proposed recommendations that foster a patient-tailored approach to mHealth contraceptives.

Background: The 'High-Risk Prevention Programme' (HRPP) involved a six-week health behaviour change programme based in general practices and aimed to address cardiovascular disease (CVD) risk in disadvantaged Irish communities.

Objectives: This pilot study aimed to establish the HRPP's likely effectiveness and acceptability to inform the development of a future definitive trial.

Methods: The HRPP was conducted at six general practices in disadvantaged areas in the Ireland East region. Patients with high CVD risk were recruited by participating practices and were allocated to either a General Practice Nurse (GPN) or Health Promotion Professional (HPP) led programme focusing on positive health behavioural change. Baseline and 12-month follow-up data were collected to capture the HRPP's likely effectiveness in promoting health outcomes and health behavioural change.

Results: The HRPP programme was completed by 270 patients. Out of these 270 patients, 245 (90.74%) completed baseline assessments, and 176 (65.19%) completed follow-up assessments at 12 months. Baseline data indicated a high level of CVD risk among patients and follow-up demonstrated positive change in several areas, especially weight (-1.95 kg, $p$ < 0.001), BMI (-0.72, $p$ < 0.001), exercise during the last week ($p$<0.001), and consumption of healthy fats in the HPP group (+60%, $p$< 0.001).

Conclusion: The HRPP was a much-needed pilot intervention, and positive results were seen in both GPN and HPP arms, especially with regards to weight loss, exercise, and dietary improvements. Future definitive trials of the HRPP are likely to be effective and acceptable in terms of combatting these issues among high-risk patients.

Background: General practitioners (GPs) often struggle to distinguish functional gastrointestinal disorders (FGID) from organic disorders in children with chronic abdominal symptoms. A referral strategy guided by faecal calprotectin (FCal) testing may help.

Objective: This study explores GPs' experiences with these children and the strategy.

Methods: GPs were sampled purposively to data saturation. Ultimately, we conducted one focus group session and 13 semi-structured interviews with 17 Dutch GPs who had been involved in a randomised controlled trial evaluating an FCal-testing strategy. The online focus group and interviews were recorded, transcribed verbatim, and subject to thematic content analysis.

Results: Four themes arose: diagnostic confidence, fear of missing something severe, reassurance and managing FGID in primary care. Although GPs typically felt confident during the diagnostic process, they did fear missing somatic or psychosocial conditions. They felt more diagnostically confident due to FCals clear indications, high diagnostic accuracy, and non-invasiveness. Reassurance was considered crucial in children with FGID, either by labelling symptoms, providing explanatory models, or offering medical interventions (e.g. FCal testing). When helping children with FGID proved too difficult, GPs referred to specialist care. Besides the integration of FCal during reassurance, the testing strategy did not help GPs manage children with FGID.

Conclusion: While the FCal-strategy improved diagnosis according to GPs, they found the primary challenge to be managing children with FGID. Nevertheless, they found the FCal-strategy beneficial, likely due to its integration into reassurance strategies. Further research focusing on enhancing communication and interventions for paediatric FGID in primary care is warranted.

Background: Atrial fibrillation (AF) is a common treatable risk factor for stroke. Screening for paroxysmal AF in general practice is difficult, but biomarkers might help improve screening strategies.

Objectives: We investigated six blood biomarkers for predicting paroxysmal AF in general practice.

Methods: This was a pre-specified sub-study of the SCREEN-AF RCT done in Germany. Between 12/2017-03/2019, we enrolled ambulatory individuals aged 75 years or older with a history of hypertension but without known AF. Participants in the intervention group received active AF screening with a wearable patch, continuous ECG monitoring for 2x2 weeks and usual care in the control group. The primary endpoint was ECG-confirmed AF within six months after randomisation. High-sensitive Troponin I (hsTnI), brain natriuretic peptide (BNP), N-terminal pro-B-type natriuretic peptide (NT-pro BNP), N-terminal pro atrial natriuretic peptide (NT-ANP), mid-regional pro atrial natriuretic peptide (MR-pro ANP) and C-reactive protein (CRP) plasma levels were investigated at randomisation for predicting AF within six months after randomisation.

Results: Blood samples were available for 291 of 301 (96.7%) participants, including 8 with AF (3%). Five biomarkers showed higher median results in AF-patients: BNP 78 vs. 41 ng/L (p = 0.012), NT-pro BNP 273 vs. 186 ng/L (p = 0.029), NT-proANP 4.4 vs. 3.5 nmol/L (p = 0.027), MR-pro ANP 164 vs. 125 pmol/L (p = 0.016) and hsTnI 7.4 vs. 3.9 ng/L (p = 0.012). CRP levels were not different between groups (2.8 vs 1.9 mg/L, p = 0.1706).

Conclusion: Natriuretic peptide levels and hsTnI are higher in patients with AF than without and may help select patients for AF screening, but larger trials are needed.

Background: People with mild intellectual disabilities (MID) experience more mental health (MH) problems than the general population but often do not receive appropriate primary MH care. Primary MH care is essential in integrative MH care and, therefore, demands high quality. To improve primary MH care for this patient group, account must be taken of the experiences of people with MID. So far, their perspectives have been largely absent from primary MH care research.

Objectives: To explore patients' experiences, needs, and suggestions for improvement regarding primary MH care for people with MID.

Methods: Qualitative study among adults with MID who visited their GP with MH problems in the previous 12 months. Semi-structured interviews were conducted using a guide based on Person-Centred Primary Care Measures. Transcripts were analysed thematically.

Results: The 11 interviews that we conducted revealed four themes. The first theme, cumulative vulnerability, describes the vulnerability - instigated by the MID and reinforced by MH problems - experienced on a GP visit. The other themes (needs regarding the GP, needs regarding the network, self-determination) arise from this vulnerability.

Conclusion: People with both MID and MH problems are extra vulnerable in primary care but desire self-determination regarding their MH care trajectory. This requires investment in a good GP-patient relationship and the organisation of additional support to meet these patients' needs, for which collaborative care with the patient, the patient's network, and other (care) professionals is of utmost importance.

Background: Factors associated with the appropriateness of antibiotic prescribing in primary care have been poorly explored. In particular, the impact of computerised decision-support systems (CDSS) remains unknown.

Objectives: We aim at investigating the uptake of CDSS and its association with physician characteristics and professional activity.

Methods: Since May 2022, users of a CDSS for antibiotic prescribing in primary care in France have been invited, when registering, to complete three case vignettes assessing clinical situations frequently encountered in general practice and identified as at risk of antibiotic misuse. Appropriateness of antibiotic prescribing was defined as the rate of answers in line with the current guidelines, computed by individuals and by specific questions. Physician's characteristics associated with individual appropriate antibiotic prescribing (< 50%, 50-75% and > 75% appropriateness) were identified by multivariate ordinal logistic regression.

Results: In June 2023, 60,067 physicians had registered on the CDSS. Among the 13,851 physicians who answered all case vignettes, the median individual appropriateness level of antibiotic prescribing was 77.8% [Interquartile range, 66.7%-88.9%], and was < 50% for 1,353 physicians (10%). In the multivariate analysis, physicians' characteristics associated with appropriateness were prior use of the CDSS (OR = 1.71, 95% CI 1.56-1.87), being a general practitioner vs. other specialist (OR = 1.34, 95% CI 1.20-1.49), working in primary care (OR = 1.14, 95% CI 1.02-1.27), mentoring students (OR = 1.12, 95% CI 1.04-1.21) age (OR = 0.69 per 10 years increase, 95% CI 0.67-0.71).

Conclusion: Individual appropriateness for antibiotic prescribing was high among CDSS users, with a higher rate in young general practitioners, previously using the system. CDSS could improve antibiotic prescribing in primary care.

Background: Rapid identification of effective treatments for use in the community during a pandemic is vital for the well-being of individuals and the sustainability of healthcare systems and society. Furthermore, identifying treatments that do not work reduces research wastage, spares people unnecessary side effects, rationalises the cost of purchasing and stockpiling medication, and reduces inappropriate medication use. Nevertheless, only a small minority of therapeutic trials for SARS-CoV-2 infections have been in primary care: most opened too late, struggled to recruit, and few produced actionable results. Participation in research is often limited by where one lives or receives health care, and trial participants may not represent those for whom the treatments are intended.

Innovative trials: The ALIC4E, PRINCIPLE and the ongoing PANORAMIC trial have randomised over 40,500 people with COVID-19. This personal view describes how these trials have innovated in: trial design (by using novel adaptive platform designs); trial delivery (by complementing traditional site-based recruitment ('the patient comes to the research') with mechanisms to enable sick, infectious people to participate without having to leave home ('taking research to the people'), and by addressing the 'inverse research participation law,' which highlights disproportionate barriers faced by those who have the most to contribute, and benefit from, research, and; in transforming the evidence base by evaluating nine medicines to support guidelines and care decisions world-wide for COVID-19 and contribute to antimicrobial stewardship.

Conclusion: The PRINCIPLE and PANORAMIC trials represent models of innovation and inclusivity, and exemplify the potential of primary care to lead the way in addressing pressing global health challenges.

Background: Primary care plays a key role in addressing domestic violence and abuse (DVA) globally. However, DVA remains underdiagnosed and inadequately addressed in primary care, necessitating a deeper understanding of patients' perspectives in the UK.

Objectives: To explore patients' perceptions of their awareness of DVA signs and their attitudes towards using the Woman Abuse Screening Tool (WAST)-short during routine primary care encounters.

Methods: An anonymous 29-item e-Survey, available in 18 languages and including information about DVA support services, was administered via the Qualtrics XM Platform^™ from March to October 2022. Eligible UK National Health Service patients aged 18+ were identified by GP practices in Northwest London and invited via SMS to participate.

Results: Data were collected from 6,967 NHS patients. The majority (78.0%) claimed awareness of the signs of DVA in adults and children, while about 22% were unaware or unsure of the signs of DVA. Nearly 85% reported insufficient public awareness about DVA. Around 70% recommended implementing the WAST-short screening tool during primary care encounters to raise awareness and support survivors. Over 50% viewed general practice as the optimal setting for identifying and referring survivors.

Conclusion: Improved public education on DVA is needed, as a significant proportion of patients remain unaware or unsure of its signs, with the majority deeming public knowledge insufficient. Patients' strong support for using standardised screening tools like the WAST-short reflects their trust in healthcare providers to conduct sensitive assessments. Integrating these tools into routine practice could enhance DVA interventions.

Background: The COVID-19 pandemic posed severe challenges to delivery of services at Primary Care level and for achieving follow-up of patients with chronic diseases.

Objectives: We analysed data from the PRICOV-19 study to explore determinants of active follow-up for chronic disease patients in seven Central and Eastern European (CEE) countries during the pandemic.

Methods: Pricov-19 was a cross-sectional study conducted within PC (Primary Care) practices in 37 European countries. We analysed data from 7 CEE countries (Bulgaria, Czech Republic, Hungary, Poland, Moldova, Romania, Ukraine) collected between November 2020 and December 2021. Practices were recruited through random or convenience sampling and participation of practices was voluntary. We performed descriptive statistics to identify the level of follow-up of chronic disease and what health system and practice-specific factors were associated with better follow-up. We used logistic regression and meta-analysis techniques to explore associations and heterogeneity between countries.

Results: 67.8% out of 978 practices reported actively following up chronic patients. Positive associations were found between active follow-up and such as having more GPs (aOR = 1.18, p-value = 0.005), an above-average chronic patient population (aOR = 3.13, p-value = 0.006), adequate government support (aOR = 2.35, p-value = 0.001), and GPs having time for guideline reading (aOR = 0.008, p-value = 1.71).

Conclusions: Patient follow-up, was influenced by different health system and practice-specific factors. The implications suggest the need for government support to enhance PC practice organisation during crises and solutions to decrease GP workload and provide tailored care for patients with chronic disease.

Background: General practitioners (GPs) form the gateway to healthcare in numerous European countries. Their role in addressing and managing overweight/obesity in children is crucial. In Dutch guidelines, GPs are encouraged to proactively address weight-related issues during patient consultations, regardless of the initial reason of the visit.

Objective(s): To examine the frequency, management and follow-up of GP visits of children for overweight/obesity and the identification by GPs of these children presenting with other complaints.

Methods: A retrospective cohort study. Health records from 2012-2021 in the Rijnmond Primary Care Database (RPCD) of children aged 2-18 with overweight/obesity who visited the GP were analysed. Children were categorised into two groups: those visiting for weight-related issues (group 1) and those visiting for other complaints but identified as overweight or obese by GPs (group 2). Data on patient demographics, reasons for contact, and management strategies were extracted.

Results: From the 120,991 children, 3035 children with documented overweight or obesity were identified, 208 were excluded. The study population comprised 2827 individuals: 55% belonging to group 1, 45% to group 2. The frequency of first visits remained stable at approximately 0.5% visits per total person-years each year. Group 1 received more referrals (74%) and follow-up consultations (45.5%) than group 2 with 17% referrals and 19.7% follow-up consultations.

Conclusion: This study highlights a concerning difference in the management of the two groups. Strategies for effective management of overweight in children and the GP's role, warrant further investigation. Especially when overweight is not the primary reason for visit.