British Journal of General Practice最新文献

Background: Postural hypotension is associated with excess mortality, falls, and cognitive decline. Postural hypotension is poorly recorded in routine general practice records. Few studies have explored measurement and diagnosis of postural hypotension in general practice.

Aim: To understand how postural hypotension is measured, diagnosed, and managed in general practice.

Design and setting: This was an online survey of general practice staff in England.

Method: Clinical research networks distributed the survey to practices, seeking individual responses from any clinical staff involved in routine blood pressure (BP) measurement. Responses were analysed according to role and demographic data using descriptive statistics. Multivariable modelling of checking for postural BP measurements was performed.

Results: There were 703 responses from 243 general practices (mean practice-level response rate 17%). Half (362; 51%) of responders were doctors, 196 (28%) nurses, and 77 (11%) healthcare assistants (HCAs). In total, 8% (58/703) did not routinely check for postural hypotension, usually citing time constraints. For the remaining 92%, postural symptoms were the predominant reason for checking (97% responders, 627/645); only 24% cited any other guideline indication for postural hypotension testing. The study found that 77% used sit-to-stand BP measurements; approximately one-quarter measured standing BP for >1 min. On regression modelling, other professionals tested less for postural hypotension than doctors (odds ratios: nurses 0.323, 95% confidence interval [CI] = 0.117 to 0.894, HCAs 0.102, 95% CI = 0.032 to 0.325, and pharmacists 0.099, 95% CI = 0.023 to 0.411).

Conclusion: Awareness of reasons, besides symptoms, and adherence to guidelines for postural hypotension testing, are low. Time is the key barrier to improved testing for postural hypotension. Clarity on pragmatic methods of measuring postural hypotension in general practice would also facilitate measurement uptake.

Background: When monitoring long-term conditions, both over- and undertesting can risk patient harm and increase healthcare costs.

Aim: To evaluate the evidence base for type 2 diabetes mellitus (T2DM) monitoring tests and develop methods for creating evidence-based testing strategies.

Design and setting: Rapid reviews were conducted and a consensus process then used to evaluate the evidence base within primary care settings.

Method: The authors identified tests that are recommended or used commonly to monitor T2DM. Filtering questions were created to examine the rationale for use of each test, which were answered by stepwise rapid reviews of evidence cited by guidelines, systematic reviews, and individual studies. A consensus group of patient representatives and clinicians voted whether tests should be included or excluded based on the evidence or whether further evidence was needed.

Results: Of 15 tests, only haemoglobin A1c, to monitor disease progression and treatment response, and estimated glomerular filtration rate, to detect chronic kidney disease, have a strong evidence base. Based on available evidence and consensus group feedback, routinely testing for fructosamine to monitor disease progression; thyroid function, vitamin B12, ferritin, folate, clotting, bone profile, C-reactive protein, erythrocyte sedimentation rate, and B-type natriuretic peptide; and liver function for adverse treatment effects of metformin was deemed unnecessary. The study found insufficient evidence for lipids and haemoglobin to screen for secondary conditions, and for vitamin B12 to screen for adverse effects in those taking metformin.

Conclusion: The study found that the evidence base for most T2DM monitoring tests is weak or absent. Clinicians should avoid non-evidence-based tests unless there are additional clinical indications for testing. Standardised evidence-based testing panels for T2DM and other long-term conditions could reduce unnecessary testing.

Background: Oesophagogastric (OG) cancer-associated symptoms are common in primary care, but most research has focused on patients with a confirmed OG cancer diagnosis, rather than those presenting with symptoms for the first time.

Aim: To examine diagnostic testing patterns for upper gastrointestinal (GI) symptoms linked to OG cancer.

Design and setting: A retrospective cohort study was undertaken, which used a linked primary care database. It included de-identified patients aged >55 years who presented with symptoms suggestive of OG cancer between 2008 and 2022.

Method: The study analysed the proportion of patients who underwent pathology, imaging, referral, upper GI endoscopy, or a test of treatment. Differences across socioeconomic groups were also examined, along with the proportion of patients diagnosed with OG cancer.

Results: The study cohort consisted of 44 402 patients, of whom 126 (0.3%) were diagnosed with OG cancer within 12 months of presentation. Reflux was the most common symptom (57%), followed by nausea (11%). Patients aged ≥75 years were less likely to be investigated or referred than those aged 56-64 years (odds ratio [OR] 0.59, 95% confidence interval [CI] = 0.56 to 0.62, P<0.001). Those from less disadvantaged areas were 1.4 times more likely to be investigated than people from the most disadvantaged areas (OR 1.44, 95% CI = 1.36 to 1.53, P<0.001). Patients on test-of-treatment medications were less likely to receive further investigation (OR 0.66, 95% CI = 0.63 to 0.69, P<0.001). Multiple symptoms and visits increased the likelihood of investigation (OR 2.77, 95% CI = 2.55 to 3.00, P<0.001).

Conclusion: Significant variations in diagnostic testing could contribute to disparities in OG cancer outcomes.

Background: Many primary care trials evaluating complex health interventions use a 'usual care' comparator. As usual care can vary across clinical sites, countries, and over time thereby affecting trial design and raising ethical considerations, attention should be given to its content prior to a trial starting.

Aim: To understand how researchers select and describe usual care comparators when designing primary care trials of complex health interventions.

Design and setting: A systematic review of primary care trial or feasibility study protocols undertaken worldwide.

Method: Electronic databases were searched from 1 July 2020 until 20 June 2022.

Results: A total of 83 protocols were included. A range of terms such as 'usual care' and 'care as usual' were used to describe usual care. Descriptions of usual care varied greatly in terms of the level of detail provided regarding selection and content, and were categorised according to the amount of detail they provided: basic (72%), moderate (16%), and comprehensive (12%). Few protocols justified the content of their usual care comparator, with most simply commenting that it was based on clinical guidelines or current practice.

Conclusion: Different terms were used to describe usual care and most primary care researchers provided limited details on the selection and content of their usual care comparators when publishing study protocols. This has implications for transparency and replicability, and suggests that researchers continue to give limited attention to the content of usual care when designing their trials.

Background: General practice receptionists are perceived as the 'gatekeepers' to primary care services and are central to managing patient demand and facilitating patient care. This role is evolving and becoming increasingly complex in a digital world.

Aim: To consider the growing role of patient-facing online services and the impact these services have on the role of the general practice receptionist.

Design and setting: A focused ethnographic case study was undertaken in eight general practices across England and 19 stakeholder interviews took place.

Method: Focused ethnographic case study and stakeholder interviews were conducted between September 2021 and July 2022.

Results: The receptionist role looks different across practices, but is now more varied and less repetitive than it has been historically. The volume of patients and number of channels by which patients contact the practice means that receptionists are dealing with increasingly complex demand management and navigation to appropriate services. This now includes online services, which has created a new element to the receptionist role - digital facilitation. The role is also largely navigated by the receptionists without any formal training and staff are mostly expected to learn on the job from other receptionists, leading to inconsistent practices.

Conclusion: The digitalisation of healthcare services impacts the workflow and consistency in task completion of general practice receptionist staff and has potential implications regarding job satisfaction and retention. In addition, the knowledge and skills required to fulfil this role are evolving and therefore may have recruitment and training implications.

Background: Haemoglobin, mean corpuscular volume (MCV), and rates of iron-deficiency anaemia (IDA) are used in primary care to investigate possible cancer symptoms, especially for gastrointestinal cancers. Underlying ethnic differences in typical test results could lead to inequalities in the diagnosis of cancer in primary care.

Aim: To investigate the distribution of low haemoglobin, low MCV, and IDA, and the rate of cancer diagnosis in patients with abnormal results, by ethnic group.

Design and setting: A retrospective cohort study using routine data collected in primary care in England was undertaken. Included patients had blood tests between 2010 and 2017, and were aged ≥40 years with no prior cancer diagnosis.

Method: Multilevel logistic regression was used to investigate the relationship between blood test results and cancer risk for patients in different ethnic groups.

Results: Low haemoglobin, low MCV, and IDA were effective in identifying patients with increased cancer risk, particularly for gastrointestinal cancers. MCV was found to be a stronger cancer indicator for White patients (diagnostic odds ratio [OR] 3.84; 95% confidence interval [CI] = 3.72 to 3.96) than for Asian (OR 1.86; 95% CI = 1.64 to 2.10) or Black patients (OR 1.75; 95% CI = 1.54 to 1.99).

Conclusion: There are some small differences in cancer risk for patients with abnormal test results, when considering patient ethnic group, especially for MCV. This is likely to be a consequence of the underlying difference in typical MCV values for patients from different ethnic groups. Further investigation is required to understand the aetiology of these differences in order to disentangle any effects on outcomes for patients with cancer.

Background: Some patients are diagnosed with cancer following self-referral to the emergency department (ED), even after consulting in primary care; however, the rationale and factors involved in the decision to self-refer are largely unknown.

Aim: To explore patients' perceptions on reasons for emergency self-referral shortly before a cancer diagnosis.

Design & setting: Qualitative interview study at a high-volume public institution in Barcelona.

Method: Semi-structured interviews were conducted with two patient groups: patients who self-referred as emergencies and never consulted primary care (non-consulters), and patients who self-referred despite consulting primary care (consulters). Data were analysed by two independent coders - an emergency doctor and a primary care physician - using a codebook approach to thematic analysis.

Results: Fifteen non-consulters and 17 consulters were interviewed. Non-consulters were more likely to belong to disadvantaged and minoritised ethnic communities. Reasons why participants self-referred to the ED were categorised under four themes: urgency/distress, advantages of the ED, quality care, and access to primary care. There was little variation between patient groups in their experiences and perceptions regarding pain intensity and related distress, and EDs' advantages in terms of accessibility and convenience. Cancer fear, uncertainty about symptoms, and frustration in accessing primary care due to language barriers were unique among non-consulters, leading to help-seeking delays. Patients' perception of the ED as a facility that provides high-quality care and is able to meet all medical needs emerged as a distinct theme among consulters.

Conclusion: Healthcare organisations and public health services bear the responsibility to promote patient education and improve communication regarding the specific roles and purposes of primary care and the ED. Increasing awareness and developing community-based programmes that target cancer fear and fatalism may encourage early presentation to primary care, especially among underrepresented and minoritised ethnic groups.Delete.

Background: Chlamydia is the most diagnosed bacterial sexually transmitted infection (STI) in England, but opportunistic testing remains low in general practice despite high prevalence among young people. Attempts to increase testing have been met with little success; therefore, there is a need to explore why rates remain low and how this may be improved.

Aim: To explore general practice staff perceptions of opportunistic chlamydia testing, including barriers, facilitators, interventions, and policies, using the Behaviour Change Wheel (BCW).

Design & setting: Qualitative interviews and focus groups were undertaken with general practice staff in England.

Method: Twenty-three semi-structured individual interviews and seven focus groups with general practice staff were conducted. Data were analysed using inductive thematic analysis, followed by thematic categorisation onto the BCW.

Results: Participants identified several barriers to chlamydia testing corresponding with BCW components, including low perceived knowledge (psychological capability), general practice context (physical opportunity), cultural norms (social opportunity), testing not prioritised (reflective motivation), and concerns about patient reactions (automatic motivation). Proposed intervention functions included education, persuasion (for example, posters), incentivisation (for example, financial incentives), and environmental restructuring (for example, computer reminders). Potential policy categories discussed were communication and marketing (for example, campaigns) and service provision (for example, GP drop-in sessions at other venues).

Conclusion: This study identified barriers to chlamydia testing in English general practice and potential ways to address these issues, contributing new insights to existing literature. This research can be utilised to design multi-component, impactful interventions to increase testing in general practice and ultimately reduce harm posed by chlamydia infections.

Background: Little is known about how GP consultation rates for children's respiratory tract infections (RTIs) have changed since the COVID-19 pandemic restrictions lifted.

Aim: To describe changes in GP consultation rates for RTIs in children aged <5 years from 2016 to 2023.

Design & setting: A population-based retrospective cohort study using electronic health records from primary care practices across England.

Method: All children aged <5 years registered with a general practice in the Clinical Practice Research Datalink Aurum database from April 2016 to March 2023 were included. Monthly GP consultation rates for RTIs from April 2021 to March 2023 were compared with the corresponding months during pre-pandemic years (April 2016 to February 2020).

Results: There were 3 226 285 GP consultations for RTIs among 2 894 539 children. Pre-pandemic, mean monthly consultation rates ranged from lows in August to highs in November (from 2368 to 8682 per 100 000 children, respectively). Following the pandemic lockdowns in 2020, monthly rates in 2021/2022 peaked in June and October at 5152 and 5942 per 100 000 children, respectively, but the winter peak was less marked than pre-pandemic and mean monthly rates were 16.8% lower (95% confidence interval [CI] = - 13.4 to - 19.6). In 2022/2023, after all restrictions were lifted, rates remained around 15% below pre-pandemic years, but the winter peak for children aged 3-4 years was 8615 per 100 000 children, exceeding mean pre-pandemic winter peaks of 6011 per 100 000 children. This was an increase of 43.3% and coincided with a streptococcal group A outbreak. Across all ages there was a sharp increase (from 1486 to 2370 per 100 000 children, around 60%) in tonsillitis, Streptococcus A, and bacterial ear infections.

Conclusion: This study shows reductions in GP consultations for RTIs in children aged <5 years since the lifting of COVID- 19 pandemic restrictions. Of concern is a sharp rise in tonsillitis, Streptococcus A, and bacterial ear infections that should be monitored.

Background: In clinical encounters with children and their parents, physicians rely on both analytical and non-analytical factors to assess the clinical problem. Research on clinical gut feeling has recognised this as a significant diagnostic factor, yet little is known about how physicians evaluate parental concerns.

Aim: To investigate which parent- and physician-related factors influence a physician's assessment of parental concerns.

Design and setting: Nine qualitative semi-structured focus group interviews were conducted with 15 GPs and 15 paediatricians in Belgium between May and August 2022.

Method: The interview transcripts were independently coded and analysed thematically using the constant comparative analysis method.

Results: The factors that physicians use to assess parental concerns can be categorised into four groups: parent-related, physician-related, context-related, and child-related factors. Within each category, there are multiple determinants, with the most influential being having multiple children as a parent, the physician's work experience, and disease severity.

Conclusion: This study confirms some determining factors that have already been described in the literature, but it also identifies new determinants (for example, having multiple children as a parent and physician fatigue). Quantitative research could assess the extent to which the identified factors are involved in the assessment of gut feeling.