British Journal of General Practice最新文献

Background: Hypertension is the leading modifiable cause of cardiovascular disease. Primary care management is predominantly individual and remains suboptimal. Interventions delivered to groups incorporate peer support and potentially offer efficient use of limited resources. Evidence for the benefits of group-delivered interventions in hypertension is unclear.

Aim: To determine whether group-delivered hypertension interventions improve blood pressure (BP) outcomes compared to usual care (UC).

Design and setting: Systematic review, meta-analyses, and meta-regression of randomised controlled trials in community, primary, or outpatient care settings.

Method: MEDLINE, Embase, Cochrane CENTRAL, and CINAHL were searched from inception to 20 March 2024 for randomised controlled trials comparing group-delivered interventions to UC for adults with hypertension. Primary outcomes were changes in systolic and diastolic BP, achievement of study BP targets and medication adherence; quality was assessed using the Cochrane Risk of Bias 2 tool. Data were pooled according to intervention type using random effects meta-analyses; predictors of BP lowering were modelled with meta-regression.

Results: Overall, 5326 citations were retrieved; 59 intervention groups (IGs) from 54 studies (13 976 participants) were included. Compared to UC, systolic BP reduced by 7.2 mmHg (95% confidence interval [CI] = 4.7 to 9.6; 23 IGs) following exercise, 4.8 mmHg (95% CI = 3.2 to 6.4; 26 IGs) following lifestyle education, and 3.6 mmHg (95% CI = 0.3 to 6.9; seven IGs) following psychotherapeutic interventions. Corresponding reductions in diastolic BP were 3.9 mmHg (95% CI = 2.6 to 5.2; 21 IGs), 2.9 mmHg (95% CI = 1.8 to 3.9; 24 IGs), and 1.2 mmHg (95% CI = -1.9 to 4.3; seven IGs). Achievement of target BP and medication adherence were infrequently reported, with equivocal findings (relative risks 1.1, 95% CI = 1.0 to 1.2, P = 0.02, 11 IGs and 1.0, 95% CI = 1.0 to 1.1, P = 0.60, seven IGs, respectively). In multivariable models, higher baseline BP and pre-existing cardiovascular morbidity were associated with greater BP reductions.

Conclusion: Group-delivered interventions were effective at lowering BP for people with hypertension compared with UC; their feasibility and cost-effectiveness in primary care require further study.

Background: Heart failure (HF) is a risk factor for stroke among people with atrial fibrillation (AF). Prognosis following an HF diagnosis is often poor, but this is not accounted for in existing stroke risk scores.

Aim: To examine stroke incidence in people with HF and AF compared with AF alone, considering the competing risk of death.

Design and setting: A population-based retrospective cohort study in English primary care, linked to secondary care Hospital Episode Statistics data.

Method: In total, 2 381 941 people aged ≥45 years were identified in the Clinical Practice Research Datalink from 2000 to 2018. HF and AF were included as time-varying covariates; 69 575 had HF and AF, 141 562 had AF alone, and 91 852 had HF alone. Hazard ratios (HRs) for first stroke are reported using the Cox model and the Fine-Gray model.

Results: Over median follow-up of 6.62 years, 93 665 people (3.9%) had a first stroke and 314 042 (13.2%) died. Over half (51.3%) of those with HF, with or without AF, died. In the fully adjusted Cox model, relative stroke risk was highest among people with AF alone (HR 2.43, 95% confidence interval [CI] = 2.38 to 2.48), followed by HF and AF (HR 2.20, 95% CI = 2.14 to 2.26). The cumulative incidence function of stroke was also highest among those with AF only once accounting for the competing risk of all-cause mortality. In a Fine-Gray model, the relative risk of stroke was similar for people with AF alone (HR 2.38, 95% CI = 2.33 to 2.43), but there was significant attenuation among those with HF and AF (HR 1.48, 95% CI = 1.44 to 1.53).

Conclusion: HF is an aetiological risk factor for stroke, yet its prognostic significance is reduced by the high incidence of death. Use of the CHA₂DS₂-VASc score may overestimate stroke incidence in some people with HF, particularly those with a poor prognosis.

Background: Rapid microbiological point-of-care tests (RM POCTs) present an opportunity to reduce antibiotic exposure and antimicrobial resistance (AMR). So far, there is limited understanding of how RM POCTs may support clinicians in primary care in the UK and how RM POCTs might be integrated into practice.

Aim: To investigate clinicians' views on how RM POCTs can influence clinical decisions and routine practice, and perspectives on how RM POCTs can impact the clinician-patient relationship.

Design and setting: A qualitative study was undertaken. The study was embedded in a multi-centre, individually randomised controlled efficacy trial, which evaluated the use of a multiplex RM POCT for suspected respiratory tract infections (RTIs) in primary care.

Method: Individual interviews were conducted with 18 clinicians (GPs, n = 9; advanced nurse practitioners, n = 4; paramedics, n = 2; trainee advanced nurse practitioner, n = 1; clinical pharmacist, n = 1; and emergency care practitioner, n = 1). Interviews were audio-recorded, transcribed verbatim, and analysed thematically informed by a realist approach.

Results: RM POCTs can guide prescribing decisions when clinicians experience diagnostic uncertainty and support communication with patients to reinforce prescribing decisions. Consequently, the perceived value of, and use of, RM POCTs varied according to clinicians' confidence in making prescribing decisions and managing patient expectations and their clinical roles. The costly and time-consuming nature of RM POCTs meant that integration of the tests into routine practice was considered unlikely at present.

Conclusion: The findings from this study highlight the potential benefits and challenges of integrating RM POCTs into routine practice. Clinicians in this study had generally favourable views towards RM POCTs. However, further RM POCT training, complementary strategies, such as communication skills training and patient education, and clear guidance on implementation should be explored to optimise RM POCT feasibility and outcomes across different primary care settings.

Background: Vulval lichen sclerosus (VLS) is a chronic inflammatory condition that is frequently misdiagnosed and under-recognised. To date, qualitative research has focused on lived experience of VLS, with women attributing diagnostic delay to poor interactions with healthcare professionals (HCPs), often due to lack of knowledge. In the UK, women with VLS are most likely to present to primary care.

Aim: To establish HCPs' perspectives on the identification, management, and education of vulval skin disease, with a focus on VLS.

Design and setting: A mixed-methods study survey undertaken across the UK.

Method: HCPs were recruited through opportunistic sampling. The survey was distributed via email and WhatsApp through professional networks and in hard-copy format at events, and completed between 1 November 2023 and 14 December 2023. Data were analysed using descriptive statistics, Spearman's rank correlations, and thematic analysis.

Results: Of 122 responders, most were GPs (n = 53) and GP trainees (n = 59). In total, 37.7% of responders had never participated in teaching or learning on vulval skin disease. Confidence in the identification of vulval skin disease positively correlated with experience, exposure, and female gender, although this last correlation was weak. The top identified barriers to diagnosis and treatment included lack of knowledge, embarrassment, and absence of VLS diagnostic criteria. Almost all participants (97.5%) felt that VLS diagnostic criteria would be helpful in clinical practice.

Conclusion: This study provides insight into the barriers to diagnosing and treating VLS in primary care. HCPs recognise deficiencies in training and referral pathways, and a lack of tools to support VLS diagnosis. Training should include skills to address stigma and embarrassment. This study highlights the importance of developing interventions, such as reproducible diagnostic criteria, to overcome barriers, thereby expediting diagnosis and treatment.

Background: Relapse contributes to the clinical and societal burden associated with depression. It is not well understood how relapse risk and prevention are managed and discussed between patients and GPs in primary care.

Aim: To understand the extent to which relapse risk and prevention are discussed and managed in general practice.

Design and setting: A qualitative study undertaken in general practice in the UK.

Method: Participants were recruited through general practices. Data were generated using semi-structured interviews and analysed using thematic analysis. Patient and public involvement informed all aspects of the study.

Results: Twenty-three people with lived experience of depression and 22 GPs were interviewed. The following three themes are presented in this paper: perceived determinants of depression course (participants viewed environmental, social, and personal factors as being most important); relapse risk and prevention (relapse was considered important but not consistently or routinely discussed in general practice consultations); and relationships and communication (participants discussed the key role of the GP-patient relationship). Conceptually, relapse was perceived as having limited meaning and usefulness in primary care, owing to the implication of an episodic, discrete course not recognised by many patients and an over-reliance on biomedical diagnosis. Longer-term follow-up and monitoring of depression could be improved in primary care.

Conclusion: We provide an evidence-informed framework to improve practice systems and GP consultations to enhance longer-term care and support for people with depression. Going forwards, acute depression management could be optimised to include discussions of relapse risk and prevention. Brief, scalable relapse prevention interventions are needed for use in primary care.

Background: Online records access, including test results, was rolled out as part of changes to the GP contract in England in 2023. Blood test result communication is important for patient-centred care, patient safety, and primary care workload. Evidence is needed to ensure that test results are communicated safely and efficiently to patients in primary care.

Aim: To summarise existing evidence for blood test result communication between primary care providers and their patients and carers.

Design and setting: A mixed-methods systematic review was undertaken.

Method: MEDLINE, Embase, PsycInfo (Ovid), CINAHL (EBSCOhost), and the Cochrane Library were searched from January 2013-September 2023. Qualitative or quantitative studies that provided information on the communication of blood test results by primary care staff to adult patients and carers were eligible for inclusion.

Results: There were 71 included studies, including 10 experimental studies and no randomised controlled trials. Study quality was mostly poor and risk of bias was high, partly owing to a lack of reported information. The studies found that patients want more information about their blood test results, particularly in terms of 'what next', and prefer results to be provided quickly. Electronic methods, such as online access or text messages, were generally well accepted but not by everyone, and not for all results. Clinicians' opinions were mixed as to whether online direct release of test results to patients was beneficial or could cause problems, such as increased patient anxiety and increased workload.

Conclusion: A range of evidence has been identified on patient and clinician preferences, and barriers and facilitators to test communication, which is particularly important in the current NHS context of a move towards patient online access.

Background: International medical graduates (IMGs) comprise more than half of GP registrars but are more likely to fail postgraduate assessments than UK graduates.

Aim: To assess whether there is an association between the language of the primary medical qualification (PMQ) and Membership of the Royal College of General Practitioners (MRCGP) results, and whether performance in previous prequalification assessments is correlated.

Design and setting: Retrospective observational study in the UK.

Method: The World Directory of Medical Schools and the UK Medical Education databases were used to obtain data for all candidates who sat the MRCGP exams between October 2013 and July 2021 (n = 28 020). Candidates were split into three cohorts: cohort 1 comprised UK graduates; cohort 2 comprised IMGs with English as the language of the PMQ, who trained in countries with English (cohort 2a) or non-English (cohort 2b) as a first language; and cohort 3 included IMGs with non-English as the language of the PMQ. Logistic and linear regression analyses were used to compare the odds of exam passing and the scores relative to pass. Associations with past Multi-Specialty Recruitment Assessment (MSRA) scores, International English Language Testing System (IELTS) scores, and Professional and Linguistic Assessments Board (PLAB) scores were examined.

Results: IMGs who trained in countries with non-English as a first language had statistically significantly lower odds of passing the exams and lower exam scores across all exam components. There were statistically significant positive correlations between MRCGP exam scores and MSRA, IELTS, and PLAB scores.

Conclusion: English being the language of the PMQ and undertaking medical training in a country with English as the native language seemed to result in statistically significantly better chances of passing the exams and better exam scores. Performance in prequalification assessments can help to identify those IMG registrars who may benefit from tailored support.