British Journal of General Practice最新文献

Background In England online services in general practice encompass a range of provision from ordering repeat medication to having a consultation. Some groups of individuals may find accessing and/or using such services difficult and may require 'digital facilitation', that is the range of processes, procedures, and personnel which seeks to support NHS patients in their uptake and use of online services. Aim To gain insight, from the perspective of general practice staff and patients/carers, into how and why digital facilitation might lead to benefits, and the key processes involved in supporting patients to use online services. Design and setting Eight general practices across England with varied geographical and socio-demographic characteristics. Methods Focused ethnographic case study of observations and interviews (n=69). Results Typically, digital facilitation was delivered in an ad hoc fashion to individual patients. Online services were delivered via multiple systems each working differently, and creating a need for support so that patients could access them. Younger practice staff were expected to deliver support on account of their age, despite there being no evidence of age-related training and experience. It was understood by practice staff that patients with challenging personal circumstances may require specific support to access online services. Conclusion At present patient use of online services is supported by digital facilitation which is primarily delivered by reception staff. Supporting patients to use online services requires review of how many services are provided and what for, and consideration for the time and effort needed to support patients to use them.

Background: Diagnosing cancer in general practice is complex, given the non-specific nature of many presenting symptoms and the overlap of potential diagnoses. This trial evaluated the effectiveness of a technology, Future Health Today (FHT), which provides clinical decision support, auditing, and quality improvement monitoring, on the appropriate follow-up of patients at risk of undiagnosed cancer.

Methods: Pragmatic, cluster randomised trial in Australian general practice. Practices were randomly assigned to receive recommendations for follow-up investigations for cancer (FHT cancer module) or the active control. Algorithms were applied to the electronic medical record and used demographic information and abnormal test results that are associated with risk of undiagnosed cancer (anaemia/iron-deficiency, thrombocytosis and raised PSA) to identify patients requiring further investigation and provide recommendations for care. The intervention consisted of the FHT cancer module, a case-based learning series and ongoing practice support. Using intention-to-treat approach, between arms difference in the proportion of patients with abnormal test results followed-up according to guidelines was determined at 12-months.

Results: 7555 patients were identified as at risk of undiagnosed cancer. At 12-months post-randomisation, 76.2% of patients in the intervention arm had received recommended follow-up (21 practices, n=2820/3709), compared to 70% in the control arm (19 practices, n=2693/3846; estimated between arm difference in percentages=2.6%, 95% CI -2.8% to 7.9%; odds ratio=1.15, 95% CI 0.87-1.53; p=0.332).

Conclusions: The FHT cancer module intervention did not increase the proportion of patients receiving guideline-concordant care. The proportion of patients receiving recommended followed-up was high, suggesting a possible ceiling effect for the intervention.

Background: People with multimorbidity (>2 long-term conditions) have poorer outcomes in areas of high socioeconomic deprivation (SED). High-quality person-centred care (PCC) is important in those with multimorbidity, but socially vulnerable populations have not, to our knowledge, informed current PCC models.

Aim: To explore how wider community factors influence management of multimorbidity in the context of high SED, how high-quality PCC is defined by patients, and whether this influences healthcare management.

Design and setting: Ethnographically informed case study in a community experiencing high SED in Scotland.

Method: Participant observation (138 h) was undertaken within four community groups who also took part in two participatory workshops. There were 25 in-depth interviews with people with multimorbidity, recruited from local general practices; emerging findings were discussed with interviewees in one focus group. Field notes/transcripts were analysed using inductive thematic analysis.

Results: Key aspects of PCC were 'patient as person', 'strong therapeutic relationship', 'coordination of care', and 'power sharing'; power sharing was particularly enabling but rarely happened (barriers often unseen by practitioners). Shared community experiences of 'being known', 'stigma', and 'none of the systems working' influenced how people approached health services and healthcare decisions. High-quality PCC may have been particularly effective in this setting because of its influence on ameliorating wider shared negative community experiences.

Conclusion: In a high SED setting PCC is important and can enhance engagement. Wider community factors have a critical influence on engagement with health care in areas of high SED and PCC may be particularly important in this context because of its influence ameliorating these. Policymakers should prioritise and resource PCC.

Background: Research activity usually improves outcomes by being translated into practice; however, there is developing evidence that research activity itself may improve the overall performance of healthcare organisations. Evidence that these relationships represent a causal impact of research activity is, however, less clear. Additionally, the bulk of the existing evidence relates to hospital settings, and it is not known if those relationships would also be found in general practice, where most patient contacts occur.

Aim: To test 1) whether there are significant relationships between research activity in general practice and organisational performance; and 2) whether those relationships are plausibly causal.

Design and setting: National data were analysed between 2008 and 2019, using cross-sectional and longitudinal analyses on general practices in England.

Method: Cross-sectional, panel, and instrumental variable analyses were employed to explore relationships between research activity (including measures from the National Institute for Health and Care Research Clinical Research Network and the Royal College of General Practitioners) and practice performance (including clinical quality of care, patient-reported experience of care, prescribing quality, and hospital admissions).

Results: In cross-sectional analyses, different measures of research activity were positively associated with several measures of practice performance, but most consistently with clinical quality of care and accident and emergency attendances. The associations were generally modest in magnitude; however, longitudinal analyses did not support a reliable causal relationship.

Conclusion: Similar to findings from hospital settings, research activity in general practice is associated with practice performance. There is less evidence that research is causing those improvements, although this may reflect the limited level of research activity in most practices. No negative impacts were identified, suggesting that research activity is a potential marker of quality and something that high-quality practices can deliver alongside their core responsibilities.

Background: Adults with learning disability face multiple adversities, but evidence on their needs and primary care experiences is limited.

Aim: To compare the characteristics and primary care experiences of adults reporting learning disability with those who did not.

Design and setting: This was an analysis of the 2022 General Practice Patient Survey, a national probability sample survey conducted in 2022 with people registered with NHS primary care in England.

Method: This analysis reports descriptive profiles, weighted and with 95% confidence intervals. Logistic regression models adjusting for gender, age, ethnicity, and area-level deprivation compared experiences of adults reporting learning disability with those who did not.

Results: Survey participants comprised 623 157 people aged ≥16 years, including 6711 reporting learning disability. Adults reporting learning disability were more likely to be male, younger, of mixed or multiple ethnicities, and live in more deprived areas. All chronic conditions included in the survey were more common in adults reporting learning disability, especially reported sensory, neurodevelopmental, neurological, and mental health conditions. Adults reporting learning disability were twice as likely to have a preferred GP, and less likely to find their practice's website easy to navigate. They were also less likely to have confidence and trust in their healthcare professional, or feel their needs were met.

Conclusion: Adults reporting a learning disability had a higher likelihood of chronic health conditions. Their reported experiences of primary care indicate that, despite recent initiatives to improve services offered, further adaptations to the consistency and ease of access to primary care is needed.

Background: Home is the preferred place of care and death for most people with advanced illness.

Aim: To examine and describe the published qualitative literature on the lived experiences of dying at home, to characterise the participants and their contexts, and to identify key gaps in knowledge, with a view to informing future research.

Design and setting: A scoping literature review, undertaken in accordance with the PRISMA-ScR guideline, examined studies focusing on the lived experiences of dying at home in the UK.

Method: The online databases CINAHL and MEDLINE were searched with relevant Medical Subject Heading (MeSH) terms and keywords to identify primary qualitative research published between 2010 and 2022, exploring the lived experiences of patients, families, and/or unpaid carers in the UK.

Results: In total, 442 articles were screened, 61 of which underwent full-text review; 13 studies were retained in the final set. All studies explored the experience of bereaved family and/or unpaid carers, and one study interviewed a person who was dying. Where specified, the majority of experiences related to deaths from cancer, many with specialist palliative care team involvement. Included studies yielded a breadth of diverse findings, with the most common subject themes relating to the availability and quality of care, and support for families and carers.

Conclusion: There is limited published evidence exploring the lived experiences of end-of-life care at home and this constrains the extent to which community services can be evidence informed in their design and delivery. More research is needed to examine the first-hand experiences of people who are dying at home, particularly for those with non-cancer conditions and where specialist services are not involved.

Background: The communication of poor prognosis from secondary to primary care helps to ensure that patients with life-limiting illness receive appropriate coordinated care in line with their preferences. However, little is known about this information-sharing process.

Aim: To determine how poor prognosis is communicated from secondary care to primary care.

Design and setting: This was an international systematic review and narrative synthesis of studies published in English.

Method: Four electronic databases were searched from 1 January 2000 to 17 May 2021, supplemented by hand-searching of key journals. One-quarter of titles and abstracts were independently screened by a second reviewer. Two reviewers undertook data extraction and quality appraisal, independently using the Mixed Methods Appraisal Tool. Data were analysed using narrative synthesis. Reporting follows Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidance.

Results: Searches identified 23 853 unique studies of which 30 met the inclusion criteria. Few studies had a focus on the interprofessional communication of poor prognosis. Information about prognosis was not commonly communicated from secondary to primary care and was more likely to occur if death was imminent. Lack of identification of poor prognosis by secondary care teams was a barrier. Facilitators included shared electronic records and direct clinician-clinician contact. GPs welcomed this information from secondary care and felt it was vital for continuity of care.

Conclusion: Although the communication of poor prognosis from secondary to primary care is highly valued it is rare and associated with cultural and systemic challenges. Further research is necessary to understand the information needs of GPs and to explore the challenges facing secondary care clinicians initiating this communication.

Background: Since 2022, general practice has shifted from responding to the acute challenges of COVID-19 to restoring full services using a hybrid of remote, digital, and in-person care.

Aim: To examine how quality domains are addressed in contemporary UK general practice.

Design and setting: Multi-site, mostly qualitative longitudinal case study, placed in UK national policy context.

Method: Data were collected from longitudinal ethnographic case studies of 12 general practices (2021-2023), multi-stakeholder workshops, stakeholder interviews, patient surveys, official reports, and publicly accessible patient experience data. Data were coded thematically and analysed using multiple theories of quality.

Results: Quality efforts in UK general practice occur in the context of cumulative impacts of financial austerity, loss of resilience, increasingly complex patterns of illness and need, a diverse and fragmented workforce, material and digital infrastructure that is unfit for purpose, and physically distant and asynchronous ways of working. Providing the human elements of traditional general practice (such as relationship-based care, compassion, and support) is difficult and sometimes even impossible. Systems designed to increase efficiency have introduced new forms of inefficiency and have compromised other quality domains such as accessibility, patient-centredness, and equity. Long-term condition management varies in quality. Measures to mitigate digital exclusion (such as digital navigators) are welcome but do not compensate for extremes of structural disadvantage. Many staff are stressed and demoralised.

Conclusion: Contemporary hybrid general practice features changes (digitalisation, physical distancing, extension of roles, and protocolisation) that have had the unintended effect of dehumanising, compromising, and fragmenting care. Policymakers and practices should urgently address the risks to patients and the traditional core values of general practice should be urgently addressed.

Background: People with long-term physical conditions are more likely to experience distress, depression or anxiety. Physical-mental comorbidity is associated with lower quality of life, poorer clinical outcomes, and increased mortality than physical conditions alone. South Asians (SAs) are the largest minority group in the UK, and more likely to have long-term conditions (LTCs) such as diabetes and heart disease.

Aim: To explore how men of SA origin with LTCs understand and experience emotional distress as well as the experiences of GPs supporting them.

Design and setting: UK qualitative study interviewing SA men with diabetes or coronary heart disease, and GPs working at practices with higher proportions of SAs.

Method: Online semi-structured interviews with SA men and GPs. Data were analysed via reflexive thematic analysis. Topic guides were modified iteratively as data collection and analysis progressed. An ethnically appropriate patient advisory group of SA men was involved in all stages of the research.

Results: Seventeen SA men with LTCs and 18 GPs were interviewed. Participants described contextualising distress including the interaction between having a LTC and distress, and the intersections of social determinants of distress including ethnicity, poverty and perceptions of prejudice. Participants understood distress as different to depression with the need to negotiate multiple identities as well as alternative paradigms of health.

Conclusion: This study highlights the influence of social determinants of distress in SA men with LTCs. It provides an insight into how primary care has the potential to address health inequalities by considering the intersection of these factors.

Background  Vulval lichen sclerosus (VLS) is a chronic inflammatory condition that is frequently misdiagnosed and under-recognised. To date, qualitative research focuses on lived experience of VLS, with women attributing diagnostic delay to poor interactions with health care 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 identification, management and education of vulval skin disease, with a focus on VLS.  Design and Setting  A survey was distributed to HCPs working in primary care.  Method The survey was distributed via professional networks and at events. Analysis comprised of descriptive statistics, Spearman's rank correlations, and thematic analysis.  Results   Of 122 respondents, 53 were General Practitioners (GPs) and 59 were GP trainees. 37.7% of respondents had never participated in teaching nor learning on vulval skin disease. Confidence in the identification of vulval skin disease positively correlated with experience, exposure and female gender. 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 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, referral pathways and lack of tools to support VLS diagnosis. Training should include skills to address stigma and embarrassment. This study highlights the importance of developing interventions to overcome barriers, expediting diagnosis and treatment, such as reproducible diagnostic criteria.