British Journal of General Practice最新文献

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 general practitioners in primary care. Aim To understand the extent to which relapse risk and prevention are discussed and managed in general practice. Design and Setting Qualitative study in general practice. Method Participants were recruited through UK 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 twenty-two GPs were interviewed. Three themes are presented in this paper: perceived determinants of depression course (participants viewed environmental, social and personal factors as being most significant); relapse risk and prevention (relapse was considered important but not consistently or routinely discussed in general practice consultations); and the key role of the GP-patient relationship and communication. Conceptually, relapse was perceived as having limited meaning and usefulness in primary care, due 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 improve longer-term care and support for people with depression. Going forwards, brief scalable relapse prevention interventions are needed to improve the ongoing care of people with depression in primary care; implementing these would require additional primary care resources.

Background The Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) has been implemented in many areas of the UK. It is unclear how ReSPECT is used in primary and community care settings. Aim To investigate how the ReSPECT process is understood and experienced in the community by clinicians, social care staff, patients, their relatives, and identify obstacles and enablers to its implementation. Design and setting. A qualitative interview and focus group study across 13 general practices in three areas in England. Method We interviewed GPs, specialist nurses, patients and relatives, and senior care home staff. Focus groups were conducted with community-nurses, paramedics, and home-care workers. Questions focused on understanding experiences of and engagements with ReSPECT. We analysed data using thematic analysis and a coding framework drawn from Normalisation Process Theory. Results Participants included 21 GPs, five specialist nurses, nine patients, seven relatives, 31 care home staff, nine community nurses, seven home-care workers and two paramedics. Participants supported ReSPECT regarding it as a tool to facilitate person-centred care. GPs faced challenges in timing introduction of ReSPECT and ensuring sufficient time to complete plans with patients. ReSPECT conversations worked best when there was a trusting relationship between clinician and patient (and their family). Anticipating future illness trajectories was difficult yet plans were rarely reviewed. Interpreting recommendations in emergencies was challenging. Conclusion The ReSPECT process has not translated as well as expected in the community setting. A revised approach is needed to address the challenges of implementation in this context.

Background: Long-term use of antipsychotics confers increased risk of cardiometabolic disease. Ongoing need should be reviewed regularly by psychiatrists.

Aim: To explore trends in antipsychotic management in general practice, and proportions of patients prescribed antipsychotics receiving psychiatrist review.

Design and setting: A serial cross-sectional study using linked general practice and hospital data in Wales (2011-2020).

Method: Participants were adults (≥18 years) registered with general practices in Wales. Outcome measures were prevalence of patients receiving ≥6 antipsychotic prescriptions annually, proportion of patients prescribed antipsychotics receiving annual psychiatrist review, and proportion of patients prescribed antipsychotics registered on UK Serious Mental Illness, Depression and/or Dementia registers, or not on any of these registers.

Results: Prevalence of adults prescribed long-term antipsychotics increased from 1.06% (95%CI 1.04 to 1.07%) in 2011 to 1.45% (95%CI 1.43 to 1.46%) in 2020. The proportion receiving annual psychiatrist review decreased from 59.6% (95%CI 58.9 to 60.4%) in 2011 to 52.0% (95C%CI 51.4 to 52.7%) in 2020. The proportion of antipsychotics prescribed to patients not on the Serious Mental Illness register increased from 50% (95%CI 49 to 51%) in 2011 to 56% (95%CI 56 to 57%) by 2020.

Conclusions: Prevalence of long-term antipsychotic use is increasing. More patients are managed by general practitioners without psychiatrist review and are not on monitored disease registers; they thus may be less likely to undergo cardiometabolic monitoring and miss opportunities to optimise or deprescribe antipsychotics. These trends pose risks for patients and need to be addressed urgently.

Background Personal continuity is an important dimension of continuity of care in general practice and is associated with many benefits including a higher quality of GP care and lower mortality rate. Over time, changes in society and healthcare have challenged the provision of personal continuity. Especially older patients experience more negative consequences from receiving discontinuous care. Aim To explore perspectives of general practitioners (GPs), older patients, practice nurses, and assistants on improving personal continuity in general practice, and to identify barriers and facilitators that affect this improvement process. Design and setting A Qualitative study using focus groups was conducted from May to August 2019. Method We organised four focus groups: two with GPs (n=17), one with patients (n=7), and one with practice assistants (n=4) and nurses (n=2). Focus groups were analysed using reflexive thematic analysis. Results Personal continuity was viewed as being provided by the entire general practice team and not just by the own GP. To improve personal continuity, it was suggested to invest in team communication and stability (e.g., by efficient use of the EHR) and retaining availability and accessibility of the own GP (e.g., by delegating tasks). Barriers and facilitators were perceived on individual (e.g., GPs' involvement in tasks), organisation (e.g., staff shortages) and societal level (e.g., payment system). Conclusion As general practice moves towards a more team-based approach to ensure personal continuity, efforts to improve personal continuity should focus on supporting team-based provision of continuous care.

Background: Generalist approaches can help address several challenges facing today's primary care. However, GPs report insufficient support to deliver advanced generalist medicine (AGM) in daily practice, struggling within a healthcare system that imposes strict adherence to single-disease focused guidelines.

Aim: To examine the professional and educational experiences of newly qualified GPs attending a course on AGM to understand how to redesign primary care systems to support their generalist work.

Design and setting: This was a qualitative study focusing on AGM in UK general practice (England), conducted in the context of the research evaluation of an online career development programme on AGM.

Method: We conducted 36 interviews and six focus groups with newly qualified GPs attending an online career development programme on AGM, and analysed data using framework analysis.

Results: Three tensions experienced by the participants were identified: tension between realistic and idealistic practice; tension between different decision-making paradigms; and tension in the formation of the GPs' professional identities. These were owing to grey areas of practice deeply rooted in primary care systems - namely areas of work not adequately addressed by current education and service design.

Conclusion: Our findings have implications for tackling the general practice workforce crisis, highlighting that solutions targeting individual problems will not suffice by themselves. By making visible the grey areas of everyday general practice, we describe the changes needed to target tensions as described by the GPs in this study to ultimately enable, enhance and make visible the complex work of generalist medicine.