British Journal of General Practice最新文献

Background: Over the past decade, the number of clinical pharmacists working within multidisciplinary teams in English general practices has expanded.

Aim: To examine changes in quality of prescribing after the adoption of clinical pharmacist roles in English general practices.

Design and setting: Longitudinal cohort study in English general practice.

Method: Two-way fixed-effects regression was used to compare differences in prescribing indicators in general practices with and without pharmacists between September 2015 and December 2019.

Results: Between September 2015 and December 2019, the proportion of practices employing a clinical pharmacist increased from 236/7623 (3.1%) to 1402/6836 (20.5%). Clinical pharmacist implementation resulted in statistically significant reductions in total costs of medicines per 1000 patients (-0.85%, 95% confidence interval [CI] = -1.50% to -0.21%), the total number of opioid prescriptions per 1000 patients (-1.06%, 95% CI = -1.82% to -0.29%), and the average daily quantity of anxiolytics per 1000 patients (-1.26%, 95% CI = -2.40% to -0.12%). Clinical pharmacist implementation also resulted in reductions in the total number of prescriptions per 1000 patients (-0.58%, 95% CI = -1.30% to 0.13%) and the total number of antibiotic prescriptions per 1000 patients (-0.51%, 95% CI = -1.30% to 0.27%) that trended towards statistical significance. There were no statistically significant differences in the share of broad-spectrum versus narrow-spectrum antibiotics (0.02%, 95% CI = -0.07% to 0.11%) and the oral morphine equivalence of high-dose opioids (>120 mg per 24 h) per 1000 patients (1.19%, 95% CI = -0.46% to 2.85%).

Conclusion: This analysis is limited by practice-level data but supports the hypothesis that clinical pharmacist implementation results in improvements in prescribing quality.

Background: Birth cohort screening has been implemented in some countries to identify the potentially 'missed population' of people with undiagnosed chronic hepatitis C virus (HCV) who may not be found through targeted approaches.

Aim: To determine uptake of HCV antibody testing using an oral swab screening method, the overall yield, whether those testing positive had risk markers in their primary care record, and the cost per case detected.

Design and setting: This was a pilot screening study set in general practices in the Southwest of England, Yorkshire and Humber, and South London.

Method: Participants consenting were sent an oral swab kit in the post and saliva samples were tested for antibodies to HCV.

Results: In total, 16 436/98 396 (16.7%) patients consented and were sent an oral swab kit. Of these, 12 216 (12.4%) returned a kit, with 31 participants (yield 0.03%) testing positive for HCV antibodies. Of those positive, 14/35 (45%) had a risk marker for HCV on their primary care record. Two (yield 0.002%) were confirmed RNA positive and referred for treatment, both had HCV risk markers. The cost per case was £16 000 per HCV antibody detected and £247 997 per chronic HCV detected.

Conclusion: Wide-scale screening could be delivered and identify people infected with HCV, however, most of these individuals could have been detected through lower-cost targeted screening. The yield and cost per case found in patients were substantially worse than model estimates and targeted screening studies. Birth cohort screening should not be rolled out in primary care in England.

Background: Clinical tools are needed in general practice to help identify children who are seriously ill. The Liverpool quick Sequential Organ Failure Assessment (LqSOFA) was validated in an emergency department and performed well. The National Paediatric Early Warning System (PEWS) has been introduced in hospitals throughout England with hopes for implementation in general practice.

Aim: To validate the LqSOFA and National PEWS in general practice.

Design and setting: Secondary analysis of 6703 children aged <5 years presenting to 225 general practices in England and Wales with acute illnesses, linked to hospital data.

Method: Variables from the LqSOFA and National PEWS were mapped onto study data to calculate score totals. A primary outcome of admission within 2 days of GP consultation was used to calculate sensitivity, specificity, negative predictive values (NPVs), positive predictive values (PPVs), and area under the receiver operating characteristic curve (AUC).

Results: A total of 104/6703 children were admitted to hospital within 2 days (pre-test probability 1.6%) of GP consultation. The sensitivity of the LqSOFA was 30.6% (95% confidence interval [CI] = 21.8% to 41.0%), with a specificity of 84.7% (95% CI = 83.7% to 85.6%), PPV of 3.0% (95% CI = 2.1% to 4.4%), NPV of 98.7% (95% CI = 98.4% to 99.0%), and AUC of 0.58 (95% CI = 0.53 to 0.63). The sensitivity of the National PEWS was 81.0% (95% CI = 71.0% to 88.1%), with a specificity of 32.5% (95% CI = 31.2% to 33.8%), PPV of 1.9% (95% CI = 1.5% to 2.5%), NPV of 99.1% (95% CI = 98.4% to 99.4%), and AUC of 0.66 (95% CI = 0.59 to 0.72).

Conclusion: Although the NPVs appear useful, owing to low pre-test probabilities rather than discriminative ability, neither tool accurately identified admissions to hospital. Unconsidered use by GPs could result in unsustainable referrals.

Background: Shingles (herpes zoster), caused by reactivation of the varicella-zoster virus, is usually diagnosed and managed in primary care. The lifetime risk of shingles in the general population is approximately 30%, and it can have a detrimental effect on quality of life. There has been little qualitative research about patient experience and understanding of shingles.

Aim: To explore patient experiences and understanding of shingles.

Design and setting: Qualitative interviews with people with shingles recruited from primary care in England.

Method: Qualitative semi-structured remote interviews were undertaken with 29 participants in a randomised controlled trial in primary care in England (ATHENA, ISRCTN14490832). Participants were aged >49 years and were diagnosed within 6 days of shingles rash onset. Interviewees were sampled for diversity in terms of pain, intervention adherence, age, gender, and ethnicity. Data were analysed using reflexive thematic analysis.

Results: Interviews took place in November 2022 to April 2023. Participants' understanding of shingles was limited, particularly pre-diagnosis. A common theme was that 'everyone has heard of it, but no one knows what it is'. Television campaigns about the shingles vaccination programme helped some to recognise the rash. Shingles was understood as a disease with a variable prognosis, resulting in a sense of uncertainty about the significance when diagnosed. Participants reported a range of symptoms, which impacted on everyday life. Some people thought their diagnosis was caused by poor mental health or challenging life circumstances, a perception sometimes reinforced by healthcare professionals. Many participants sought meaning in their diagnosis, reflecting on, and sometimes changing, their life and circumstances.

Conclusion: Primary care practitioners should be aware of the broad spectrum of patient knowledge, and the potential for better understanding to promote early attendance and treatment to reduce the impact of shingles.