British Journal of General Practice最新文献

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: 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: 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: 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.