British Journal of General Practice最新文献

Background: Safety-netting advice (SNA) can help in the management of acutely ill children.

Aim: To assess the effectiveness of different SNA methods on antibiotic prescription and consumption in acutely ill children.

Design and setting: Systematic review and network meta-analysis of randomised controlled trials, cluster randomised trials, non-randomised studies of interventions, and controlled before-after studies in ambulatory care in high-income countries.

Method: MEDLINE, Embase, Web of Science Core Collection, and Cochrane Central Register of Controlled Trials were searched (22 January 2024). Risk of bias (RoB) was assessed with Cochrane's RoB 2 tool, the Revised Cochrane Tool for Cluster-Randomised Trials, and the Risk Of Bias In Non-randomised Studies - of Interventions tool. Certainty of evidence was assessed using the Confidence in Network Meta-Analysis approach. Sensitivity analyses and network meta-regression were performed.

Results: In total, 30 studies (20 interventions) were included. Compared with usual care, paper SNA may reduce: antibiotic prescribing (odds ratio [OR] 0.66, 95% confidence interval [CI] = 0.53 to 0.82, I ² = 92%, very low certainty, three studies, 35 988 participants), especially when combined with oral SNA (OR 0.40, 95% CI = 0.08 to 2.00, P-score = 0.86); antibiotic consumption (OR 0.39, 95% CI = 0.27 to 0.58, low RoB, one study, 509 participants); and return visits (OR 0.74, 95% CI = 0.63 to 0.87). Compared with usual care, video SNA, read-only websites, oral SNA, and web-based SNA (in descending order of effectiveness) may increase parental knowledge (ORs 2.33-4.52), while paper SNA may not (ORs 1.18-1.62). Similarly, compared with usual care, video SNA and web-based modules may improve parental satisfaction (ORs 1.94-4.08), while paper SNA may not (OR 1.85, 95% CI = 0.48 to 7.08).

Conclusion: Paper SNA (with oral SNA) may reduce antibiotic use and return visits. Video, oral, and online SNA may improve parental knowledge, whereas video SNA and web-based modules may increase parental satisfaction.

Background: Diagnostic testing is prevalent among children with persistent non-specific symptoms (PNS), and both undertesting and overtesting have negative consequences for child and society. Research in adults with PNS has shown that GPs use diagnostic testing for reasons other than diagnosis, but comparable research has not, to the best of our knowledge, been conducted in children. Understanding GPs' perspectives of testing decisions in children could provide insights into mechanisms of undertesting and overtesting.

Aim: To investigate GPs' perspectives of conducting or refraining from diagnostic testing in children with PNS and the differences compared with their motives when treating adults.

Design and setting: Qualitative study using semi-structured interviews with Dutch GPs.

Method: We purposively sampled GPs until data saturation. Reasons for conducting or refraining from diagnostic tests were explored using two real-life cases from daily practice. Online video interviews were transcribed verbatim. Data were collected and analysed concurrently by thematic content analysis.

Results: Twelve GPs participated. Their decision making involved a complex trade-off among four themes: medical considerations (for example, alarm symptoms), psychosocial factors (for example, doctor-patient relationship), consultation management (for example, 'quick fix'), and efficient resource utilisation (for example, sustainability). Compared with when treating adults, GPs were more hesitant to conduct diagnostic testing in children because of their higher vulnerability to fearing invasive procedures, lower probability of organic disease, and reduced autonomy.

Conclusion: As in adults, GPs' decisions to conduct diagnostic tests in children were motivated by reasons beyond diagnostic uncertainty. Educational programmes, interventions, and guidelines that aim to change the testing behaviours of GPs in children with PNS should target these reasons.

Background: Paediatric otorrhoea (PO) is a symptom-based diagnosis encompassing acute and chronic ear infections that cause otorrhoea in children and young people (CYP).

Aim: To understand the burden of PO on primary care services.

Design and setting: This was a longitudinal population study in UK primary care.

Method: Data from the Clinical Practice Research Datalink (CPRD Aurum), January 2005 to December 2019, was analysed. CYP <17 years of age with otorrhoea were included. Standardised annual incidence and presentation rates were estimated. Poisson regression modelling was used to determine risk ratios comparing sex, age, and Index of Multiple Deprivation (IMD). A probabilistic simulation scaled-up estimates for the UK population.

Results: The cohort included 6 605 193 CYP, observed over 32 942 594 person-years. There were 80 454 people with incident cases and 106 318 presentations of PO during the 15-year period, equating to standardised annual incidence and presentation rates per 1000 patient-years of 2.42 (95% confidence interval [CI] = 2.40 to 2.44) and 3.15 (95% CI 3.13 to 3.17), respectively. In the UK this equates to 41 141 primary care appointments per year. Incidence was higher in males, those aged 0-2 years, and those living in the least deprived quintile. Treatment involved oral antibiotics (57.1%, 45 931/80 454), no prescription (28.1%, 22 569/80 454), topical antibiotics (9.7%, 7797/80 545), or a combination (4.9%, 3910/80 545). The cost to NHS primary care is estimated at £1.97 million per year.

Conclusion: To the authors' knowledge, this is the first longitudinal population-based study investigating PO that demonstrates the burden on primary care. Antimicrobial prescribing predominantly follows National Institute for Health and Care Excellence guidelines using oral amoxicillin. Aminoglycosides are the most frequently prescribed topical antibiotic despite the concern of ototoxicity.

Background A growing literature examines the way two changes in primary care - the shift towards remote working, and the diversification of practice teams to incorporate, for instance, physician associates and paramedics - affect patient care within the practice. However, little is known about these changes' effects on community nurses. Aim To explore community nurses' experiences of delivering palliative care in the context of GPs' new ways of working. Design and Setting Qualitative study using focus groups. Method Focus groups were conducted on Zoom with community nurses working in the UK. Data were analysed thematically, using constant comparison. Results Community nurses described extending their roles in palliative care. Alongside pride and satisfaction about this, participants raised several concerns and dissatisfactions, some of which they associated with changes in GPs' ways of working. Two dissatisfactions concerned remote working. First, remote communication with colleagues was seen as creating obstacles to nurses' everyday collaboration with GPs, damaging important working relationships. Second, nurses increased their workload by taking the lead in person-centred care where they saw remote provision by GPs as unsatisfactory. Where workforce diversification led to delegating home visits to paramedics or nurse practitioners, community nurses described feeling a lack of the "GP back-up" that many identified as essential for community palliative care. Conclusion When considering and evaluating interventions that change the way GPs work, policy-makers and commissioners should look not only at consequences affecting primary care teams, but also at effects across the complex ecosystem within which these teams operate.

Background: Faecal Immunochemical Testing (FIT) is now core to the management of patients presenting in primary care with symptoms of possible colorectal cancer. Patients with a positive FIT (≥10μg Hb/g faeces) qualify for an urgent suspected cancer referral. FIT negative patients are typically managed in primary care or referred through routine pathways.

Aim: To examine practitioners' experiences of delivering symptomatic FIT, identifying perceived benefits, disbenefits and implementation issues, to inform potential future service improvements.

Design and setting: Qualitative interview study with primary and secondary care health professionals, from across the UK, involved in delivering symptomatic FIT pathways.

Method: 30 semi-structured interviews with professionals from a range of specialties. An iterative topic guide informed interviews while allowing freedom to explore novel lines of inquiry. Pseudo-anonymised transcripts were coded and themes identified and developed.

Results: Symptomatic FIT was seen to be beneficial for increasing confidence in clinical decision-making and enriching the pool of patients being definitively investigated for colorectal neoplasia. There were varying views on the impact of symptomatic FIT on workload with the burden of additional workload generally seen to be located in primary care. Concerns about current practice included over-use of FIT, burden of investigations in patients with false-positive results and diagnostic delays, for both cancer and benign disease. Uncertainties existed around management of patients with rectal bleeding, appropriate strategies for safety-netting, and the value of repeat FIT.

Conclusion: Symptomatic FIT is largely seen as beneficial; however, health professionals would welcome further evidence and guidance around optimal application.

Background: Post-inpatient discharge is a risky time for older patients, especially those with polypharmacy and multi-morbidity. General practice care at this time, including the processes for managing hospital discharge summaries, lacks standardisation and is of variable quality. Understanding these processes will support the design of interventions and guidance to improve general practice management of the post-discharge period.

Aim: Understand and visualise how ongoing care for older people after discharge from hospital is organised in general practice, including the processes for managing discharge summaries.

Design and setting: 10 practices in the West Midlands, England took part in a rapid ethnography in which we mapped their systems of post-discharge care.

Method: Data sources included: informal conversations with staff, practice policies and direct observations of discharge summary handling. Fieldnotes and quotes were subject to an interpretivist framework analysis. A systems modelling technique (FRAM) was used to present visual representations of the professional roles working in these complex systems.

Results: Three basic typographies of system emerged based on professional roles: GP led, Pharmacist led and Administrative led. We report on three themes which weave around the FRAM process maps: comfort with demands of administrative role; general practice team dynamics; and interaction with patients.

Conclusion: General practice systems for inpatient discharge summary processing are complex and varied. New roles in general practices are being used extensively, often requiring significant input in supervision by GPs. Our findings highlight safety features of different systems and should help practices understand the advantages/limitations of models they work within.

Aim: To develop and internally validate a model predicting life-threatening events for out-of-hours primary care callers with shortness of breath.

Method: This cross-sectional study includes data from 1,952 patients with shortness of breath who called out-of-hours primary care between September 2020 and August 2021. Four logistic regression models were developed with life-threatening events as the outcome. We started with a model of age and gender (model 1) and successively added call characteristics (calling at night and someone else calling on behalf of the patient; model 2), symptoms (cough, fever, inability to speak full sentences and wheezing; model 3), and medical history and medication use (cardiovascular and/or pulmonary; model 4). The models were internally validated using optimism correction via bootstrap with 1000 repetitions. Performance measures of discrimination (c-statistic) and calibration (calibration intercept and slope) were determined.

Results: Approximately 17% of callers with shortness of breath had a life-threatening event. Model 3 performed best. This model exhibited good discriminative ability (internal validation c-statistic of 0.764 (95% CI: 0.739 to 0.792)) and was well calibrated. All models had a high net benefit compared to using no model. Models 3 and 4 had a higher net benefit compared with models 1 and 2. As models 3 and 4 were similar in terms of net benefit, the model with fewer parameters (model 3) is preferred.

Conclusion: A prediction model consisting of age, gender, call characteristics, and symptoms holds promise for improving telephone triage of callers to out-of-hours primary care with shortness of breath.