British Journal of General Practice最新文献

Background General practice has a key role in reducing inequity in access to sexual and reproductive health (SRH). Unplanned pregnancy, abortion and STIs are increasing and disproportionately affects deprived communities and ethnic minority groups. The candidacy framework offers a practical, theoretical framework for understanding the complex interactional processes of access to SRH in general practice. Aim To use the candidacy framework to explore access of SRH in general practice. The seven interaction stages include, identification of need, navigation of services, permeability of services, appearing and asserting need, adjudication by healthcare professional, offers or resistance of offer and the local operating conditions or local production of candidacy. Design and setting This study involved a systematic review with qualitative evidence synthesis using a framework approach. Methods A systematic search of MEDLINE, EMBASE, PUBMED, and the Web of Science was conducted to identify primary qualitative research studies exploring access to SRH in general practice from practitioner, public, and patient perspectives in countries with universal healthcare. The candidacy framework was used to synthesise the findings. Results Analysis of 42 studies revealed the impact of stigma, shame, and embarrassment among individuals, communities, and healthcare practitioners. Findings showed limited inclusion of demographics such as ethnicity and socio-economic status. Barriers to access were more evident for those from lower socio-economic communities, ethnic minorities and LGBTQ+. There are multiple barriers, which include the behaviours of healthcare professionals who have a crucial role in recognising an individual's SRH need. Conclusions General practice offers a cradle-to-grave healthcare service, which should have SRH as a priority area of provision. Further understanding is needed of the impact of historic harms by medicine and healthcare on racialised individuals and gender minorities.

Background: UK Asian and black patients experience longer cancer diagnostic intervals - period between initial symptomatic presentation in primary care and cancer diagnosis.

Aim: To determine whether these differences are due to prolonged primary care intervals (period between first primary care presentation and secondary care referral), referral interval (period between referral and first secondary-care appointment) or secondary care interval (period between the first secondary care appointment and diagnosis).

Design and setting: We conducted a cohort study of patients with seven common cancers (breast, lung, prostate, colorectal, oesophagogastric, myeloma, and ovarian), diagnosed after presenting symptoms in English primary care.

Methods: Information on symptom presentation and cancer diagnosis was extracted from cancer registry-linked primary care data. Accelerated failure-time models were used to investigate ethnic differences across all four intervals.

Results: Across all sites, diagnostic intervals were longer for Asian and black patients compared to white patients. Site-specific analyses showed that, for myeloma, lung, prostate, and colorectal, the secondary care interval was longer in Asian and black patients who also had longer primary care interval in breast and colorectal cancer. There was little evidence of ethnic differences in referral interval.

Conclusion: We found evidence of ethnic differences in diagnostic intervals, with prolonged secondary care intervals for four common cancers and prolonged primary care intervals for two. Although these differences are relatively modest, they are unjustified and may indicate shortcomings in healthcare delivery that disproportionately affect ethnic minorities.

Background: Presenting to primary care with fatigue is associated with a wide range of conditions, including cancer, although their relative likelihood is unknown.

Aim: To quantify associations between new-onset fatigue presentation and subsequent diagnosis of various diseases, including cancer.

Design and setting: A cohort study of patients presenting in English primary care with new-onset fatigue during 2007-2017 (the fatigue group) compared with patients who presented without fatigue (the non-fatigue group), using Clinical Practice Research Datalink data linked to hospital episodes and national cancer registration data.

Method: The excess short-term incidence of 237 diseases in patients who presented with fatigue compared with those who did not present with fatigue is described. Disease-specific 12-month risk by sex was modelled and the age-adjusted risk calculated.

Results: The study included 304 914 people in the fatigue group and 423 671 in the non-fatigue group. In total, 127 of 237 diseases studied were more common in men who presented with fatigue than in men who did not, and 151 were more common in women who presented with fatigue. Diseases that were most strongly associated with fatigue included: depression; respiratory tract infections; insomnia and sleep disturbances; and hypo/hyperthyroidism (women only). By age 80 years, cancer was the third most common disease and had the fourth highest absolute excess risk in men who presented with fatigue (fatigue group: 7.01%, 95% confidence interval [CI] = 6.54 to 7.51; non-fatigue group: 3.36%, 95% CI = 3.08 to 3.67; absolute excess risk 3.65%). In women, cancer remained relatively infrequent; by age 80 years it had the thirteenth highest excess risk in patients who presented with fatigue.

Conclusion: This study ranked the likelihood of possible diagnoses in patients who presented with fatigue, to inform diagnostic guidelines and doctors' decisions. Age-specific findings support recommendations to prioritise cancer investigation in older men (aged ≥70 years) with fatigue, but not in women at any age, based solely on the presence of fatigue.

Background: Better continuity in primary and secondary care is linked to improved health outcomes, but it is unclear whether the sociodemographic determinants of continuity are the same in both settings and whether continuity measures in each setting are associated.

Aim: To examine the determinants of relational continuity in general practice (GP) and fragmented outpatient specialty care in people with clusters of Multiple Long-Term Conditions (LTCs) and the association between continuity in each setting.

Design and setting: A cohort of patients ≥18 years registered to general practices in England throughout 2019, and with linked hospital outpatient records. Patients with two or more of 212 LTCs and with at least three GP and three outpatient appointments were included.

Method: The Continuity of Care Index (COCI) was calculated separately for visits to the same i) GP and ii) outpatient specialty and we calculated associations of sociodemographic factors and number of LTCs with COCI scores. We also assessed the association between indices in each setting using univariable and multivariable fractional logit regression.

Results: Of 1,135,903 patients, 56.2% were ≥60 years. Age was the strongest determinant of continuity in GP, whereas number of LTCs was the strongest determinant in secondary care. Although statistically significant (p<0.001) the relationship between the COCI in GP and outpatients was clinically insignificant in both univariable and multivariable models.

Conclusion: We found a lack of strong association between continuity of care in GP and outpatient settings. This suggests that fragmented hospital care is not mitigated by increased continuity in GP.

Background: effectiveness of single disease management programs (DMP) in general practice may be limited for patients with low socioeconomic status (SES), as DMPs insufficiently take into account the specific problems and needs of this population. A Person-Centred Integrated Care (PC-IC) approach focusing on patient's needs could address these problems.

Aim: to explore experiences of patients with (multiple) chronic diseases with regard to the acceptability of a general practice-based PC-IC approach, with a focus on patients with low SES, and to establish which modifications are needed to tailor the approach to this group.

Design and setting: in 2021, a 6 month feasibility study in seven general practices in the Netherlands was carried out. The healthcare professionals provided care based on a PC-IC approach to patients with diabetes, chronic respiratory diseases and/or cardiovascular disorders.

Method: a qualitative study using focus group discussions, in-depth interviews, and semi-structured telephone interviews in a combined total of 46 patients with chronic diseases and multimorbidity, including 31 patients with low SES.

Results: an overall positive experience of participants with the PC-IC approach was observed. Discussing their health made patients feel being taken more seriously, and provided the opportunity to discuss their life and health concerns. Recommended adaptations of the PC-IC approach for patients with low SES include creating comprehensible materials and offering communication training for healthcare professionals.

Conclusion: the PC-IC approach seems helpful for chronic disease patients, provided that it is tailored to their skills and abilities. Several modifications for patients with low SES were suggested.

Background: Presenting to primary care with fatigue is associated with a wide range of conditions, including cancer, although their relative likelihood is unknown.

Aim: To quantify associations between new-onset fatigue presentation and subsequent diagnosis of various diseases, including cancer.

Design and setting: A cohort study of patients presenting in English primary care with new-onset fatigue during 2007-2017 (the fatigue group) compared with patients who presented without fatigue (the non-fatigue group), using Clinical Practice Research Datalink data linked to hospital episodes and national cancer registration data.

Method: The excess short-term incidence of 237 diseases in patients who presented with fatigue compared with those who did not present with fatigue is described. Disease-specific 12-month risk by sex was modelled and the age-adjusted risk calculated.

Results: The study included 304 914 people in the fatigue group and 423 671 in the non-fatigue group. In total, 127 of 237 diseases studied were more common in men who presented with fatigue than in men who did not, and 151 were more common in women who presented with fatigue. Diseases that were most strongly associated with fatigue included: depression; respiratory tract infections; insomnia and sleep disturbances; and hypo/hyperthyroidism (women only). By age 80 years, cancer was the third most common disease and had the fourth highest absolute excess risk in men who presented with fatigue (fatigue group: 7.01%, 95% confidence interval [CI] = 6.54 to 7.51; non-fatigue group: 3.36%, 95% CI = 3.08 to 3.67; absolute excess risk 3.65%). In women, cancer remained relatively infrequent; by age 80 years it had the thirteenth highest excess risk in patients who presented with fatigue.

Conclusion: This study ranked the likelihood of possible diagnoses in patients who presented with fatigue, to inform diagnostic guidelines and doctors' decisions. Age-specific findings support recommendations to prioritise cancer investigation in older men (aged ≥70 years) with fatigue, but not in women at any age, based solely on the presence of fatigue.