BMC primary care最新文献

Background: General practices have been tasked with increasing detection of atrial fibrillation (AF) to reduce stroke. Paroxysmal AF is often missed through usual care but can be detected through screening with repeated ECGs over a period of time using hand-held ECG devices. As part of the drive to detect AF, screening with such devices is being encouraged by both policy makers and industry. It is unclear whether general practice should be leading this effort. Previously, we showed that there was no quantitative difference between a centralised administration and general practice-delivered AF screening programme in terms of the quality and numbers of ECGs generated. Here, we aimed to assess the strengths and weaknesses of each approach using qualitative methods.

Methods: We compared programme delivery by one UK general practice and by a non-clinical centralised administration for two UK general practices in a qualitative study to explore how to conduct screening for AF in a planned trial. From September to December 2020, we conducted semi-structured interviews with 19 staff members. We took field notes of implementation issues arising during observation of 4.5 h of training and collected 15 training evaluation forms. Data were analysed thematically sensitised by the Consolidated Framework for Implementation Research. Analysis focused on the strengths and weaknesses of the different approaches.

Results: While both general practice staff and centralised administrators showed motivation to deliver a screening programme, there were differences in skills and capacity. General practice staff provided continuity of care and offer other care in parallel. They could use relational and communication skills to potentially engage those from underserved communities, but were limited by resources. Centralised administrators, with a singular focus on screening, could deliver a consistently high performance and undertake more complicated administration. Their initial anxieties about communication skills reduce with training and experience.

Conclusions: In screening for AF, primary care and centralised administration demonstrate different strengths and weaknesses. A hybrid approach with centralised screening and primary care signposting, particularly for underserved communities, might be optimal. Awareness of this may help policy makers optimise the use of primary care in the drive to detect AF.

Primary care offers an important pathway for timely diagnosis and treatment of mild cognitive impairment and dementia. Transformative changes require a structured approach to implementation of early diagnosis workflows. Planning, designing, implementing, and sustaining are important aspects of these improvements. A practical approach for health system leaders is provided.

Background: As the COVID-19 pandemic accelerated the uptake of virtual primary care (VPC) in Canada, debates over how it ought to be encouraged or discouraged, governed and paid for have intensified. Within these debates there has been little attention paid to the details of which technologies are being deployed to deliver VPC and how those technologies interact with non-technical factors to ensure efficiency and effectiveness.

Methods: The aims of the study included drawing out pragmatic considerations for policy makers by identifying the various constellations of VPC technology that are being deployed; characterizing how key informants see them working and to what purpose; and describing how those technologies are interacting with non-technical factors to shape success. 29 qualitative interviews were conducted with mid-level VPC experts from the provinces of Alberta, Nova Scotia, and Ontario.

Results: Key informants saw a broad range of VPC technologies as improving access to primary care by increasing efficiency and coordination. They deployed VPC to improve the accessibility, availability, and accommodativeness of care. They described VPC technologies interacting with and relying on: human efforts, funding models, and the institutional contexts for their success.

Conclusions: Policy-makers seeking to optimize VPC will want to consider ways to support not just purchases of technology, but: the human effort required to choose and manage technology; the funding mechanisms that incentivize the efficient use technology; and the institutional contexts and cultures that underpin access improvements through technology.

Background: Less than one in five eligible adults has received lung cancer screening (LCS) with low dose computed tomography in the U.S. We aimed to determine factors associated with intentions to undergo LCS.

Methods: Cross-sectional survey of LCS-eligible English and Spanish speaking adults in two primary care systems in Massachusetts and Oklahoma from 02/2023-05/2024. Surveys assessed smoking, lung cancer and LCS history, attitudes, beliefs, and psychological factors. Associations between these factors and screening intentions were assessed with multivariable logistic regression using bootstrap sampling to select model variables, and latent class analysis plus chi-square tests to measure associations between classes and intentions.

Results: Of 292 LCS eligible survey respondents, most were currently smoking (n = 174, 59.6%), some had previously undergone LCS (n = 115, 39.5%), and 29.5% (n = 86) were 'extremely likely' to screen in the next 12 months. In regression models, having a healthcare provider recommend LCS (odds ratio [OR]: 4.22, 95% confidence interval (CL) 2.40-7.44), being 'somewhat' or 'extremely worried' about getting lung cancer (OR 2.45, 95%CI 1.40-4.32), and speaking English at home (OR 3.54, 95% CI 1.74-7.17) were associated with intention to screen. Four latent classes emerged that varied by age, race, ethnicity, smoking status, screening self-efficacy, perceived risks, and cancer worry. Classes were significantly associated with screening intentions (p < .0001).

Conclusions: Factors associated with LCS intentions highlight opportunities to expand screening. Attending to content for Hispanic adults, increasing discussions of LCS by health care providers, and tailoring communications to incorporate cancer worry could increase use of this life-saving intervention.

Background: Changes in healthcare governance and the rise of evidence-based medicine (EBM) have over the last decades contributed to an increase in guideline-driven management of general practice. There is a lack of recent studies investigating how this continuous development affects the practice of Swedish general practitioners (GPs) from a broad perspective. Thus, this study aims to explore how Swedish GPs relate to management control through guidelines, how it affects their daily practice and work environment, and how they reflect on its consequences.

Methods: We conducted semi-structured, face-to-face interviews during 2024 with 11 GPs from all across Sweden. The transcribed interview data were analysed using thematic analysis.

Results: We constructed three themes, each representing a field of tension created by guidelines: (1) Torn between high ambitions and their resulting negative side effects, (2) Guidelines promote measurable over unmeasurable knowledge, and (3) Although autonomy in relation to guidelines is highly valued, there are compelling reasons to submit. The first theme reflects a broad agreement on the benefits of guidelines and support of the growing ambitions they reflect. However, guidelines also result in increasing work-load and reduce flexibility in healthcare collaboration. The second theme highlights that because guidelines tend to prioritise measurable over non-measurable knowledge, other aspects of GPs' professional skills risk being underused and underdeveloped. The third theme captures how GPs exercise a high degree of autonomy in relation to guidelines, yet occasionally relinquish their clinical discretion. These tensions may result in side-effects such as a deteriorating work environment, crowding-out effects, fragmented healthcare, and potentially reduced quality in areas of general practice that are difficult to measure.

Conclusions: While management control through guidelines entails many benefits, the participants in this study also reported several adverse effects on both the quality of care and the work environment. Promoting quality by organizing healthcare through increasingly complex guidelines may seem like a natural approach in a system that focuses strongly on measuring outcomes, but it is also important for healthcare decisionmakers and guideline developers to acknowledge its potential side effects.

Background: Although support for tobacco smoking cessation provided by general practitioners (GP) has proven effective, such an approach remains quite rare. We designed a behavioural science-based intervention to improve GP support for patients to quit smoking. The present study aimed to evaluate the effectiveness of this in-office paper-based intervention by comparing it with a no-intervention control group.

Methods: We conducted an online randomised controlled trial between January and May 2024 among GPs in France. The intervention consisted in sending a kit containing an information sheet for GPs outlining the main stages of brief advice for smoking cessation, questionnaires for patients asking them about their smoking status and, for those who smoked, their motivation to quit, as well as a poster to be displayed in each GP's waiting room to encourage people who smoke tobacco to complete the questionnaire. The primary outcome was the proportion of people who smoke with whom GPs had discussed smoking cessation on their last full working day five weeks after the kit had been sent out. The secondary outcome was the likelihood that GPs provided cessation support (e.g., prescribed nicotine replacement therapy (NRT), proposed a follow-up consultation, and/or referred patients to other professionals) on the same day.

Results: Of the 800 GPs recruited, 641 fully completed the final survey (333 in the intervention group and 308 in the control group). The proportion of people who smoke with whom GPs had discussed cessation was significantly higher in the intervention group (59.0% vs. 52.3%, p < 0.05). The likelihood of a follow-up consultation being offered to patients who smoke was also significantly higher in the intervention group (73.8% vs. 60.3%, p < 0.05). The likelihood of NRT prescription or referral were not significantly different between groups (82.4% vs. 77.9%, and 23.3% vs. 21.5%, respectively).

Conclusions: Providing simple paper-based tools was associated with a greater likelihood of GPs discussing smoking cessation with their patients. This kind of intervention could usefully complement other primary care interventions, for example training, remuneration and financial incentives or care pathway reorganisation, with a view to significantly decreasing smoking prevalence.

Trial registration: The study was retrospectively registered on 25 November 2024 (ISRCTN10207960).