The experiences of DMS trained GPs and direct entrants in their first 5 years post CCT: a qualitative analysis
DOI: 10.3399/bjgp19X702749
Background
In developing the Ministry of Defence (MoD) First5 network, a database of all Tri-Service doctors in their First5 years post receiving their certificate of completion of training (CCT). However, on building the database, up to 23% of doctors, trained by the MoD were no longer regular service military personal within 5 years of completing their GP training.
Aim
To explore the experience of Defence Medical Services (DMS) trained GPs and direct entrants in in their First5 years post CCT.
Method
An invitation was extended to all GPs currently in the DMS and all those that trained in the Defence Deanery, who gained their CCT between 2011 and 2018. An initial focus group of was conducted, the themes then contributed to the semi-structured interview questions.
Results
Five themes were identified from the focus groups and interviews: Is the apprenticeship model dead? What is my role again? ‘I just don’t think they got the best care they could’ve’. The importance of autonomy and innovation. Should I stay or should I go now?
Conclusion
DMS should work to establish an environment in which all military First5s have autonomy over their practice; the ability innovate; and a forum in which they can share. This must go hand-in-hand with newly qualified military GPs being supported in their management and administrative learning, while being mentored by an engaged colleague to help understand ‘what’s next’ in their portfolio career.
Jodie Blackadder-Weinstein, Academic Department of Military General Practice
Email: jodie.blackadder{at}gmail.com
Michael Smith, Academic Department Military General Practice
Occupational therapy: an emerging role in primary care
DOI: 10.3399/bjgp19X702761
Background
GPs in the UK are under significant pressure in delivering primary care and this has highlighted the need for workforce development. Occupational therapists (OTs) are highly skilled practitioners working across health and social care sectors. Educated at pre-registration level to work with physical and mental health issues, OTs can potentially provide valuable support to GPs. To date OTs are not routinely utilised within primary care. For over 10 years the University of Southampton OT Department has developed placements in a range of settings for students, but never previously in primary care.
Aim
The focus of this study was to determine whether role emerging placements in primary care enhanced the learning of OT students and to consider what can be learned about the role of occupational therapy in primary care.
Method
A case study approach was used to evaluate the project. Methods of data collection for this study included: observation of small group teaching sessions and end of placement interviews with students, educators, and members of the primary care teams involved in the placements.
Results
Analysis of the data indicates OT skills can be utilised in general practice in a number of ways, in certain areas, potentially saving face-to-face consultations with GPs.
Conclusion
OTs are an underutilised profession in frontline primary care. The role of OT has not been well researched as a 'first point of contact' healthcare professional in primary care. OTs' broad training in mental health, physical frailty, and learning disabilities are potentially valuable to service delivery in general practice.
Emily Chamberlain, Southampton GP Education Unit
Email: emilylchamberlain{at}googlemail.com
Juliette Truman, School of Health and Social Care, Bournemouth University
Samantha Scallan, Southampton GP Education Unit
Johnny Lyon-Maris, Health Education England (Wessex)
Amanda Pike, West Hampshire Clinical Commissioning Group
Medical students' perceptions of a career in general practice
DOI: 10.3399/bjgp19X702773
Background
Recruitment into general practice is falling and many training programmes in the UK have unfilled training posts. In 2016 NHS England pledged to increase the number of graduates entering GP training to 50%. However in 2017 only 15.3% of foundation year 2 doctors commenced general practice.
Aim
This work aims to understand medical students’ perceptions of a career in general practice, and how this may affect their career intentions.
Method
As part of a larger, longitudinal study at four UK universities. First and fourth year students were invited to a focus group to discuss their perceptions of a career in general practice. The recordings were transcribed and content analysis was performed.
Results
The perceptions discussed could be broadly grouped into three categories. ‘The GP’ highlighted students’ ideas of the GP as someone who was dedicated, could create rapport, and wanted a family life. The ‘Job of the GP’ indicated students were positive about the continuity of care the job offered, but felt the work was isolating and paperwork heavy. Finally, external factors such as denigration and the ‘GP land’ concept also had an impact on students’ perceptions.
Conclusion
Further work is needed to understand how these perceptions develop, how this may impact students career intentions, and how this research could be used to improve GP recruitment. This data will form part of a wider longitudinal study, the results of which will be analysed for themes and personal narratives of the students.
Kimberley Banner, Newcastle University, Institute of Health and Society
Email: kimberley.banner{at}gmail.com
Hugh Alberti, Newcastle University
Jane Stewart, University of Newcastle
Risk prediction models that use routinely collected electronic health data: generalisable and useful in heterogeneous settings?
DOI: 10.3399/bjgp19X702785
Background
Healthcare sites (practices) may vary in quality of data recording and populations. Risk predictions models that use routinely collected data do not test generalisability to heterogeneous practices.
Aim
To assess the extent of variability between practices on individual patients’ risk of cardiovascular disease (CVD) that is not taken into account by the risk prediction model QRISK3.
Method
A longitudinal cohort study from 1 Jan 1998 to Jan 2015 in 392 general practices (including 3.6 million patients) from the Clinical Practice Research Datalink (CPRD). This was a shared frailty model to incorporate QRISK3 predictors, practice variability, and simulations to measure random variability.
Results
There was considerable variation in data recording between general practices. Practices on 5th percentile of missingness of body mass index have 18.7% patients with missing values and 60.1% on the 95th percentile. The crude incidence rates also varied considerably between practices (from 0.4 to 1.3 CVD events per 100 patient-years, respectively). The estimates of individual CVD risks with the random effect model were inconsistent with the estimated QRISK3 risk. For patients with a QRISK3 CVD risk of 10%, the 95% range of predicted risks were between 7.2% and 13.7% with the random effects model. Random variability only explained a small part of this. The random effects model was similar to QRISK3 for discrimination and calibration.
Conclusion
Risk prediction models that use routinely collected electronic health data can have limited generalisability and accuracy in predicting individual patient risks in heterogeneous settings. They need to be based on more robust evidence on causal risk factors.
Yan Li, Farr Institute for Health Informatics Research University of Manchester
Matthew Sperrin, Farr Institute for Health Informatics Research University of Manchester
Miguel Belmonte, Farr Institute for Health Informatics Research University of Manchester
Alexander Pate, Farr Institute for Health Informatics Research University of Manchester
Darren Ashcroft, Pharmacoepidemiology, University of Manchester
Tjeerd Van Staa, Farr Institute for Health Informatics Research University of Manchester
Email: tjeerd.vanstaa{at}manchester.ac.uk
An audit on the use and utility of midstream specimen of urine cultures in general practice
DOI: 10.3399/bjgp19X702797
Background
A midstream specimen of urine (MSU) culture is a diagnostic test commonly used to guide the management of suspected lower urinary tract infections (LUTI). Inappropriate use of MSUs leads to unnecessary treatment of asymptomatic bacteriuria, delayed antibiotic prescriptions, and increased costs.
Aim
This audit investigates the use of MSUs in a primary care practice in Birmingham before and after an educational intervention designed to increase adherence to guidelines.
Method
All MSUs sent during June and July 2017 for non-pregnant adults were audited. Patient demographics, request details, indications, dipstick results, and relevant prescriptions were extracted from the electronic record. Clinical management was compared with the National Institute for Health and Care Excellence (NICE) quality standard QS90. Results were presented to practice staff; training based on QS90 was given and supported by new management algorithms. Re-audit was then undertaken over another 2-month period.
Results
The audit included 157 samples, with a further 138 samples in the re-audit. The proportion of MSU samples that were clinically indicated increased from 66% to 77% following the educational intervention. Suspected LUTI was the most common indication in both audit cycles: 68% and 64% respectively. Adherence to QS90 increased from 68% to 84% and improvements were seen among both doctors (71% to 78%) and practice nurses (36% to 55%).
Conclusion
Educational intervention and the introduction of management algorithms improved adherence to NICE QS90. There is scope for enhancement with further education and uptake of management algorithms. The cohort is small and limited to one practice, but could easily be repeated on other sites.
Bethany Shears, University of Birmingham
Email: bcs366{at}student.bham.ac.uk
Samuel Finnikin, University of Birmingham
GPs’ decisions about prescribing anticipatory medicines at the end of life: a qualitative study
DOI: 10.3399/bjgp19X702809
Background
GPs have a central role in decisions about prescribing anticipatory medications (AMs) to help control symptoms at the end of life. Little is known about GPs’ decision-making processes in prescribing AMs and the subsequent use of prescribed drugs.
Aim
To explore GPs’ decision-making processes in the prescribing and use of AMs for patients at the end of life.
Method
A qualitative interpretive descriptive enquiry with a purposive sample of 13 GPs working across one English county. Data was collected in 2017 via semi-structured interviews and analysed inductively using Braun and Clarke’s thematic analysis.
Results
Three themes were constructed from the data: 1) ‘Something we can do’: AMs were a tangible intervention GPs felt they could offer to provide symptom relief for patients approaching death. 2) ‘Getting the timing right’: the prescribing of AMs was recognised as a harbinger of death for patients and families. GPs preferred to prescribe drugs weeks before death was expected, while recognising this meant that many prescribed AMs were never used. 3) ‘Delegating care while retaining accountability’: GPs relied on nurse to assess when to administer drugs and keep them updated about their use.
Conclusion
GPs view AMs as key to symptom management for dying people. AMs are routinely prescribed even though they are often not used. In order to feel comfortable delegating care, GPs need regular access to nurses and trust in their skills to administer drugs appropriately. Patient and family experiences of AMs, and their preference for involvement in decision-making about their use warrant urgent investigation.
Ben Bowers, The Primary Care Unit, Institute of Public Health, University of Cambridge School of Clinical Medicine
Email: bb527{at}medschl.cam.ac.uk
Kristian Pollock, Faculty of Medicine and Health Sciences, University of Nottingham,
Sam Barclay, The Primary Care Unit, Institute of Public Health, University of Cambridge School of Clinical Medicine
Stephen Barclay, The Primary Care Unit, Institute of Public Health, University of Cambridge School of Clinical Medicine
Measuring the effectiveness of embedding social workers in integrated primary health care teams working with older adults with complex needs
DOI: 10.3399/bjgp19X702821
Background
Despite the policy agenda for health and social care collaboration currently focused on integrated care systems, there is limited evidence that examines whether embedding social workers in integrated primary health and social care teams working with older adults is effective.
Aim
The study aimed to establish whether embedding social workers in integrated primary care teams (IPCTs) for older adults in Nottinghamshire was cost-effective.
Method
A mixed methods approach collected quantitative and qualitative data that was triangulated using a TRI-Q model. Cost and care quality data were collected from patients in receipt of social worker involvement in three different IPCTs. Patients with similarly complex needs, who were receiving involvement from social work only district teams in the same localities acted as a comparator group. Interviews were conducted with patients and carers and with social workers and GPs working in the IPCTs. Seven focus groups were conducted with IPCT members representing social work and health disciplines.
Results
The cost data were analysed using ANCOVA to identify any significant differences in costs across the teams. The result showed costs in two of the IPCTs were significantly lower than controls. Care quality indicators were also greater in these IPCTs. Thematic analysis highlighted the important of knowledge exchange that arose from social work embeddedness as indicative of the optimal conditions for effective integrated working and care delivery to be achieved.
Conclusion
The findings suggested that embedding social workers in IPCTs offers both higher quality and more cost-effective care for older people if the optimum conditions for integration are met.
Di Bailey, Nottingham Trent University
Gabriella Mutale, Nottingham Trent University
Email: gabriella.mutale{at}ntu.ac.uk
Improving access and continuity in general practice: practical and policy lessons
DOI: 10.3399/bjgp19X702833
Background
Improved access to general practice is seen by policy makers as essential to address patient expectations and reduce demand for A&E, but little is known about its impact on continuity.
Aim
This study examined the impact of policies to improve access on continuity and described practical approaches to delivering both improved access and continuity.
What is the evidence that continuity within general practice benefits patients, or is important to health professionals?
Which primary care patients are more likely to want continuity of care, and how likely are they to report receiving it?
How might policy initiatives to improve access affect continuity of care, and to what extent is there evidence of this?
What factors might best support continuity of care in the context of improved access?
Method
A rapid literature review, semi-structured interviews with providers and one commissioner, and two expert workshops were combined, with quantitative analysis of practice-level data and 2017 GP Patient Survey data.
Results
Various sociodemographic and clinical factors shape patients’ desire for, and ability to obtain, continuity. We will present the limited evidence available on the impact of improved access on continuity and describe practical approaches to support continuity across three broad areas: service design, workforce development, and technology.
Conclusion
It is possible to offer both improved access and continuity if this is an explicit objective of service redesign. Commissioners and policymakers should attach greater priority to continuity and commission further research to understand the longer-term impacts of improved access and working at scale on continuity, patient experience, and wider outcomes.
Nina Hemmings, Nuffield Trust
Email: nina.hemmings{at}nuffieldtrust.org.uk
Rebecca Rosen, Nuffield Trust
William Palmer, Nuffield Trust
Eilis Keeble, Nuffield Trust
Sally Williams, Inquisit Ltd
Charlotte Paddison, Nuffield Trust
Candace Imison, Nuffield Trust
ARRIVE: Ambulance paramedics Responding to urgent patient Requests In general practice for home Visits — Evaluation development
DOI: 10.3399/bjgp19X702845
Background
In response to rising demand for health care and limited availability of GPs, paramedics are increasingly working in general practices, most commonly to carry out home visits. UK policy supports this change which involves role substitution across professional groups and sectors of care. In Wales, schemes have been introduced over the past few years, with various configuration, employment, and governance arrangements, but we do not know the risks and benefits of Paramedics working in Primary Care (PPC), or which model works best. There is an urgent need to better understand the PPC innovation.
Aim
To describe the evidence base, theoretical underpinning and current initiatives; and determine the feasibility of undertaking a definitive evaluation of PPC in order to produce generalisable evidence to inform policy and practice.
Method
A survey of Welsh Health Boards has been undertaken to identify sites and stakeholders to take part in qualitative interviews. A feasibility study will be conducted with three GP practice sites: one with a directly-employed paramedic; one with a Welsh Ambulance Service-employed paramedic; and a control site. Data will be collected for the following outcomes: 1) number of home visits requested; 2) home visit outcomes (the proportion resolved, further home visit required, emergency admission, 999 call placed); 3) prescribing patterns; 4) subsequent healthcare contacts; 5) patient satisfaction; 6) serious adverse events; and 7) cost profile.
Results
Welsh Health Board survey and qualitative findings will be available at the time of the conference.
Conclusion
We will submit an application for a fully powered application to NIHR HS&DR if indicated by our progression criteria.
Jenna Jones, Swansea University
Email: jennabulger{at}hotmail.co.uk
Mark Kingston, Swansea University
Timothy Driscoll, Swansea University
Adrian Edwards, Cardiff University
Bridie Evans, Swansea University
Ather Hussain, Swansea University
Mari James, Patient and Public Involvement
Lesley Griffiths, Patient and Public Involvement
Grayham Mclean, Welsh Ambulance Services NHS Trust
Leigh Keen, Welsh Ambulance Services NHS Trust
Ceri Phillips, Swansea University
Alison Porter, Swansea University
Helen Snooks, Swansea University
Alan Watkins, Swansea University
Cluster randomised feasibility trial to test the routine use of the Needs Assessment Tool: Cancer (NAT:-C) in primary care to reduce unmet patient and carer needs and determine the feasibility of a definitive trial
DOI: 10.3399/bjgp19X702857
Background
People with cancer commonly have unidentified palliative care needs. The NAT-C is a validated tool to identify and triage unmet needs.
Aim
To assess the feasibility and acceptability of a primary care cRCT of the NAT-C: 1) recruiting four GP-practices and 40–60 patients, 2) uptake of NAT-C, 3) questionnaire completion 4) acceptability of measures.
Method
A non-blinded cRCT with process evaluation. Patients with active cancer were identified through cancer registries or opportunistically. Carers were nominated by patient-participant. Participants completed measures at baseline, 1, 3, and 6 months. Patients booked a 20-minute GP-assessment post-baseline. Patients, carers, and GP practice staff participated in interviews and focus groups.
Results
Five GP practices were approached, four recruited and trained in the use of the NAT-C. Practices were randomised (1:1) to provide a consultation with a known NAT-C trained clinician, or a clinician as usual. Forty-seven patients and 17 carers were recruited. Process evaluation informed refinement of study invitations. Recruitment rate showed a trial was feasible. Forty-three (94%) patients received a study appointment, 42/43 (95%) attended and 32/43 (76%) a NAT-guided consultation. The proposed primary outcome measure (Supportive Care Needs Survey) was completed by 43 (91%) at 1 month and the proportion with ≥1 moderate–severe unmet need fell from 72% (baseline) to 45%. Fifteen patient interviews and four focus groups with GP practices were conducted. Participants supported the definitive trial and found measures acceptable.
Conclusion
A definitive cRCT is feasible based on the recruitment rate, intervention uptake, and data collection.
Joseph Clark, Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull
Email: joseph.clark{at}hyms.ac.uk
Elvis Amoakwa, Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull
John Blenkinsopp, University of Northumbria
David Currow, Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull
Amanda Farrin, Leeds Institute of Clinical Trials Research, University of Leeds
Robbie Foy, Leeds Institute of Health Sciences, University of Leeds
Una Macleod, Hull York Medical School, University of Hull
David Meads, Leeds Institute of Health Sciences, University of Leeds
Alexandra Wright-Hughes, Leeds Institute of Clinical Trials Research, University of Leeds
Miriam Johnson, Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull
Skill mix in primary care: the scale and distribution of skill mix in GP practice across England
DOI: 10.3399/bjgp19X702869
Background
Decades of under investment in primary care and inattention to suboptimal recruitment and retention of GPs and nurses have contributed to a workforce crisis. The General Practice Forward View sets out how the government is planning to achieve a strengthened model of general practice. A key element of this proposal is to expand the workforce by employing an increasingly diverse range of practitioners i.e. ‘skill mix’. The commitment to broadening skill mix in primary care is reiterated in the NHS Long Term Plan (LTP), with the announcement of a 5-year deal to boost investment in primary care. A significant proportion of this investment focuses on increasing the number of ‘new’ roles such as clinical pharmacists, physiotherapists, physician associates, and paramedics.
Aim
This presentation offers an early analysis of the scale and distribution of current skill mix in general practice across England. This is part of a wider study about how skill mix is affecting outcomes, costs, and experiences of healthcare in England.
Method
Descriptive analysis of a longitudinal practice-level workforce data set using the practice-level workforce Minimum Data Set (wMDS).
Results
We will present early findings about how staffing has changed and average changes within a region or a clinical commissioning group.
Conclusion
These data will indicate the extent of progress towards achievement of the LTP vision of skill mix employment. Findings will inform our future analysis of the structures, contexts, and processes of these new ways of working and provide policymakers, commissioners, and practices with evidence about the wider effects of skill mix.
Imelda McDermott, University of Manchester
Email: imelda.mcdermott{at}manchester.ac.uk
Sharon Spooner, University of Manchester
Jon Gibson, University of Manchester
Matt Sutton, University of Manchester
Mark Hann, University of Manchester
Kath Checkland, University of Manchester
Damian Hodgson, University of Manchester
Anne McBride, University of Manchester
Investigating the impact of case-mix on general practice cancer diagnostic outcome indicators
DOI: 10.3399/bjgp19X702881
Background
The Cancer Services profiles report indicators of cancer diagnostic activity for all English general practices. A recent study reported that several indicators were dominated by chance, with some practice-level variation explained by the practice’s age-sex profile.
Aim
To assess the variation explained by patient-level case-mix and whether the practice age-sex profile adequately adjusts for this.
Method
Five indicators from Cancer Waiting Times (2016/17, 6050 practices) or Routes to Diagnosis (2015, 6355 practices) data were considered: Two Week Wait (TWW) conversion and detection rates, and emergency-, referred- and other-diagnosis proportions. Mixed-effect logistic regression adjusted for patient-level case-mix, using national cancer registration data on age, sex, deprivation, referral/cancer-type and, where possible, ethnicity and stage at diagnosis, with and without practice-level age-sex profile.
Results
Chance explained 60–85% of practice-level variation, with the combination of chance and patient-level case-mix explaining 75% (TWW conversion rate) to 89% (emergency diagnosis proportion). For TWW conversion rate, there was considerable overlap in the variance explained by practice- and patient-level factors. For the other indicators, practice- or patient-level factors were largely independent.
Conclusion
Chance is not synonymous with case-mix and is the dominant source of variation in single-year practice indicators. Therefore, we recommend the continued aggregation of data over multiple years. For most studied indicators, adjustment for the age-sex profile of the whole practice population is not a substitute for case-mix of individual cancer patients and so should not be used. Patient-level case-mix adjustment leads to a modest reordering of practices and so may not be a priority.
Carolynn Gildea, Public Health England
Email: carolynn.gildea{at}phe.gov.uk
Georgios Lyratzopoulos, University College London
Sean McPhail, Public Health England
Ruth Swann, CRUK-PHE Partnership
Gary Abel, University of Exeter
A randomised controlled trial of the effect of providing online risk information and lifestyle advice for the most common preventable cancers
DOI: 10.3399/bjgp19X702893
Background
Prevention offers an effective public health strategy for cancer control. One approach that could be incorporated within general practice is the provision of personalised risk information. Few trial data are available concerning the impact of cancer risk information on behaviour.
Aim
To assess the short-term effects on computed cancer risk and self-reported health-related behaviours of providing personalised cancer risk information.
Method
A total of 1018 participants, recruited through the online platform Prolific, were randomised to either a control group receiving cancer-specific lifestyle advice alone or one of three intervention groups receiving the same lifestyle advice alongside their estimated 10-year risk of developing one of the five most common preventable cancers. Cancer risk was calculated from self-reported behavioural risk factors and presented in one of three formats: bar-chart, pictograph, or qualitative scale. The primary outcome was change from baseline in computed risk relative to an individual with a recommended lifestyle (RRI) at 3 months. Secondary outcomes included: self-reported health-related behaviours, accuracy of risk perception, risk conviction, anxiety, worry, intention to change behaviour, self-efficacy, and response-efficacy.
Results
At immediate follow-up, accuracy of risk perception (P<0.001), risk conviction (P <0.001), and response-efficacy (P = 0.04) increased in all intervention groups. After 3 months there were no between-group differences in change in RRI (P = 0.68) or any of the secondary outcomes.
Conclusion
This study has shown that a risk communication intervention can increase short-term risk accuracy and response efficacy and for the first time that risk conviction can be manipulated through risk communication. However, these effects were not sustained over time or associated with behaviour change.
Golnessa Masson, The Primary Care Unit, Institute of Public Health, University of Cambridge School of Clinical Medicine
Email: golnessa.masson{at}nhs.net
Katie Mills, Primary Care Unit, Institute of Public Health, University of Cambridge
Simon J Griffin, Primary Care Unit, Institute of Public Health, University of Cambridge
Stephen J Sharp, MRC Epidemiology Unit, Institute of Metabolic Science, University of Cambridge
William MP Klein, Behavioral Research Program, National Cancer Institute
Stephen Sutton, Behavioural Science Group, The Primary Care Unit, Institute of Public Health, University of Cambridge School of Clinical Medicine
Juliet A Usher-Smith, The Primary Care Unit, Institute of Public Health, University of Cambridge School of Clinical Medicine
Evaluation of a countywide alternative to QOF, aimed at improving person-centred coordinated care
DOI: 10.3399/bjgp19X702905
Background
The Quality Outcomes Framework (QOF) for general practice is one of the largest pay-for-performance schemes in the world. The scheme, however, is sometimes viewed as anachronistic, with recent proposals for a slimmed down QOF. Over the last few years, Somerset have been trialling a system with national implications: 55 GP practices in Somerset established the Somerset Quality Practice Scheme (SPQS) — a de-incentivisation of QOF — with the goal of redirecting resources towards improved Person Centred Coordinated Care (P3C), especially for those with long-term conditions.
Aim
An evaluation of the SPQS scheme to establish benefits (for example in provision of P3C) or disbenefits (for example in emergency admissions).
Method
A longitudinal evaluation from 55 SPQS practices and 17 regional controls. Patient experiences (2363 patients), staff experiences (127 professionals), and organisational data (for SPQS and control practices) were collected. Emergency admission data was analysed for ambulatory-sensitive conditions across Somerset.
Results
Discretion from QOF resulted in time savings in the majority of practices. Organisational data revealed a significant increase in P3C. Care delivery was improved via stronger federation-level agreements and informal networks, increased multidisciplinary working, reallocation of resources for other healthcare professionals and changes to the structure and timings of GP appointments. Patient and practitioner experiences were similar in SPQS versus control practices. No disbenefits were detected in admissions data.
Conclusion
The SPQS scheme leveraged time savings and reduced administrative burden via discretionary removal of QOF, enabling participating practices to engage in a number of schemes aimed at improving care for people with LTCs.
James Close, University of Plymouth
Email: james.close{at}plymouth.ac.uk
Ben Fosh, University of Plymouth
Richard Byng, University of Plymouth
Richard Blackwell, South West Academic Health Science Network
Louise Witts, South West Academic Health Science Network
Louise Hall, South West Academic Health Science Network
Helen Lloyd, University of Plymouth
What is the evidence behind guideline recommendations to monitor chronic diseases in UK primary care?
DOI: 10.3399/bjgp19X702917
Background
More than half of tests ordered by GP practices are to monitor long-term conditions such as high blood pressure, diabetes, and chronic kidney disease (CKD). There is a large variation in ordered tests between GP practices, suggesting some tests may not be appropriate. Unnecessary testing should be avoided as it can generate anxiety for patients, increase workload for doctors, and increase costs for the health service.
Aim
The objective was to review monitoring strategies for hypertension, type 2 diabetes, and CKD patients and to investigate the evidence-base underlying these recommendations.
Method
Current UK guidelines on the relevant diseases were reviewed. Any guidance on the use of laboratory tests for disease monitoring (not including drug monitoring recommendations), the recommended frequency of testing, as well as the level of evidence on which the guidance was based was extracted.
Results
Guidelines for the use of monitoring tests in primary care for hypertension, diabetes, and CKD are unclear and incomplete; for example, recommended frequency of testing varied between guidelines or was not specified at all. Current recommendations for monitoring chronic diseases are largely based on expert opinion; robust evidence for optimal monitoring strategies and testing intervals is lacking.
Conclusion
In the absence of clear evidence, clinicians should consider which tests are likely to influence patient management and should ensure that there is a clear clinical rationale for each test that they perform. Future research should address what the optimal strategy for monitoring chronic conditions consists of, and how it can be evaluated.
Martha Elwenspoek, NIHR CLAHRC West / University of Bristol
Email: martha.elwenspoek{at}bristol.ac.uk
Rita Patel, NIHR CLAHRC West / University of Bristol
Jessica Watson, NIHR CLAHRC West / University of Bristol
Ed Mann, Tyntesfield Medical Group, Bristol
Katharine Alsop, Nightingale Valley Practice, Bristol
Penny Whiting, NIHR CLAHRC West / University of Bristol
‘Just asking the question’: a qualitative study of health professionals’ experiences and perceptions of recording torture in vulnerable migrants in primary care settings
DOI: 10.3399/bjgp19X702929
Background
A large proportion of vulnerable migrants may be survivors of torture, with complex health needs as a result; yet there is a lack of guidance or understanding of how to identify and record signs of torture. Clinical professionals in primary care are in a unique position to care for and support this patient population.
Aim
The primary aim of this study was to explore the primary care context of how signs of torture could be better recorded to support patients and meet their needs.
Method
This was a qualitative research study conducted through remote interviews with health professionals from a range of clinical backgrounds and experience of working with survivors of torture.
Results
Twelve health professionals participated in the study, with results analysed using applied thematic analysis. Seven themes were identified, ranging from the barriers to asking about and disclosing torture, the underlying purpose of doing so, political factors affecting this issue and various ways to potentially improve recording torture.
Conclusion
Before clinical professionals can record torture, they must first ask the patient about it as survivors are unlikely to raise the topic themselves. Many clinical professionals lack the awareness or confidence to do this, thereby warranting further discussion on strategies to educate clinical professionals about torture. Accessible guidance and a simple, systematic method to identify survivors of torture which is suitable for a primary care setting is necessary, with suggestions for further research including routine enquiry and targeted screening.
Gemma Whyatt, Brighton and Sussex Medical School
Email: gemma{at}objenix.com
Max Cooper, Brighton and Sussex Medical School
Feasibility, acceptability, and content of video consulting in primary care
DOI: 10.3399/bjgp19X702941
Background
Government leaders have called for increased use of video-consulting (VC) in clinical practice. Although provided by the private sector, it is rarely used in NHS primary care. It is unclear how VC differs from telephone (TC) or face-to-face consulting (FTFC), or how useful clinicians and patients find it.
Aim
To assess the feasibility and acceptability to patients and clinicians of running a VC service in general practice and to explore differences in duration and content compared with FTFC and TC.
Method
VC equipment was installed in six GP practices and 13 clinicians were asked to identify patients who required follow-up consultations and who had access to a smart-device or laptop. They were offered the choice of a VC, TC, or FTFC. Consultations were audiorecorded and content analysed using the RIAS system. Patient and clinician views were obtained by questionnaires and interviews.
Results
One hundred and forty-seven patients were recruited (FTFC = 51, TC = 51, VC = 45). VC users were generally younger. VCs and TCs were shorter (mean VC 5.9, TC 5.6, FTFCs 9.6 minutes), addressed fewer problems (mean VC 1.5, TC 1.7, FTFC 2.0) and had less information exchange than FTFCs. Technical problems were common, but VCs offered significant advantages over TC in terms of non-verbal communication. VC was considered particularly useful to working and housebound people and for those with mental health problems.
Conclusion
VC has distinct advantages over TC. When integrated into current systems VC will provide an alternative to FTFC. Where formal physical examination is not required (discussing test results, medication changes and mental health) it offers considerable time savings to patients.
Eddie Donaghy, University of Edinburgh
Vicky Hammersley, University of Edinburgh
Helen Atherton, University of Warwick
Annemieke Bikker, University of Edinburgh
Hannah Mcneilly, University of Edinburgh
John Campbell, University of Exeter
Brian McKinstry, University of Edinburgh
Email: brian.mckinstry{at}ed.ac.uk
GPs' views about their role when children and young people disclose a history of bullying in the community: a qualitative study
DOI: 10.3399/bjgp19X702953
Background
Bullying among children and young people (CYP) can lead to both physical and mental health consequences. CYP may disclose episodes of bullying and seek help from their GP. Therefore GPs have an important role in dealing with the mental and physical health consequences of bullying. However, there is currently little research on GPs’ views and perceptions on their role in dealing with bullying.
Aim
To explore GPs views about their role in dealing with disclosures of bullying by CYP.
Method
Semi-structured interviews were conducted with GPs in England. Purposive sampling was used to achieve variation in GP demographics. Data were collected until thematic saturation was reached and analysed using the constant comparative method.
Results
Data from 14 semi-structured interviews revealed three main themes: GP experience, bullying in schools and cyberbullying, and training needs. There was an encompassing feeling that dealing with disclosures of bullying came down to a GP’s clinical experience rather than guideline recommendations, which do not currently exist; and that bullying was a precipitating factor in presentations of CYP’s mental health issues. Continuing professional development opportunities are needed. Such opportunities should include both the nature and health consequences of bullying, including cyberbullying, for which GPs felt ill prepared but which was reported to affect their practice.
Conclusion
GPs feel they have a role to play in managing and supporting the health of CYP who disclose bullying. However, they feel ill equipped in dealing with these disclosures. There is a need for collaboration between GPs and education services to improve support.
Vibhore Prasad, King's College London
Email: vibhore.prasad{at}kcl.ac.uk
Laura Condon, School of Medicine, University of Nottingham
GPPCOS: exploring women’s experience of the management of PCOS in general practice
DOI: 10.3399/bjgp19X702965
Background
Polycystic ovarian syndrome (PCOS) affects up to one in five women, with the diagnosis and management mostly occurring in general practice. The condition can affect many parts of a woman’s physical and mental health. Recent evidence shows that women often experience a delay in diagnosis and that there is a high rate of underdiagnosis.
Aim
To research patients’ perspectives as to how PCOS is managed in general practice, whether it is being viewed as a ‘multisystem’ condition rather than just one of fertility, and how the long-term effects of the syndrome are being addressed.
Method
A questionnaire was designed to investigate women’s experience of how PCOS is being diagnosed, treated, and managed in general practice, including consideration of its longer-term potential consequences. Women were signposted to the questionnaire through websites/social media of four charities/patient support networks and BBC Radio Leicester.
Results
In total 333 women completed the questionnaire. Only 12% of women recalled having been told by a GP about the risk of developing diabetes and none recalled being told about endometrial hyperplasia. Although 74% felt PCOS had impacted on their mental health only 39% had discussed this with their GP. In 116 cases (35%) women did not recall their weight being addressed despite having a body mass index of ≥25.
Conclusion
PCOS appears not to be viewed as a chronic metabolic condition, with women not able to recall being told of their higher risks for comorbid conditions. Concurrent mental health problems are often not being addressed.
Sarah Hillman, University of Warwick
Email: sarahchillman{at}hotmail.com
Jeremy Dale, University of Warwick
Carol Bryce, University of Warwick
Plugging in the safety gaps: an exploration of patients’ attitudes towards an integrative approach to gathering safety information via Electronic Health Records (EHRs)
DOI: 10.3399/bjgp19X702977
Background
It is now widely accepted that patients can meaningfully provide feedback on the safety of their care, and recent efforts have concentrated on novel ways of gathering this feedback. Increasingly, patients are encouraged to access their electronic health record (EHR), with access associated with improved patient satisfaction and enhanced patient safety through identifying medication errors.
Aim
With a view to developing a novel intervention to gather safety information from patients in primary care, this study aimed to explore patients’ views on the feasibility and acceptability of inputting feedback on care experiences directly into their EHR.
Method
A qualitative design and opportunity sampling strategy was used. Fifteen primary care users participated in semi-structured interviews which focused on inputting feedback into EHRs. Thematic analysis was utilised to analyse transcribed interviews.
Results
The majority of participants were interested in viewing their EHR and felt they would benefit from providing feedback about their care experiences directly into their EHR. Three key themes were identified: monitoring EHR for improvement; security of EHR; and centralising EHR across care settings. Specific barriers and levers were recognised within each theme.
Conclusion
Allowing patients to have access to their EHR has the potential to improve patient experience and safety from a primary care user perspective. Nevertheless, there are barriers to consider such as, potential to increase staff workload as additional capacity may be required to interpret and act on feedback to produce service improvements.
Abigail Albutt, Bradford Institute for Health Research
Email: abigail.albutt{at}bthft.nhs.uk
Gemma Louch, Bradford Institute for Health Research
Jane O'Hara, Bradford Institute for Health Research
Katy Shire, Bradford Institute for Health Research
Binish Khatoon, Bradford Institute for Health Research
Do South Asian Communities 'Act FAST'?
DOI: 10.3399/bjgp19X702989
Background
Rapid medical assessment and treatment of patients with transient ischemic attack (TIA) or stroke significantly reduces the risk of recurrent stroke. Previous research has shown that delays to initial medical assessment are due to lack of an urgent response to symptoms. In comparison to other communities living within the UK, South Asians have a higher risk of stroke/TIA. Therefore, it is critically important to explore stroke/TIA knowledge and anticipated response to symptoms, within this community.
Aim
This study aims to provide preliminary evidence of stroke knowledge and awareness of the relaunched ‘Act FAST’ campaign in the South Asian community and to provide evidence of successful participant recruitment from 'hard to engage' groups.
Method
A pilot mixed methods study, incorporating focus group discussions and a short ‘tick box’ style paper survey, designed to assess and explore participant knowledge of stroke/TIA symptoms, and awareness of the relaunched 'Act FAST' campaign. Barriers and facilitators to stroke education and the suitability of mass-media campaigns are also discussed during the focus groups. All participants were recruited from places of worship.
Results
The authors will present highlights from the ‘on-going’ study including; the recruitment strategy, barriers and facilitators to recruitment in Sikh temples and preliminary findings from 68 completed surveys. Highlights from the focus group discussions will be presented, alongside participant suggested methods to improve stroke/TIA knowledge in Indian communities.
Conclusion
Preliminary findings suggest awareness of stroke symptoms in the Indian community, but less awareness of TIA. Non-English speakers may be less aware of ‘Act FAST’.
Dawn Coleby, Coventry University
Email: ac7301{at}coventry.ac.uk
Nick Taub, University of Leicester
Amit Mistri, University Hospitals of Leicester
Andy Turner, Coventry University
Jane Coad, Coventry University
Petra Wark, Coventry University
Krishna Bhatti, Coventry University
Kusminder Chahal, Coventry University
Wei-Peng Teo, Deakin Institute
University of Limerick — Graduate Entry Medical School, General Practice Quality Assurance Initiative
DOI: 10.3399/bjgp19X703001
Background
At 18 weeks duration, University of Limerick — Graduate Entry Medical School (UL–GEMS) has the longest general practice clinical attachment for medical students in Ireland and fulfils the educational criteria for a Longitudinal Integrated Clerkship (LIC).The longer the clinical placement the greater the imperative to see that these practices achieve satisfactory educational standards.
Aim
This project describes a quality assurance initiative of general practices that participate in the education of medical students at GEMS.
Method
A literature review of previous quality assurance initiatives in relation to general practices that teach medical students was performed. Information gained from this process was then compared with UL-GEMS own criteria for teaching general practices. A set of criteria by for assessing teaching general practices was devised. The assessment process included a combination of self-assessment by the GP tutors and practice visits by the UL-GEMS teaching staff.
Results
Nearly 100% of teaching practices had the correct teaching facilities, such as own room for the student or own computer. Suggested teaching methods, such as parallel consulting, as advised by the Department of General Practice were carried by 100% of practices. Use of the two-way feedback form and the GP/Student manual was poor. GP tutors requested more regular visits form the GP teaching staff as well as more guidance on content for formal tutorials so that a consistency teaching approach could be achieved.
Conclusion
This was the first quality assurance initiative on an extended clinical placement. The knowledge gained will lead to a more inclusive standard setting process for teaching medical students in general practice settings.
Aidan Culhane, Department of General Practice, Graduate Entry Medical School, University of Limerick
Email: drculhane1{at}eircom.net
Patrick O'Dwyer, Department of General Practice, Graduate Entry Medical School, University of Limerick
Andrew O'Regan, Department of General Practice, Graduate Entry Medical School, University of Limerick,
Liam Glynn, Department of General Practice, Graduate Entry Medical School, University of Limerick
An exploration of the views and training status of GPs in Ireland on termination of pregnancy following its legalisation
DOI: 10.3399/bjgp19X703013
Background
In May 2018, abortion laws in Ireland were liberalised allowing medical abortion for the first time. It was envisaged that Irish GPs would provide this service.
Aim
To elicit the views and level of preparedness of Irish GPs to provide medical termination of pregnancy.
Method
In total 222 practising GPs were surveyed. Participants are affiliated with the Graduate Entry Medical School (GEMS) in the University of Limerick, as well as graduates of the University Specialist Training Programme in General Practice.
Results
The response rate was 57% (127/222): 93.7% of GPs were willing to share abortion information with their patients; 48.0% would be willing to prescribe abortion pills before 12 weeks’ gestation, with 37.0% unwilling to do so. A further 40.9% of responders believed that such a service should not be part of general practice, with a further 17.3% indicating uncertainty. 72.4% believed that those who do not wish to be part of the process should be entitled to a conscientious objection (CO) but should also be obliged to refer a woman to a participating doctor. Over four-fifths (82.7%) of GPs had no training in this area of practice, with 3.2% indicating that they had sufficient training. The majority of responders feel that necessary support services such as counselling are not currently available.
Conclusion
Exploring the views and experiences of GPs in Ireland on this topic reveals many issues which need to be resolved before the service can be rolled out in a safe manner. It will be vital for state and professional bodies to provide appropriate education and guidance.
Raymond O'Connor, Department of General Practice, Graduate Entry Medical School, University of Limerick
Email: raymond.oconnor{at}ul.ie
Eimear Spain, Graduate Entry Medical School, University of Limerick
Jane O'Doherty, Department of General Practice, Graduate Entry Medical School, University of Limerick
Michael O'Mahony, Student Counselling Service, University of Limerick
Active participation of ‘real-time’ patients in undergraduate medical education: a qualitative study
DOI: 10.3399/bjgp19X703025
Background
The ‘patient’s voice’ is increasingly emphasised in educational strategies. However, much of this has focused on patients who have been recruited to have a primary educational role. Students also benefit from interaction with ‘real-time’ patients who attend the clinical settings with diverse health problems. The involvement of these patients does not usually extend to having an active part in the learning encounter, where the patient completes a potential triadic relationship with the clinical teacher and student.
Aim
To identify ways to enhance the active participation of ‘real-time’ patients in medical students’ training.
Method
Focus groups were conducted with patients, who were selected purposively from an earlier questionnaire survey. The discussions were audiorecorded, transcribed, and analysed using thematic analysis.
Results
A total of twenty-three participants attended four focus groups in general practices across the North East of England. Patient involvement in medical education may be described using Communities of Practice theory. Patients’ role within the educational Community of Practice is mainly peripheral. Factors affecting their active involvement may operate at the micro level (individual teaching consultation), organisational level, or within the NHS. Issues identified include patients’ awareness about medical education, ambiguity about their role, attitude of the doctor, and processes for consent and feedback.
Conclusion
This research has provided insights into patients’ perspectives towards their involvement in medical education. The data may provide evidence for a practical framework to encourage and prepare patients to play an active role in educational processes.
Adedoyin Alao, Newcastle University
Email: adedoyin.alao{at}nhs.net
Bryan Burford, Newcastle University
Susan Hrisos, Newcastle University, Institute of Health and Society
Hugh Alberti, Newcastle University
David Kennedy, Newcastle University
Roger Barton, Newcastle University
Gillian Vance, Newcastle University
Impact of a diagnostic decision support system on GP clinical documentation
DOI: 10.3399/bjgp19X703037
Background
Kostopoulou and colleagues designed and evaluated a diagnostic decision support system (DSS) that presented GPs with differential diagnoses to consider at the start of the consultation. The DSS was integrated with the electronic health record (EHR) and evaluated in simulated consultations (34 GPs consulting with 12 actors), where it was found to improve diagnostic accuracy.
Aim
To evaluate the impact of the DSS on GP clinical documentation.
Method
Secondary data analysis. The analysis dataset consisted of all data items that the 34 GPs recorded during their consultations with the 12 actors (408 consultations). Each GP had conducted six consultations with the EHR alone, and six with the integrated DSS. The 12 patient scenarios had a pre-defined set of clinical cues and differential diagnoses. For each patient scenario, a Delphi panel of five GPs identified which cues were consistent with each differential diagnosis. The data items recorded, either in free text or code, were counted. These were referenced against the Delphi panel’s matrix of cues and diagnoses. For each GP, it was estimated what proportion of the recorded data was consistent with the diagnosis that they finally gave.
Results
Using the DSS increased the total amount of information documented (b = 3.58 [95% confidence interval {CI} = 2.81 to 4.35] P<0.001) and reduced the proportion of documentation that was consistent with the GP’s final diagnosis (b = –0.08 [95% CI = –0.11 to –0.05] P<0.001), suggesting less bias.
Conclusion
Using the DSS led to more complete and less biased documentation. This has implications for the use of routine EHR data to create clinical prediction rules.
Chris Tracey, Imperial College London
Email: chris.tracey{at}doctors.org.uk
Brendan Delaney, Imperial College London
Olga Kostopoulou, Imperial College London
Developing a safety-netting intervention for the earlier diagnosis of cancer in primary care: the Shared Safety Net Action Plan (SSNAP)
DOI: 10.3399/bjgp19X703049
Background
Diagnosing cancer earlier broadens treatment options and improves survival outcomes. When symptoms do not indicate a cancer diagnosis referral, evidence suggests patients could play an important role in achieving a faster cancer diagnosis by assisting with symptom follow-up and review. Little is known about how to engage patients in diagnosis and what a safety-netting intervention involving patients in primary care might entail.
Aim
Stage 1 assessed components considered important for patient involvement in diagnosing cancer earlier in primary care and explored three possible strategies. Stage 2 aimed to co-design a safety-netting intervention with and for primary care patients and professionals.
Method
Stage 1 involved a systematic review, thematic analysis of 15 interviews with GPs, nurse practitioners and patients and a dissemination workshop with 18 stakeholders. For intervention development and refinement, stage 2 involved 3 stakeholder workshops using co-design processes; five focus groups with patients and primary care practices, underpinned by COM-B Framework.
Results
Stage 1: the systematic review found no interventions involving patients. Interviews identified three key themes for patient involvement: keeping the door open; roles and responsibilities; and fear of cancer. Ideally, safety-netting should involve verbal discussion and plan, written information, and optional post-consultation prompt. Stage 2: barriers and facilitators of capability, opportunity and motivation to use the intervention were identified. A safety-netting intervention for primary care was co-produced, the Shared Safety Net Action Plan (SSNAP).
Conclusion
Key components for patient involvement and safety-netting were identified. SSNAP is acceptable to patients and health professionals and assessment of feasibility in practice is now required.
Jane Heyhoe, Bradford Institute for Health Research
Email: jane.heyhoe{at}bthft.nhs.uk
Caroline Reynolds, Bradford Institute for Health Research
Rebecca Lawton, University of Leeds
Intervention to reduce vitamin testing in primary care: a randomized controlled trial
DOI: 10.3399/bjgp19X703061
Background
Although vitamin tests are increasingly ordered by GPs, an evidence-based indication is often lacking.
Aim
To rationalise and reduce ordering of vitamin D and B12 tests by educating GPs and their patients about the merits and pitfalls of performing vitamin tests.
Method
A two-armed cluster randomised study assessing the effectiveness of two separate interventions on the number of vitamin tests ordered. In total 26 health centres in the Netherlands participated (200 000 patients). De-implementation group 1 received education and a 3-monthly benchmarking of their own vitamin test ordering behaviour. De-implementation group 2 received the same intervention, but supplemented with educational material for patients. The primary study endpoint was the total reduction in vitamin D and B12 tests ordered at the end of the study as compared to a 1-year pre-intervention period. Secondary outcomes were the number of deficient test results, the number of (high dose) vitamin prescriptions, and the direct cost savings.
Results
The number of vitamin D tests ordered at the end of the 1-year study period as compared to a 1-year pre-intervention period decreased with 23%. For vitamin B12 tests an overall reduction of 20% was found. Adding patient information had additional value over training and benchmarking of GPs, which was significant for vitamin D (–29% with and –19% without patient information), compared to respectively –22% and –18% for vitamin B12.
Conclusion
A structured intervention programme, including training of GPs and benchmarking their ordering of diagnostic tests, resulted in a significant reduction in ordered vitamin tests.
Saskia Van Vugt, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht
Evelien de Schepper, Department of General Practice Erasmus Medical Centre Rotterdam
Email: e.deschepper{at}erasmusmc.nl
Niek De Wit, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht
Patrick Bindels, Department of General Practice Erasmus Medical Centre Rotterdam
National Cancer Diagnosis Audit: avoidable delays to diagnosis
DOI: 10.3399/bjgp19X703073
Background
A prolonged time taken to diagnose cancer can lead to poorer survival and reduced quality of life. Characterising avoidable delays to a patient’s diagnosis could help to direct quality improvement initiatives aimed at enhancing patient safety and ultimately patient outcomes.
Aim
To assess the validity of data on avoidable delays collected as part of the English National Cancer Diagnosis Audit (NCDA) and to estimate the predictors of avoidable delays to diagnosis by patient demographics and cancer type.
Method
Participating general practices (n = 439; 5% practices) submitted primary care data on patients (n = 17 042) diagnosed with cancer in 2014 in England. GPs reported delays to the diagnosis that they considered avoidable. Quantile regression was used to understand the impact of an avoidable delay on the diagnostic interval. Logistic regression models were used to investigate the factors associated with avoidable delay.
Results
The GP recorded an avoidable delay to cancer diagnosis in 24% of cases (n = 3372). The median diagnostic interval was 57 days longer in patients where an avoidable delay was recorded. Results have shown significant associations between avoidable delay and certain cancer types (odds ratio [OR] 1.73 for stomach versus lung cancer) and an increasing number of comorbidities (OR 1.43 for patients with ≥3 versus 0).
Conclusion
GP-reported data showed a longer diagnostic interval in patients thought to have had an avoidable delay to their diagnosis, indicating construct validity of the data collected. Data from the NCDA is being used to better understand avoidable delays to diagnosis, and identify possible solutions for improving the diagnostic pathway in some cases.
Ruth Swann, CRUK-PHE Partnership
Email: ruth.swann{at}phe.gov.uk
Georgios Lyratzopoulos, University College London
Greg Rubin, University of Newcastle
Elizabeth Pickworth, Public Health England
Sean McPhail, Public Health England
The evaluation of large-scale collaborations between primary care general practices
DOI: 10.3399/bjgp19X703085
Background
General practice is under mounting pressure to ensure its future sustainability. Collaborations between GP practices are perceived as one way to respond to these pressures and they have been mandated by The NHS Long Term Plan.
Aim
The aim of this study was to investigate the facilitators, barriers, impacts, and costs associated with collaboration.
Method
A rapid evidence assessment was carried out between September and November 2018. Publications over the last 20 years were eligible for inclusion if they were in English and covered any high-income OECD country. Publications between 1998 and 2012 inclusive, were limited to reviews only. No methodological restrictions were applied to publications between 2013 and 2018. A total of 52 publications were included for final data extraction (36 academic and 16 grey literature).
Results
Facilitators of GP collaboration include strong leadership, external support, trusting relationships, clear roles and objectives, and mutual shared history/vision. Barriers to collaboration were tied to an absence of key elements such as lack of clarity, core skills, time, human resources, trust, financial support, face-to-face interactions, and leadership. Positive impacts of collaboration included the delivery of high-quality health care, better clinical health outcomes, and improve employee satisfaction while negative impacts included challenging GP autonomy, feeling overwhelmed by workload, and a reduction of continuity of care for patients.
Conclusion
There are numerous facilitators to GP collaboration. Barriers are often present as an absence of facilitators. Further research is needed to evidence the impact(s) and cost-effectiveness of GP practice collaboration.
Amelia Harshfield, RAND Europe
Email: aharshfi{at}rand.org
Natasha Elmore, RAND Europe
Jon Sussex, RAND Europe
Routine health monitoring and preventative care for people with dementia in UK primary care
DOI: 10.3399/bjgp19X703097
Background
UK National Dementia Strategies prioritise fair access to dementia treatment for all. It has been shown that people from black and minority ethnic (BME) groups are diagnosed later and those are less likely to receive anti-dementia medication.
Aim
It is hypothesised that access to primary care services post diagnosis is also reduced in ethnic minority groups.
Method
The Health Improvement Network (THIN) database of UK primary care records was analysed between 2015 and 2016, all patients with dementia were identified, and health service use was compared. Annual GP consultations, blood pressure (BP), weight/body mass index (BMI), Quality and Outcomes Framework (QOF) dementia review, and flu vaccination recordings were compared between ethnic groups.
Results
Over 20 000 individuals with a dementia diagnosis aged 50–105 years were included. There was no significant difference between white, black, and Asian groups across all outcomes. Overall 80% received an annual BP check, 86% received at least one annual GP consultation, 68% received an annual dementia review, and 48% had a weight/BMI recorded. People with dementia who did not have cardiovascular risk factors were less likely to have their BP checked (59%) and be seen by a GP.
Conclusion
There do not appear to be ethnic inequalities in primary care service use post-dementia diagnosis. The overall proportion receiving an annual dementia review and weight check was low, despite recommendations that a care plan should be reviewed annually (including nutrition as a key priority). Post-diagnosis support and preventative care should be prioritised in general practice for all people living with dementia.
Cini Bhanu, University College London
Email: c.bhanu{at}ucl.ac.uk
Mary Elizabeth Jones, University College London
Kate Walters, University College London
Irene Petersen, University College London
Claudia Cooper, University College London
Implementation of social prescribing to reduce frequent attender consultation rates in primary care
DOI: 10.3399/bjgp19X703109
Background
The impact of social determinants on health has been established. Evidence shows that addressing social needs through link workers can improve wellbeing and consultation rates. This is of importance since demand on primary care appointments is high and access to primary care is pivotal to the NHS as a whole.
Aim
To evaluate whether frequently-attending patients who might benefit from social prescribing, can be recognised through a computer search of risks for isolation, loneliness, or social pressures and whether a social intervention has an effect on wellbeing and consultation rate.
Method
Patients highlighted as frequent attenders (≥20 GP/nurse practitioner [NP] appointments in past 12 months) were screened for appropriateness of referral to link worker. A social risk tool was applied to select patients most at risk of social isolation. Patients who agreed had a pre- and post-intervention wellness score calculated. Number of appointments pre- and post-intervention were also recorded and matched by month. Post-intervention questionnaires allowed collation of qualitative data analysing patient opinions of the scheme.
Results
There was an average increase in wellbeing score post-intervention of 0.8/5. The average reduction in appointments for GPs and NPs combined was 5.1 appointment/patient (37% reduction) at 6 months and 12.9 appointments/patient at 1 year (53% reduction).
Conclusion
The numbers in this project are small, but it supports the growing evidence that social prescribing can improve patient well-being and sustained reduced demand for GP and NP appointments. It supports the suggestion that computer searches can delineate a high-risk population.
Adam Jeyes, University of Birmingham
Laura Pugh, Cape Hill Medical Centre
Email: lpugh{at}nhs.net
Health experiences of asylum seekers and refugees in Wales
DOI: 10.3399/bjgp19X703121
Background
The numbers of asylum seekers and refugees in Wales have recently increased sharply, but we know little of their health experiences.
Aim
To investigate asylum seekers’ and refugees’ experiences of health care, especially what helped or hindered.
Method
Eight volunteer peer researchers were recruited from asylum-seeking and refugee communities; and trained to run the quantitative survey. They worked in small groups with support from team members. The Statistical Package for Social Sciences (SPSS) was used to describe, analyse, and present results.
Results
The 210 responders included 90 known refugees, 89 known asylum seekers, and 11 known to have been refused asylum. Although 79% of responders reported attending an initial health assessment on arriving in Wales, and 94% reported that they were currently registered with a GP, only 36% found it easy or very easy to make an appointment with their GPs. Awareness of services was mixed: best known was the 999 service, with 77% reporting that they knew how to access it. Sixty-six per cent reported using health care in working hours, and 28% reported use out of hours. Key influences on these statistics included knowledge of the NHS and how to navigate it, language barriers, and cultural factors.
Conclusion
This study provides valuable insight into asylum seekers’ and refugees’ experiences of health care. Together with our complementary qualitative study it suggests that a compassionate approach to providing care, building on existing good practice, and with additional resources for training and support services, can reduce healthcare inequalities for asylum seekers and refugees.
Ian Russell, Swansea University
Email: i.t.russell{at}swansea.ac.uk
Ashrafunessa Khanom, Swansea University
Gill Richardson, Public Health Wales
Daphne Russell, Swansea University
Rebecca Scott, Public Health Wales
Helen Snooks, Swansea University
Evaluating the use of CKD trigger tools across practices in east London: a qualitative study in primary care
DOI: 10.3399/bjgp19X703133
Background
Early identification of people with chronic kidney disease (CKD) in primary care, enables proactive clinical management. CKD trigger tools designed as patient safety tools, alert GP practices when falling estimated glomerular filtration rates (eGFR) are identified from the patient record. The tool’s aim is to alert clinicians to possible CKD progression, and invites written reflection by the GP of the ‘referral’ or ‘non-referral’ outcomes of patients identified.
Aim
To evaluate how the CKD trigger tool is used across practices in east London. To examine how the differences in the practitioner use and perceived value of the tool is characterised by interview transcripts, compared with the written reflections.
Method
Eight semi-structured interviews were undertaken with six GPs, one pharmacist, and one practice manager. The reflection free-text data were organised into categories, of ‘yes’ and ‘no’ referrals, dividing further each category by ‘young’ and ‘old’ cases. Thematic analysis was applied to the interview transcripts. Arising themes were supplemented by the descriptive analysis of the reflection.
Results
In total 1921 reflection comments were examined, 1770 ‘No’ referrals (935 aged <60 years) and 151 ‘Yes’ referrals (81 aged <60 years), covering a 2-year period. Four themes emerged from the interviews: ‘Getting started …’, ‘Workflow’, ‘Trigger tool as a learning tool’, and ‘Patient safety’.
Conclusion
The study highlights that administratively well organised practices found that the tool could be readily embedded into their workflow. Reflection data highlighted cases of poorly controlled diabetes and/or hypertension for the ‘yes–young’ referrals. Generally, ‘No’ referrals emphasised the implementation of a clinical management plan.
Vian Rajabzadeh, Queen Mary University of London
Nicola Thomas, London South Bank
Email: nicola.thomas{at}lsbu.ac.uk
Sally Hull, Queen Mary University of London
Can a mobile app improve mental health service use in 16–25-year olds? An analysis of Afloat
DOI: 10.3399/bjgp19X703145
Background
Seventy-five per cent of mental health conditions arise before the age of 18 years. However, 18–24-year olds are the least likely to receive care. Barriers to accessing treatment in this group are thought to include a lack of awareness of available services and stigma. eHealth is a strong means of connecting with this vulnerable group.
Aim
To develop a mobile app which facilitates access to mental health care for young people and to assess its potential impact on service use.
Method
In total 127 participants aged 16–25 years and living in the UK were recruited. Questionnaires were used to assess their mental health status, mental health literacy, resource use, barriers to support, and confidence levels. They were then each invited to download the new Afloat app. After using the app for 3 months these parameters were reassessed via follow-up questionnaires.
Results
Preliminary results from 57 participants showed that 50% of users said they would be more likely to seek help for mental health issues and 50% had more confidence to do so as a result of Afloat. The majority of users said that the app had no impact on their service use. For all services including mental health specialist, GP, medication, online support/apps and hospital/A&E Afloat was more likely to increase rather than decrease service use. The remaining responses are being analysed.
Conclusion
The app may help to increase mental health service use in this cohort. A longer trial with qualitative analysis would help to ascertain if these changes were sustained and appropriate.
Komal Chadha, London School of Economics
Email: komalchadha{at}doctors.org.uk
The earlier identification of mental health problems in children and young people in primary care using their linked GP-hospital records
DOI: 10.3399/bjgp19X703157
Background
Attention deficit hyperactivity disorder (ADHD) is a common neurodevelopmental disorder affecting 3–5% of the population of children and young people (CYP). CYP with mental health problems report long delays in the diagnosis of mental health problems. ADHD is recognised in just under 1% of children and young people in English primary care and qualitative work suggests that parents (carers) report to their GPs prior to obtaining a diagnosis of ADHD but a detailed knowledge of reasons for presenting to health care is lacking.
Aim
To ascertain the reasons for attendance to health care for CYP with compared to CYP without ADHD.
Method
Using the Clinical Practice Research Datalink (CPRD) with linked Hospital Episodes Statistics (HES) data, all medical records for CYP with ADHD were extracted. Up to five CYP without ADHD were selected at random matched by age, sex, and GP practice. All GP and hospital medical records were extracted and inspected in the 2 years prior to the date of diagnosis of ADHD in the index case.
Results
There were 8135 CYP with ADHD and 40 614 CYP without ADHD. Medical records from GP, hospital diagnosis codes, and operative procedure codes have been extracted. A description of the reasons for attendance to healthcare in the 2 years prior to diagnosis (index date) will be presented at the conference.
Conclusion
A detailed knowledge of reasons for attendance to healthcare for CYP with versus CYP without CYP will assist GPs, paediatrics, educationalists, and CYP's parents (carers) may help to identify ADHD earlier than is currently possible.
Vibhore Prasad, King's College London
Email: vibhore.prasad{at}kcl.ac.uk
Fertility awareness based contraceptive apps: a case study in the digital age
DOI: 10.3399/bjgp19X703169
Background
Fertility awareness based (FAB) contraceptive mobile applications (apps) rely on women logging their menstrual cycle data to predict non-fertile days. Paid social media advertisements for these apps have led to hundreds of thousands of downloads. This rapidly expanding market lacks quality assurance, reflective of wider issues surrounding innovation versus regulation of digital health interventions.
Aim
To present the results of a literature review carried out to bring together data on FAB contraceptive apps, to better understand the validity of evidence for their use as contraceptive methods. This is combined with context on the climate of advertising and regulation, to illustrate the challenges of innovation in the digital age.
Method
Databases Medline and Embase were searched according to the strategy: ‘fertility-based awareness AND app*’. Eight articles were included in the final thematic analysis.
Results
This study found apps being used for contraception that were not developed for this purpose; apps inaccurately reporting reliability for preventing pregnancy; there is a need for further training for women using FAB contraceptive apps; and there are limitations of current evidence base and challenges to improving this. In the context of poor regulation and advertising loop holes there is significant risk of misleading users of FAB contraceptive apps.
Conclusion
The limited evidence on FAB contraceptive apps should be applied to the public with caution. Incongruities between women’s understanding and expectations of FAB apps compared to reality demonstrate the need for robust regulation around paid advertising, issues echoed elsewhere with other digital health interventions.
Lara Shemtob, Royal Free Hospital NHS Trust
Email: lara.shemtob{at}nhs.net
Rebecca Littlewood, Whittington Health NHS Trust
Home-based rehabilitation for heart failure with reduced ejection fraction: the REACH HF multicentre RCT
DOI: 10.3399/bjgp19X703181
Background
Cardiac rehabilitation (CR) improves health-related quality of life (HRQOL) and reduces hospitalisations in patients with heart failure (HF), but international uptake of CR for HF remains low.
Aim
To compare the REACH-HF (Rehabilitation EnAblement EnAblement in CHronic Heart Failure) intervention: a facilitated self-care and home-based CR programme to usual care (UC) for adults with HF with reduced ejection fraction (HFrEF) and to assess the long-term cost-effectiveness of the intervention. The primary hypothesis was that the addition of the REACH-HF intervention to UC would improve disease-specific HRQOL (Minnesota Living with Heart Failure questionnaire [MLHFQ]) at 12 months compared with UC alone.
Method
Multicentre randomised trial.
Results
There were 216 participants: 78% male, average age 70 years, and mean left ventricular ejection fraction of 34%. Overall, 185 (86%) participants provided data for the primary outcome. At 12 months, there was a significant and clinically meaningful between-group difference in the MLHFQ score of –5.7 points (95% CI = –10.6 to –0.7) in favour of the REACH-HF intervention group (P = 0.025). The mean cost of the REACH-HF intervention was £418 per participant, which was associated with a per patient mean quality-adjusted life year (QALY) gain of 0.23 and an increased mean cost of £400 compared with usual care, resulting in a cost per QALY gained of £1720.
Conclusion
The REACH-HF facilitated intervention was clinically superior in disease-specific HRQoL at 12 months and economic modelling shows that it is cost-effective. REACH-HF offers an affordable alternative to traditional centre-based programmes to address current low CR uptake rates for HF.
Hasnain Dalal, University of Exeter Medical School
Email: h.dalal{at}nhs.net
Rod Taylor, Institute of Health Research, University of Exeter Medical School
Variation in tests for people with type 2 diabetes, hypertension, or chronic kidney disease in UK primary care
DOI: 10.3399/bjgp19X703193
Background
Rates of pathology testing are rising in the UK, with significant geographical variability. Around 50% of overall GP laboratory testing represents monitoring for chronic conditions such as high blood pressure, type 2 diabetes, and chronic kidney disease (CKD). Overuse of tests for monitoring chronic conditions may be a potential source of harm; causing patient anxiety, downstream tests/referrals, overdiagnosis, increase GP workload and increase health service costs. On the other hand, failure to test may lead to missed diagnoses, complications, patient harm and litigation.
Aim
This study aims to use an open cohort to examine current variation in the use of tests for individuals with type 2 diabetes, hypertension, and CKD>2 across the UK.
Method
Clinical Practice Research Datalink (CPRD) data will be used to consider what tests have been ordered for people with these conditions and look at variation over time, and by region, age, sex, ethnicity, and socioeconomic position using age–sex-standardised utilisation rates, descriptive statistics, and multilevel Poisson regression.
Results
An estimated 1.2 million patients within the CPRD database have previously been diagnosed with any of the chronic conditions with over 11 million tests. Some 1 029 496 patients have hypertension, 344 613 with diabetes, and 271 897 with CKD>2, with much overlap. The results from this study will help to find what tests are currently used among patients with these conditions and to quantify variation in testing.
Conclusion
This work will be used to inform the development of testing algorithms for patients with these conditions in primary care.
Rita Patel, NIHR CLAHRC West / University of Bristol
Email: rita.patel{at}bristol.ac.uk
Martha Elwenspoek, CLAHRC West
Jessica Watson, NIHR CLAHRC West / University of Bristol
Ed Mann, Tyntesfield Medical Group, Bristol
Katharine Alsop, Nightingale Valley Practice, Bristol
Penny Whiting, NIHR CLAHRC West / University of Bristol
Physical activity for treatment of irritable bowel syndrome: Cochrane systematic review
DOI: 10.3399/bjgp19X703205
Background
Current recommendations for patients with irritable bowel syndrome to partake in physical activity do not incorporate evidence from all available randomised control trials (RCTs), with little information regarding potential adverse effects.
Aim
To assess the benefits and harms of physical activity interventions in adults diagnosed with irritable bowel syndrome.
Method
Ten electronic databases including CENTRAL, MEDLINE and EMBASE were searched until 24 November 2017 for RCTs comparing a physical activity intervention with no intervention, usual care, or another intervention; assessing a validated measure of symptoms, quality of life (QoL), and bowel movement in any setting.
Results
Nine RCTs with data for 326 participants were included. Interventions included yoga (n = 5), advice and support (n = 2), treadmill exercise (n = 1), and Qigong (n = 1) compared with usual care (n = 4), walking (n = 2), diet (n = 1), or medication only (n = 2). A meta-analysis of three studies demonstrated a large and statistically significant improvement in reported IBS symptoms (standardised mean difference –1.06, 95% confidence interval = –2.08 to –0.04; N = 84). However, evidence was rated as very low quality, providing very little confidence in the effect estimate. In additional meta-analyses, physical activity did not conclusively demonstrate improvements in QoL or abdominal pain. The quality of evidence was judged very low and low respectively, providing little confidence in the effect estimates. There was insufficient evidence to assess adverse effects due to poor trial reporting.
Conclusion
A small body of low to very-low quality evidence suggests physical activity may improve symptoms but not QoL or abdominal pain in people with irritable bowel syndrome but findings are uncertain.
David Nunan, University of Oxford
Email: david.nunan{at}phc.ox.ac.uk
José M Ordóñez-Mena, University of Oxford
Nia Roberts, University of Oxford
Elizabeth Thomas, University of Oxford
Kamal Mahtani, University of Oxford
The incidence, prevalence, and management of plantar heel pain in Dutch general practice
DOI: 10.3399/bjgp19X703217
Background
Plantar heel pain (PHP) is a common cause of foot complaints, but information on the occurrence in primary care is scarce.
Aim
The objective of this study was to determine the incidence and prevalence of PHP and to gain insight in types of treatments provided to patients with PHP in primary care.
Method
A cohort study was conducted in a healthcare database containing the electronic general practice medical records of approximately 1.9 million patients throughout the Netherlands. A search algorithm was defined and used to identify cases of PHP in the years 2013–2016. Descriptive statistics were used to obtain the incidence and prevalence of PHP. Data on the management of PHP was extracted in a random sample of 1000 patients.
Results
The overall incidence of PHP was 3.81 (95% confidence [CI] = 3.75 to 3.87) per 1000 patient years and the overall prevalence of PHP was 0.4374% (95% CI = 0.4369 to 0.4378). Incidence of PHP peaked in the last quarter of every calendar year. The GP applied a wait-and-see policy at the first consultation for PHP in 18.0% of patients. The most commonly applied interventions included prescription for NSAID (19.9%), referral to a paramedical podiatric specialist (19.7%), and advice to wear insoles (16.4%): 34.0% of patients received multiple interventions (range 2–11) and 30.9% had multiple consultations for PHP (range 2–8).
Conclusion
PHP appears to be common in primary care. Despite a lack of evidence for most treatments, multiple interventions are applied. This urges the need for future research on effectiveness of treatments.
Nadine Rasenberg, Department of General Practice, Erasmus Medical Centre Rotterdam
Email: n.rasenberg{at}erasmusmc.nl
Sita MA Bierma-Zeinstra, Department of General Practice, Erasmus Medical Centre Rotterdam
Patrick Bindels, Department of General Practice, Erasmus Medical Centre Rotterdam
Johan van der Lei, Department of Medical Informatics, Erasmus Medical Centre Rotterdam
Marienke Van Middelkoop, Department of General Practice, Erasmus Medical Centre Rotterdam
Socioeconomic deprivation and benzodiazepine/Z-drug prescribing: a cross-sectional study of practice-level data in England
DOI: 10.3399/bjgp19X703229
Background
Benzodiazepines and Z-drugs (such as zopiclone) are widely prescribed in primary care in England. Prescribed for various indications, such as anxiolysis and insomnia, it has been previously reported that an association may exist with deprivation.
Aim
To determine whether there was an association between benzodiazepine/Z-drug prescribing (overall, and by individual drug) and practice-level socioeconomic deprivation in England.
Method
Monthly primary care prescribing data for 2017, as well as practice age and sex profile, were downloaded from NHS Digital. Prescribing was aggregated by year. Drug doses were converted to their milligram-equivalent of diazepam to allow comparison. Practice-level Index of Multiple Deprivation (IMD 2015) scores were obtained from Public Health England. Multiple linear regression was used to examine the association between IMD and prescribing (for all benzodiazepines/Z-drugs, and individually), after adjusting for practice sex (% male) and older age (% >65 years) distribution. Practice-level prescribing was defined as milligrams of diazepam-equivalent per 1000 registered patients in 2017.
Results
On univariate analysis, overall benzodiazepine prescribing was positively associated with practice-level IMD score, with more prescribing in more deprived practices (P<0.001). After adjusting for practice age and sex profile, IMD score remained an independent predictor of prescribing levels (P<0.001). These associations were consistent for all benzodiazepines/Z-drugs when analysed separately.
Conclusion
Higher practice-level socioeconomic deprivation, as described by IMD score, was associated with increased benzodiazepine/Z-drug prescribing. This may, in part, be a reflection of an underlying association of the indications for prescribing and socioeconomic deprivation. Further work is required to more accurately define the underlying reasons for these associations.
Stephanie Soyombo, University of Warwick
Harpal Aujla, University of Warwick
Rhian Stanbrook, Medwyn Surgery, Surrey
David Capewell, Outwood Park Medical Centre, Wakefield
Mary Shantikumar, Central Surgery, Rugby
Daniel Todkill, University of Warwick
Saran Shantikumar, University of Warwick
Email: saran.shantikumar{at}warwick.ac.uk
A qualitative evaluation of a Clinical Effectiveness Scheme in London
DOI: 10.3399/bjgp19X703241
Background
Clinical Effectiveness Southwark (CES) is a London-based primary care Quality Improvement (QI) scheme with the aim of improving clinical quality across local general practice. In order to improve patient outcomes in selected long-term conditions, a team of four GPs, working with other professionals, developed condition-based short guides, clinical templates, and other educational interventions.
Aim
A mixed methods evaluation of the processes and impact of CES in its implementation and operation phases.
Method
In the first year, qualitative methods were used which included 18 interviews, one focus group and observation of 53 meetings, educational events and teleconferences. The data were analysed thematically using NVivo software. The result of surveys with local clinicians about their use of CES guides are reported.
Results
In the first year since formation, CES produced seven clinical guides and three templates. Six months after the launch of the first three guides, 57% of the survey responders reported using at least one guide in their practice. Electronic templates took longer than expected to develop. The existence of other (typically online) guidelines and a wish for even shorter, more concise, guides were among the reasons reported by those who did not use the guides on a regular basis.
Conclusion
There is a demand from GPs and nurses for high quality, well-written, short, easy to use, local guides for various conditions.
Guy Shefer, King's College London
Email: guy.1.shefer{at}kcl.ac.uk
Maria Kordowicz, King's College London
MEDREV: feasibility study of a combined pharmacy–health psychology intervention to improve care for people with dementia with behaviour that challenges in care homes
DOI: 10.3399/bjgp19X703253
Background
‘Behaviour that Challenges’ is common in older people with dementia in care homes and treated with antipsychotics. Policy is focused on reducing the use of antipsychotics in people with dementia and therefore reducing harm. This submission reports results on a NIHR-funded feasibility study MEDREV.
Aim
To assess the feasibility of medication review by a specialist dementia care pharmacist combined with staff training with the objective of limiting the inappropriate use of psychotropics.
Method
Care homes were recruited. People meeting the inclusion (dementia; medication for behaviour that challenges), or their personal consultee, were approached. A specialist dementia care pharmacist reviewed medication and made recommendations. Care staff received a 3-hour training session promoting person-centred care and GPs’ brief training. Data were collected on recruitment and retention, and implementation of recommendations. Other outcomes included the Neuropsychiatric Inventory-Nursing Home version, quality of life (EQ-5D/DEMQoL), cognition (sMMSE), and health economic (CSRI). Qualitative interviews explored expectations and experiences.
Results
Medication reviews were conducted in 29 of 34 residents recruited and the pharmacist recommended reviewing medication in 21 of these. Fifteen (71.4%) of these were antidepressants: 57.1% (12 of 21) of recommendations were implemented and implementation took a mean of 98.4 days. Non-implementation themes for will be presented. One hundred and sixty-four care staff received training (care homes = 142; primary care = 22). Twenty-one participants (care home managers = 5; GPs = 3; nurses = 2; care staff = 11) were interviewed.
Conclusion
The study was feasible, although the approach would need modification to improve the uptake of reviews and reduce the delay in implementation. Most of the recommendations related to antidepressants.
Ian Maidment, Aston University on behalf of the MEDREV team
Email: i.maidment{at}aston.ac.uk
The Safer Prescription of Opioids Tool (SPOT) — a novel clinical decision support digital health platform for opioid conversion in palliative and end-of-life care: a single centre pilot study
DOI: 10.3399/bjgp19X703265
Background
Opioid conversion is complex and currently performed manually using tables of approximate equivalence, often in high pressure clinical situations. Apps that offer opioid dose conversion are available but there are concerns about their accuracy, reliability, and clinical validation.
Aim
The study evaluated a novel opioid dose conversion app, The Safer Prescription of Opioids Tool (SPOT), as a clinician decision support (CDS) platform. The secondary objective was to use SPOT to describe patterns of opioid dose conversion in palliative and end-of-life care.
Method
This prospective clinical utility single-centre pilot study followed a mixed methods design. Prescribers completed an initial survey exploring their current opioid prescribing practice. Thereafter prescribers used SPOT for opioid dosage conversions in parallel to their usual clinical practice. Lastly, prescribers evaluated SPOT through a survey and focus group. SPOT was evaluated using clinical data across primary, secondary and tertiary care in palliative care and end of life care settings at a Scottish Health Board in both out-of-hours and in-hours.
Results
SPOT correctly matched the Gold Standard result in 258 of 268 (96.3%) calculations. Users had a statistically significant increase in confidence in prescribing opioids after using SPOT. A majority (62%) of conversions were for cancer pain. Focus group feedback highlighted perceived benefits in Quality Improvement and Safety when using SPOT.
Conclusion
SPOT is a safe, reliable and validated CDS that has significant potential to reduce harms from opioid dosing errors, particularly in primary care, including rural primary care, and the out-of-hours setting.
Roger Flint, NHS Tayside
Email: rflint{at}nhs.net
Scott Jamieson, Angus Health and Social Care Partnership
Dean Buchanan, NHS Tayside
S Botros, NHS
Joanna Forbes, NHS
Sir Alfred Cuschieri, Scuola Superiore Sant’Anna
J George, NHS Tayside
Learning from diagnostic error when primary care services are located in or alongside emergency departments: a theory generating mixed-methods study
DOI: 10.3399/bjgp19X703277
Background
New healthcare service models are being introduced to help manage increasing demand on emergency healthcare systems including the provision of primary care services in or alongside emergency departments. There is little research evidence to guide decisions about how service models can be most effective and safe.
Aim
Focusing on diagnostic error, the aim was to learn why errors occur to identify priority interventions.
Method
Two data sources were used to identify diagnostic error reports including: coroners’ reports to prevent future deaths; and the National Reporting and Learning System (NRLS). A cross-sectional, mixed-methods theory-generating study which used a multi-axial PISA classification system based on the recursive model for incident analysis, was carried out.
Results
Nine Coroners’ reports (from a total of 1347 community and hospital reports, 2013–2018) and 217 NRLS reports (from 13 million, 2005–2015) were identified describing diagnostic error with learning relevant to primary care services in or alongside emergency departments. Clinical presentations included musculoskeletal injuries; unwell infants; headaches; and chest pains. Findings highlighted a difficulty identifying appropriate patients for the primary care service; underinvestigation; misinterpretation of diagnostic tests; underuse of safeguarding protocols; and inadequate communication and referral pathways between the services.
Conclusion
Priority areas to minimise risk of diagnostic error when primary care services are located in or alongside emergency departments include clinical decision support to triage and stream patients to the appropriate care setting; contextualised, workplace-based education and training for primary care staff; and standardised computer systems, communication and referral pathways between emergency and primary care services.
Alison Cooper, Cardiff University
Email: coopera8{at}cardiff.ac.uk
Andrew Carson-Stevens, Cardiff University
Niro Siriwardena, University of Lincoln
Adrian Edwards, Cardiff University
- © British Journal of General Practice 2019