Yonder: a diverse selection of primary care relevant research stories from beyond the mainstream biomedical literature
Colonoscopy
Although I’ve been fortunate enough to have never experienced one myself, the grimaces of horror I see on the faces of patients who’ve had one tell me that a colonoscopy is undoubtedly one of the most invasive and unpleasant of all medical procedures. But it does, of course, play a crucial role in the diagnosis of important conditions including colorectal cancer. In a recent North American study, a research team asked a group of older adults (aged between 75 and 89 years) with a history of colonic polyps about their experiences of surveillance colonoscopy.1 Fear of cancer, trust in the colonoscopy procedure, and provider advice played prominent roles in patient decisions to return for surveillance. Most felt they should make screening decisions with input from providers, and that providers should engage them in these decisions and base recommendations on their patients’ personal history and health, not on how old they are or on actuarial data. Notwithstanding the use of the depressingly de-professionalising term ‘provider’ for healthcare professionals, the paper neatly describes the multiplicity of possible human responses to an invasive diagnostic procedure.
Bone health
Fragility fractures in older people can cause significant pain, impaired mobility, social isolation, mental health problems, and reduced mortality. There is, therefore, a need to optimise osteoporosis treatment and fracture prevention strategies. Given that these approaches rely heavily on patient engagement, a US research team recently synthesised qualitative literature to determine patient knowledge, beliefs, and concerns about osteoporosis.2 Participants felt they had inadequate knowledge about osteoporosis and were particularly uninformed about risk factors, causes, treatment, and prevention. Areas of concern for participants included diagnosis, medication side effects, and inadequate information from primary care providers. The authors suggest that credible online resources are needed to address these information gaps.
Risk communication
Cardiovascular risk tools such as QRisk are now widely used in primary care, and the recent focus on early diagnosis of cancer has led to an increased interest in corresponding cancer risk assessment tools, such as QCancer. As these tools have not been widely adopted to date, a UK research team recently sought to explore the perspectives of patients and clinicians on their use in communicating cancer risk information.3 Participants suggested ways to improve communication: personalising risk information; involving patients in use of the tool; sharing risk information openly; and providing sufficient time when using the tool during consultations. It is the last of these that I suspect is most critical, and frustratingly, is probably also the most challenging to ameliorate in the current healthcare climate.
Task shifting
Vertical task shifting refers to a process where specific tasks are moved to either administrative staff or health professionals with fewer qualifications, and it is widely accepted to be a legitimate strategy that is usually motivated by best possible utilisation of limited resources. Horizontal task shifting, meanwhile, occurs when tasks are shifted between levels of equivalent professional competence, such as from secondary care to primary care physicians. In Norway, much like in the UK, there has been a great deal of formal and informal horizontal task shifting occurring in recent years, which prompted a recent study exploring the impact of this phenomenon on patient safety.4 Analysing GPs’ posts in a private Facebook group, the research team found that ‘spill-over’ work dispatched to GPs generated administrative hassle and hazardous delay of necessary examinations. Overdiagnosis, reduced access and endangered accountability occurred when time-consuming procedures and pre-investigation before referral were pushed upon GPs. Resource-draining chores beyond GPs’ proficiency were also dispatched without appropriate instruction or equipment. The authors conclude that policymakers need to carefully consider the unintended consequences of horizontal task shifting and improve the implementation of policy decisions to ensure patient safety across the healthcare system.
- © British Journal of General Practice 2020