Preventative health screening community events, a mechanism to target minority ethnic populations in improving primary care utilisation to improve health outcomes
DOI: 10.3399/bjgp20X711005
Background
Preventative medicine has become a central focus in primary care provision, with greater emphasis on education and access to health care screening. The Department of Health reports existing health inequalities and inequalities in access within ethnic minority groups. Studies assessing the value of community engagement in primary care have reported variable outcomes in term of subsequent service utilisation.
Aim
To consider the benefit of community-based health screening checks to improve access and health outcomes in minority ethnic groups.
Method
An open community health screening event (n = 43), to allow targeted screening within an ethnic minority population. Screening included BP, BMI, BM and cholesterol. Results were interpreted by a healthcare professional and counselling was provided regarding relevant risk factors. Post-event feedback was gathered to collate participant opinion and views.
Results
Seventy-nine per cent of participants were from ethnic minority backgrounds: 64% were overweight or obese and 53% of participants were referred to primary care for urgent review following abnormal findings. All those referred would not have accessed healthcare without the event referral. All (100%) participants believed it improved health education and access to health care.
Conclusion
This study clearly demonstrates the value of targeted community-led screening and education events in public health promotion. There was a significant benefit in providing community-based screening. There is a need for a longitudinal analysis to determine the impact on health outcomes and long-term access to healthcare provision.
Raza Naqvi, University of Nottingham
Octavia Gale, University of Nottingham
Address for correspondence Raza Naqvi, University of Nottingham
Email:raza.naqvi{at}icloud.com
Bringing together child health professionals and dental experts to tackle oral health in children
DOI: 10.3399/bjgp20X711017
Background
In the UK, poor oral health among children continues to be a major public health concern. Primary care professionals are encouraged to take a proactive approach in engaging parents and carers to develop better oral health practices for their children. Unfortunately, research has shown that patients are often exposed to inconsistent and at worst conflicting advice.
Aim
To increase the confidence of primary care professionals in their knowledge surrounding preventative oral health and ensure the delivery of consistent and proactive oral health advice.
Method
A local dentist and dental health educator were invited to a general practice multidisciplinary meeting to deliver an educational session on oral health advice for children. Qualitative and quantitative data in form of a questionnaire was collected to analyse the impact of the education session.
Results
The meeting was attended by 15 healthcare professionals including GPs, paediatricians, a community mental health representative, and a school nurse. There were 78% of attendees who reported that they had never received any formal teaching on oral health care prior to this session. Qualitative data highlighted specific gaps in knowledge, while confidence ratings suggest significant improvement in confidence of attendees in their knowledge of oral health in children.
Conclusion
Achieving good oral health for all children requires the support of a wide range of healthcare professionals. Further education sessions such as this encourages joint learning and relationship building between professionals and influences behaviour to improve child health care as part of making every contact count. The emerging Primary Care Networks provide an excellent setting to deliver this education.
Vinoshini Vasikaran, Connecting Care for Children, Imperial College Healthcare NHS Trust
Arpana Soni, Connecting Care for Children, Imperial College Healthcare NHS Trust
Mando Watson, Connecting Care for Children, Imperial College Healthcare NHS Trust
Address for correspondence Vinoshini Vasikaran, Connecting Care for Children, Imperial College Healthcare NHS Trust
Email:vinoshini.vasikaran{at}nhs.net
The annual dementia review: exploring current practice in primary care
DOI: 10.3399/bjgp20X711029
Background
Dementia is a global public health challenge, the significant consequences of which are recognised in global and national health policies. Despite approaches to improve the implementation of evidence-based dementia care in primary care and the inclusion of indicators for dementia in the Quality and Outcomes Framework (QOF), there is consistent evidence that people with dementia and their family carers lack access to care which meets their needs.
Aim
This study aims to explore current practice regarding the annual dementia review in primary care by investigating: 1) what ‘should’ be happening in annual dementia reviews; 2) how dementia reviews are delivered in a sample of general practices; 3) the barriers and facilitators to the implementation of evidence-based care in dementia reviews; and 4) the experience of these reviews from the perspectives of people with dementia and their informal carer(s).
Method
Qualitative methods will be used. In the first stage, semi-structured interviews with national and regional experts in dementia policy and healthcare will be used to explore what ‘should’ be happening in an annual dementia review. In the second stage, interviews with primary healthcare team members will explore how annual dementia reviews are delivered in a sample of practices in North East England. Interviews with people with dementia and their carers will then be used to explore how reviews are experienced by service users. Thematic analysis will be used to analyse data.
Results
Key themes from the first stage will be presented and their implications in primary care discussed.
Conclusion
The research plan for the second stage will be presented.
Johanne Dow, Newcastle University
Alison Wheatley, Newcastle University
Catherine Exley, Newcastle University
Louise Robinson, Newcastle University
Address for correspondence Johanne Dow, Newcastle University
Email:johanne.dow{at}newcastle.ac.uk
Resilience in advanced cancer caregiving
DOI: 10.3399/bjgp20X711041
Background
Family caregivers of advanced cancer patients are at risk for developing mental disorders. Despite this risk, the majority seem to adapt well, and throughout the caregiving period, their trajectory is characterised by healthy functioning. However, GPs struggle with making timely assessments of caregivers at risk for mental dysfunction, since they often fail to seek medical help for themselves and the appropriate research about resilience in cancer caregivers is scarce. Moreover, research is hampered by the lack of a universal definition or theoretical framework.
Aim
To propose a comprehensive definition and framework for further research in family caregiving for advanced cancer patients.
Method
Inspired by the hermeneutic methodology, reviews and concept analyses on resilience following a potentially traumatic event were searched and analysed. Conforming to the hermeneutic methodology, article collection from PubMed, EMBASE, CINAHL, and PsycInfo was followed by analysis and was stopped when saturation was reached. Elements consistently arising from the definitions of resilience were listed and the theoretical frameworks were compared.
Results
The APA definition: ‘resilience is the process of adapting well in the face of adversity, trauma or threats’ and Bonanno’s framework ‘temporal elements of resilience’ are proposed.
Conclusion
There is a need for studies on resilience in caregivers of advanced cancer patients. Resilience is context-dependent, hence, study results cannot be transferred as such from one clinical situation to another. Furthermore, conceptual ambiguities hinder the interpretation and comparison of study results. For further research on resilience in caregivers of advanced cancer patients, we suggest the APA definition of resilience and Bonanno’s framework.
Sophie Opsomer, KU Leuven
Jan De Lepeleire, KU Leuven
Emelien Lauwerier, Ghent University
Peter Pype, Ghent University
Address for correspondence Sophie Opsomer, KU Leuven
Email:sophie.opsomer{at}kuleuven.be
Dermatology in primary care: an audit of the proportion of patients who present to general practice with a dermatological problem that could be self-managed
DOI: 10.3399/bjgp20X711053
Background
A considerable proportion of GPs’ workload is dermatological. It is important to investigate what common skin conditions encountered in primary care can be self-managed, in an effort to alleviate the burden on primary care.
Aim
The purpose of the audit was to identify the proportion of consultations that are dermatological in nature and analyse potential for self-management by patients.
Method
Data was collected using the patient electronic record system (EMIS) in general practice. A search was made for all consultations from the 17 April to 15 May 2019, which included all new presenting complaints that were dermatological in nature. The criteria for self-management included advising over the counter (OTC) medication or reassurance. On the other hand, a case was deemed not self-manageable if prescription only medication (POM) was prescribed or if a referral to dermatology was made.
Results
There were a total of 2175 consultations, where 246 (11.31%) cases were dermatological. Of the 246, 80 cases (32.5%) could be self-managed. There were 46 different dermatological presenting complaints of which the 5 most common included: rash (51 cases), dermatitis (44 cases), acne vulgaris (13 cases), moles (12 cases), dry skin (11 cases). None of the acne or moles cases could be self-managed, whereas 23%, 68.2%, 72.7% of rashes, dermatitis, and dry skin cases, respectively, could be self-managed.
Conclusion
Certain dermatological conditions have more potential for self-management than others. Research into teledermatology as a means of addressing patient concern and providing clinical information is important in order to reduce unnecessary consultations.
Luamar Dolfini, St Georges, University of London
Yogesh Patel, South London and Maudsley NHS Foundation Trust
Address for correspondence Luamar Dolfini, St Georges, University of London
Email:luamar{at}hotmail.co.uk
Improving access to appointments at Laurie Pike Health Centre
DOI: 10.3399/bjgp20X711065
Background
Rising demand makes it increasingly difficult for patients to access appointments. Laurie Pike Health Centre (LPHC) operates a predominantly same-day booking policy in order to manage appointment requests from its 18 000 patients. We sought to quantify the number of requests, in order to estimate the unmet demand.
Aim
1) To estimate the met and unmet demand for same-day appointments; 2) To assess how capacity for same-day appointments compares to demand; 3) To analyse how well LPHC is utilising its available appointment slots.
Method
We created a data collection tool to count the total number of patient requests by type. We grouped types into four categories: 1) medical appointment requests; 2) sick notes and results requests; 3) other appointment requests (such as healthcare assistant, nurse); and 4) admin/other. Category-specific percentages were applied to call log data to estimate the number of appointment requests per category. Capacity was measured by counting the total number of same-day GP/advanced nurse practitioner (ANP) appointment slots. Consultation records for GP/ANP appointments were analysed to assess the appropriateness of the booking.
Results
Estimated average demand for same-day GP/ANP appointments was 222 per day. Average same-day capacity was 112 slots. After introducing pharmacist and video consultations, average capacity increased to 194 slots per day, a shortfall of 28 appointments. Consultation records indicated that 41% of GP/ANP appointments could have been seen by other practitioners; for example, musculoskeletal practitioners (14%).
Conclusion
GP/ANP appointments alone cannot meet patient demand but a diversified workforce might. Alongside this, efforts to improve care navigation may free up to 41% of GP/ANP appointment slots.
Jordan Moxey, Sandwell and West Birmingham Hospital Trust
Will Murdoch, Laurie Pike Health Centre
Address for correspondence Jordan Moxey, Sandwell and West Birmingham Hospital Trust
Email:jordan.moxey{at}nhs.net
The development of palliative care education and training for GPs in Yangon, Myanmar: a workshop success
DOI: 10.3399/bjgp20X711077
Background
Palliative care is an important but often overlooked component of primary care. In Myanmar, early emergence of palliative care is being seen, however no formal community-based services yet exist. Present challenges include resource scarcity and inadequate education and training.
Aim
Our goal was to improve understanding and approach towards palliative care by GPs in Yangon.
Method
An initial survey was performed among 42 GPs in Yangon, Mandalay, and Meiktila in March 2019 demonstrating a gap in current training needs and willingness by GPs for this to be improved. A 2-day workshop, the first ever of its kind, was subsequently designed and held for 20 local GPs, consisting of interactive seminars delivered in Burmese.
Results
Improvement in knowledge and confidence were used as measures of success. A true/false-style quiz was distributed pre- and post-workshop demonstrating a mean total score improvement of 15%. Self-reported confidence rating scores regarding confidence when: 1) managing palliative patients; 2) providing holistic care; and 3) breaking bad news, increased by a mean of 25%.
Conclusion
The greatest outcome from this workshop, by far, was the enthusiasm and awareness it generated, support was even gained from the President of the Myanmar Medical Association despite his initial reservations about developing this area. Ultimately, the workshop behaved as an advocate for the introduction of a regular palliative care lecture into the local Diploma in Family Medicine curriculum; it also spurred a group of GPs to further this work and turn the workshop into a regular teaching event.
Kerran Kandola, NHS Thames Valley and Wessex Leadership Academy
Myint Oo, General Practitioners Society of Myanmar
Address for correspondence Kerran Kandola, NHS Thames Valley and Wessex Leadership Academy
Email:kerran91{at}googlemail.com
What influences Roma women attending NHS cervical screening? Knowledge, fear, and passive consent
DOI: 10.3399/bjgp20X711089
Background
Recent immigration from Eastern Europe poses new challenges in engaging with women eligible to have smears. The Roma population have low socioeconomic status, low educational status, and a life expectancy 10 years lower than other EU citizens. An audit of smear uptake in four ‘Deep End’ Sheffield practices identified as having >1000 registered Roma Slovak patients, demonstrated smear uptakes between 53% to 40%, all of which are below the Sheffield CCG average of 73.5%.
Aim
To establish the barriers, facilitators and attitudes of Roma women towards accessing the NHS cervical screening.
Method
Semi-structured interviews were recorded, transcribed, and analysed thematically using an iterative, with independent verification of emergent themes. Interviews continued to data saturation. Interviews were carried out in the patient’s home or a community centre, facilitated by a trained interpreter.
Results
Sixteen women who self-identified as Roma, were interviewed. The overarching themes of ‘language discordance’, ‘poor educational attainment’, and ‘passivity in receiving care’, influenced the women’s likelihood of smear uptake or the need for screening. These emergent themes underpinned a longstanding distrust of the role of the state in relation to the health needs of the community.
Conclusion
It is vital that we develop and evaluate appropriate interventions to increase smear uptake in migrant and other vulnerable populations. There is a need for the UK to adapt screening programmes to maximise uptake within ‘hard to reach’ groups, such as the ‘Roma’, who are likely to be at the highest risk of cancer and late presentation of the disease.
David Lehane, University of Sheffield
David Kandrac, University of Sheffield
Elizabeth Walton, University of Sheffield
Caroline Mitchell, University of Sheffield
Address for correspondence David Lehane, University of Sheffield
Email:d.lehane{at}sheffield.ac.uk
General practice is ‘different’: qualitative study of acculturation experiences of East Staffordshire general practice specialty trainees
DOI: 10.3399/bjgp20X711101
Background
Undergraduate medical education and postgraduate foundation training are largely secondary care based. General practice trainees also spend nearly half of their training in hospital rotations. Little is known about factors that support effective transition into general practice specialty training or belongingness experiences throughout training.
Aim
To explore the reported experiences of general practice trainee transition into general practice, training in hospital settings, and views of the future.
Method
Semi-structured interviews with 18 purposively selected trainees plus observation and stakeholder discussions by a visiting Sri Lankan general practice trainee attending the vocational training scheme in a participant observer role.
Results
Mastering core skills of general practice, undergraduate and early experience in general practice during specialty training, and general practice trainer guidance and role modelling facilitated transition. A reduced sense of belongingness during hospital rotations impacted on training and work. Building bridging social connections, personal agency initiatives to bring general practice relevance into hospital training, and secondary care affiliative behaviours were adaptive strategies. Allocation to more general practice relevant duties was thought to create value within the hospital team. General practice trainees are thriving with the support of general practice trainers and colleagues, vocational training scheme, and good work/life balance. International graduates require additional support in specific areas.
Conclusion
Adequate support towards transition into general practice and fostering belongingness in hospital settings is important due to the wider impact on training, patient care, and primary/secondary care integration. We propose a theoretical explanation based on Wenger’s social learning model, which may have useful practical implications.
Dinusha Perera, Faculty of Medicine, University of Kelaniya, Sri Lanka
Kay Mohanna, University of Worcester
Address for correspondence Dinusha Perera, Faculty of Medicine, University of Kelaniya, Sri Lanka
Email:dinusha{at}kln.ac.lk
A primary care network analysis: natural communities of general practices in London
DOI: 10.3399/bjgp20X711113
Background
Primary care networks (PCNs) are a new organisational hierarchy introduced in the NHS Long Term Plan with wide-ranging responsibilities. The vision is that they represent ‘natural’ communities of general practices with boundaries that make sense to practices, other healthcare providers, and local communities.
Aim
Our study aims to identify natural communities of general practices based on patient registration patterns, using network analysis methods and unsupervised clustering to create catchments for these communities.
Method
Patients resident in and attending GP practices in London were identified from Hospital Episode Statistics from 2017 to 2018. We used a series of novel methods for unsupervised graph clustering. A cosine similarity matrix was constructed representing similarities between each general practice to each other, based on registration of patients in each Lower Super Output Area (LSOA). Unsupervised graph partitioning using Markov Multiscale Community Detection was conducted to identify communities of general practices. Catchments were assigned to each PCN based on the majority attendance from an LSOA.
Results
In total 3 428 322 unique patients attended 1334 GPs in general practices LSOAs in London. The model grouped 1291 general practices (96.8%) and 4721 LSOAs (97.6%), into 165 mutually exclusive PCNs. The median PCN list size was 53 490 and a median of 70.1% of patients attended a general practice within their allocated PCN, ranging from 44.6% to 91.4%.
Conclusion
With PCNs expected to take a role in population health management and with community providers expected to reconfigure around them, it is vital we recognise how PCNs represent their communities. This method may be used by policymakers to understand the populations and geography shared between networks.
Thomas Beaney, Imperial College London
Jonathan Clarke, Imperial College London
Mauricio Barahona, Imperial College London
Address for correspondence Azeem Majeed, Imperial College London
Email:thomas.beaney{at}imperial.ac.uk
Workforce Race Equality Standard survey in general practice: Lewisham 2019
DOI: 10.3399/bjgp20X711125
Background
The NHS Workforce Race Equality Standard (WRES) was introduced in 2015 and is mandatory for NHS trusts. Nine indicators have been created to evaluate the experiences of black and minority ethnic (BME) staff compared with the rest of the workforce. The trust data published showed a poor experience of BME staff compared with non BME staff.
Aim
To introduce the concept of WRES into general practice and create a baseline from which improvement can be made. A diverse workforce will better serve its population and this will improve health outcomes.
Method
We conducted a survey among all general practice staff members, clinicians, and non-clinicians and asked open-ended questions built around four WRES indicators most applicable to general practice, over a 6-week period in August and September 2019.
Results
We collected 151 responses out of a total workforce of around 550. The response rate between clinicians and non-clinicians was equal 50.6% versus 49.4%. The distribution of non BME staff 51% versus BME staff 49% mirrors the diverse population of Lewisham. 54% of BME staff experienced bullying from patients, their relatives, and members of the public. 25% experienced bullying from a colleague or staff member in the workplace and 22% of BME staff changed jobs as a result of this.
Conclusion
BME staff in general practice report high levels of racism, especially from service users. In 22% this led to a career change. A zero-tolerance policy needs to be enforced and a multi-pronged approach is required to address this.
Sebastian Kalwij, Lewisham CCG
Address for correspondence Sebastian Kalwij, Lewisham CCG
Email:sebastiankalwij{at}mac.com
‘Would you like to join the NHS Organ Donor Register?’ A general practice feasibility study
DOI: 10.3399/bjgp20X711137
Background
A shortage of organ donors exists in the UK and targeting family consent is key for increasing donation consent rates. Registration on the NHS Organ Donor Register (NHS ODR) facilitates this, as it guides families on their loved ones donation preference. In general practice, an opportunity to register is provided, however only to new patients. To improve access to registration opportunities, an intervention was designed where general practice staff asked their patients if they wished to register as an organ donor.
Aim
To assess an organ donation registration intervention for feasibility and acceptability in a UK general practice setting.
Method
One general practice, in Luton, UK, conducted the intervention for 3 months (April to July 2018). Training was held in March 2018, and leaflets and posters were displayed for the 3-month period. An embedded experimental mixed-methods design was used, with data collected via SystmONE questionnaires, surveys and focus groups.
Results
The intervention was found to be feasible and acceptable to conduct with some patients by some staff members. During the 3 months, patients were asked in 12.4% of face-to-face consultations (n=812). Nurses and healthcare assistants were more able to conduct the intervention than doctors. Lack of time, telephone consultations, and it not being appropriate were the most common reasons for not asking. Finally, 244 patients joined the NHS ODR; 30.4% of those asked.
Conclusion
This study demonstrates that general practice could be a feasible location in which an intervention designed to increase NHS ODR registration could be conducted
Catrin Pedder Jones, Institute for Health Research, University of Bedfordshire
Chris Papadopoulos, University of Bedfordshire
Gurch Randhawa, University of Bedfordshire
Zeeshan Asghar, NHS Blood and Transplant
Address for correspondence Gurch Randhawa, University of Bedfordshire
Email:gurch.randhawa{at}beds.ac.uk
An exploration of stakeholders’ perceptions of the extent to which the individual and collective views of patients with long-term conditions and their carers are heard and used to inform commissioning decisions within primary care
DOI: 10.3399/bjgp20X711149
Background
Involving patients and carers in decisions that influence the delivery of health services is a statutory requirement across the NHS. However, current evidence suggests a gap exists between the theory, legislation and policy intentions and their practical implementation.
Aim
This research aimed to identify the nature and extent of that perceived gap.
Method
Adopting a mixed-methods approach using questionnaires and semi-structured interviews, stakeholders’ perceptions were explored regarding the extent to which the views of patients with long-term conditions and their carers are heard and used within primary care, across four clinical commissioning groups. Descriptive statistics were used to analyse the quantitative data; thematic analysis was applied to explore the qualitative data.
Results
Data analysis demonstrated considerable difference between patients’ and carers’ perceptions and those of healthcare professionals regarding how well involvement is implemented. Three key themes emerged that were perceived to influence the effectiveness of involvement. These related to the need for effective communication of relevant, accessible information that meets people’s requirements; the need to take account of individuals’ expectations, ability, motivation, assumptions, and previous experience; and the need for organisations to provide effective systems and processes, including adequate time and focused training to support involvement, in addition to robust monitoring and evaluation of the extent to which outputs from involvement influence commissioning decisions.
Conclusion
The literature suggests that no existing framework addresses all three key themes. Therefore, a revised framework for involvement was developed, informed by the three key themes, that can be tested across a larger sample and different healthcare settings.
Jane Brooks, University of Portsmouth
Address for correspondence Jane Brooks, University of Portsmouth
Email:jane.brooks{at}port.ac.uk
Identification and management of frailty in English primary care: a qualitative study of national policy
DOI: 10.3399/bjgp20X711161
Background
Policymakers are directing attention to addressing the needs of an ageing population. Since 2017, general practices in England have been contractually required to identify and code ‘frailty’ as a new clinical concept and, in doing so, support targeted management for this population with the aim of improving outcomes. However, embedding frailty policies into routine practice is not without challenges and little is currently known about the success or otherwise of the programme.
Aim
To explore the implementation of a national policy on frailty identification and management in English primary care.
Method
Semi-structured interviews were conducted with GPs (n = 10), nurses (n = 6), practice managers (n = 3) and health advisors (n = 3). Normalisation Process Theory (NPT) and System Thinking provided sensitizing frameworks to support data collection and analysis.
Results
Primary care professionals were starting to use the concept of frailty to structure care both within practices and across organisations, however, there was widespread concern about the challenge of providing expanded care for the identified needs within existing resources. Concerns were also expressed around how best to identify the frail subpopulation and the limitations of current tools for this, and there was a professional reticence to use the term ‘frailty’ with patients.
Conclusion
Findings suggest that additional focused resources and the development of a stronger evidence base are essential to facilitate professional engagement in policies to improve the targeted coding and management of frailty in primary care.
Harm van Marwijk, Brighton and Sussex Medical School
Tom Blakeman, University of Manchester
David Reeves, University of Manchester
Khulud Alharbi, University of Manchester
Address for correspondence David Reeves, University of Manchester
Email:david.reeves{at}manchester.ac.uk
Study design of the Fasting In diabetes Treatment (FIT) trial: a randomised, controlled, assessor blinded intervention trial which examines the effect of intermittent use of a fasting mimicking diet in patients with type 2 diabetes
DOI: 10.3399/bjgp20X711173
Background
Caloric restriction is an effective way to treat type 2 diabetes (DM2). However, chronic restriction of food intake is difficult to sustain. Intermittent total fasting exerts similar metabolic effects, but may be even more challenging for most patients. A fasting mimicking diet (FMD) was designed to achieve the metabolic benefits of total fasting, despite considerable calorie content. The effects of a FMD in DM2 patients are still unknown.
Aim
To determine the effect of intermittent use (5 consecutive days a month during a year) of a FMD in DM2 patients on metabolic parameters and DM2 medication use compared to usual care.
Method
One hundred DM2 patients from general practices in the Netherlands with a BMI ≥ 27 kg/m2, treated with lifestyle advice only or metformin, will be randomised to receive the FMD plus usual care or usual care only. Primary outcomes are HbA1c and DM2 medication dosage. Secondary outcomes are anthropometrics, blood pressure, plasma lipid profiles, quality of life, treatment satisfaction, metabolomics, microbiome, MRI (for example, cardiac function and fat distribution), cost-effectiveness, and feasibility in clinical practice.
Results
The first 70 patients are included. Follow up will be completed in April 2021.
Conclusion
Our results will show whether monthly cycles of a FMD are feasible in clinical practice, if they improve metabolic parameters and/or reduce the need for medication in DM2 and if this is a cost-effective intervention.
Elske van den Burg, Public Health and Primary Care, Leiden University Medical Center
Marjolein Schoonakker, Public Health and Primary Care, Leiden University Medical Center
Elske van den Akker, Medical Decision Making, Leiden University Medical Center
Ko Willems van Dijk, Human Genetics, Leiden University Medical Center
Hildo Lamb, Radiology, Leiden University Medical Center
Hanno Pijl, Internal Medicine, Leiden University Medical Center
Mattijs Numans, Public Health and Primary Care, Leiden University Medical Center
Petra van Peet, Public Health and Primary Care, Leiden University Medical Center
Address for correspondence Elske van den Burg, Public Health and Primary Care, Leiden University Medical Center
Email:e.l.van_den_burg{at}lumc.nl
Emergency Admission Risk Prediction (EARP) tools in primary care to reduce emergency admissions to hospital: clash of evidence and practice
DOI: 10.3399/bjgp20X711185
Background
Policy initiatives have incentivised use of EARP tools in primary care to reduce emergency admissions. A recently published trial in South Wales found that EARP increased emergency admissions and emergency department attendances without clear benefits. This cost the NHS an additional £76 per patient per year. But the use of EARP in primary care across the UK was unknown.
Aim
To assess implementation and facilitators use of EARP tools in primary care across the UK.
Method
Structured email survey of 235 UK primary care commissioners across the UK.
Results
There were 148 (87%) of 171 responders (73%) who reported that EARP tools were available in their areas. We identified 39 different EARP tools in use. Access to EARP tools varied widely by country: Northern Ireland (100%), Scotland (91%), England (76%) and Wales (14%). Promotion by NHS commissioners, and engagement of clinical leaders and practice managers were identified as the most important factors in encouraging use of EARP tools. Research evidence was seen as less important. Nearly 40% of areas using EARP reported that they had revised services as a result, but few reported use of EARP for service evaluation.
Conclusion
Though EARP tools are widely available in primary care, new evidence shows that they are counter-productive. We estimate that by delaying the dissemination of EARP for evaluation NHS Wales saved >£200 million per year. We encourage further research and discussion about next steps in use of EARP tools in emergency admission prevention in the UK.
Helen Snooks, Swansea University
Mark Kingston, Swansea University
Alison Porter, Swansea University
Hayley Hutchings, Swansea University
Ian Russell, Swansea University
Address for correspondence Helen Snooks, Swansea University
Email:h.a.snooks{at}swan.ac.uk
Anticipatory care planning for older adults: a trans-jurisdictional feasibility study
DOI: 10.3399/bjgp20X711197
Background
As the population of older adults’ increases, the complexity of care required to support those who choose to remain in the community has also increased. Anticipatory Care Planning (ACP) through earlier identification of healthcare needs is evidenced to improve quality of life, decrease the number of aggressive futile interventions, and even to prolong life.
Aim
To determine the feasibility of a cluster randomised trial to evaluate the implementation and outcomes of Anticipatory Care Planning (ACP) in primary care to assist older adults identified as at risk for functional decline by developing a personalised support plan.
Method
GP practices were randomised into control/intervention groups stratified by jurisdiction [Northern Ireland (UK) and the Republic of Ireland (RoI)], and by setting (urban and rural). Participants were included if they were a) aged ≥70 years, b) 2 or more chronic medical conditions, c) 4 or more prescribed medications. The Anticipatory Care Plan consisted of home visits where the study nurse discussed patients’ goals and plans. An action plan was put in place following consultation with patient’s GPs and study Pharmacist.
Results
Eight primary care practices participated; four in the UK and four in the RoI. Sample n = 64. Data was collected pertaining to patient quality of life, mental health, healthcare utilisation, costs, perception of person-centred care, and the use of potentially inappropriate medication.
Conclusion
Unique insights relating to the trans-jurisdictional delivery of healthcare services in the UK and RoI were observed which has implications on service delivery for older adults.
Dagmar Corry, Queens University Belfast
Julie Doherty, Queens University Belfast
Adrienne McCann, Queens University Belfast
Frank Doyle, Royal College of Surgeons Ireland
Christopher Cardwell, Queens University Belfast
Gillian Carter, Queens University Belfast
Mike Clarke, Queens University Belfast
Tom Fahey, Royal College of Surgeons Ireland
Paddy Gillespie, National University of Ireland Galway
Kieran McGlade, Queens University Belfast
Peter O’Halloran, Queens University Belfast
Emma Wallace, Royal College of Surgeons Ireland
Kevin Brazil, Queens University Belfast
Address for correspondence Dagmar Corry, Queens University Belfast
Email:dagmar.corry{at}qub.ac.uk
Vitamin D deficiency is associated with increased risk of postural hypotension in older men: a cross-sectional analysis from The British Regional Heart Study
DOI: 10.3399/bjgp20X711209
Background
There is growing interest in the role of vitamin D in extra-skeletal health, including postural hypotension. Postural hypotension is found in 1 in 5 community-dwelling adults aged 60 years and above. It increases risk of falls, fractures, cardiovascular disease and all-cause mortality. Better understanding of the aetiology of postural hypotension may help yield more effective treatment options than those that are currently available.
Aim
The aim of this study was to investigate the association between circulating vitamin D, parathyroid hormone and postural hypotension.
Method
This was a cross-sectional analysis of 3620 community-dwelling men living in the UK (mean age 68.6 years; standard deviation 5.5 years). Vitamin D status (nmol/L) was categorised as sufficient (≥50), insufficient (≥25 – <50), or deficient (<25). Parathyroid hormone levels were categorised by quintiles. Postural hypotension was defined by consensus criteria as a decrease in systolic blood pressure ≥20 mmHg and/or diastolic blood pressure ≥10 mmHg that occurred within three minutes of standing.
Results
Compared to sufficient levels of vitamin D, vitamin D deficiency increased risk of postural hypotension that specifically occurred within one minute of standing (OR 1.51, 95% CI = 1.06 to 2.15) in multinomial, multiple logistic regression. Neither vitamin D insufficiency, nor elevated parathyroid hormone, were associated with postural hypotension.
Conclusion
In this study, vitamin D deficiency was associated with increased risk of postural hypotension. Further research may help clarify whether treating vitamin D deficiency can reduce the degree of postural hypotension, or if preventing the progression to vitamin D deficiency can reduce the incidence of postural hypotension.
Artaza Gilani, University College London Research Department of Primary Care & Population Health
Sheena Ramsay, Institute of Health & Society, Newcastle University
Paul Welsh, University of Glasgow
Olia Papacosta, University College London Research Department of Primary Care & Population Health
Lucy Lennon, University College London Research Department of Primary Care & Population Health
Peter Whincup, Population Health Research Institute, St George’s, University of London
S Goya Wannamethee, University College London Research Department of Primary Care & Population Health
Address for correspondence Artaza Gilani, University College London Research Department of Primary Care & Population Health
Email:artaza.gilani{at}ucl.ac.uk
How can referrals of patients who are obese to the local exercise referral scheme be increased? A UK based primary care quality improvement study
DOI: 10.3399/bjgp20X711221
Background
Obesity is classified as a body mass index (BMI) >30kg/m2 and contributes to poor health outcomes in the UK. In 2017–18, obesity resulted in 711,000 hospital admissions. The National Institute for Health and Care Excellence (NICE) recommends GPs educate patients who are obese and refer them to exercise programmes. Our practice, Brierley Park Medical Centre, (NHS Mansfield and Ashfield CCG) is in a 4th decile most deprived region of North Nottinghamshire (UK) and serves a population of 9,288. The local exercise referral scheme (ERS) allows clinicians to refer patients to the local gym for a reduced fee at the point of access.
Aim
To calculate and increase the number of adult patients who are obese in our practice who are referred to the local ERS.
Method
The number of adult obese patients who were referred to the local ERS scheme from October 2018 to September 2019 was calculated. An intervention comprising internal system alerts, GP education utilising Making Every Contact Count framework and targeted patient group text alerts was designed and delivered. Pre (cycle 1) and post (cycle 2) intervention data from November to February were generated and compared.
Results
In total, 2766 adult obese patients (29.8% of practice population) were identified: 16 (0.2%) patients were referred to ERS during cycle 1.96 (1%) patients were referred during cycle 2.
Conclusion
The interventions that we have designed and implemented have increased the number of referrals to ERS and may be applied to similar primary care settings.
Vasudev Zaver, Sherwood Forest Hospitals NHS Foundation Trust and Brierley Park Medical Centre, Huthwaite
Stephen Wormall, Elective Clinical Lead NHS Mansfield and Ashfield CCG, NHS Newark and Sherwood CCG, GP at Brierley Park Medical Centre
Vibhore Prasad, King’s College London and Brierley Park Medical Centre, Huthwaite
Keshara Perera, Sherwood Forest Hospitals NHS Foundation Trust and Brierley Park Medical Centre, Huthwaite
Address for correspondence Vasudev Zaver, Sherwood Forest Hospitals NHS Foundation Trust and Brierley Park Medical Centre, Huthwaite
Email:vasudev.zaver{at}nhs.net
Evaluating interprofessional education: initial learning from a domestic abuse conference
DOI: 10.3399/bjgp20X711233
Background
The importance of multi-agency working to identify, prevent and reduce domestic abuse is widely recognised. Interprofessional learning opportunities can provide a supportive learning environment for multi-agency practitioners to explore and develop collaborative approaches to improve health outcomes for vulnerable children, young people and their families.
Participants drawn from Kent GP trainees, student Health Visitors, School Nurses, Midwives, Social Workers, student Teachers and Special Educational Needs Coordinators (SENCOs), and postgraduate Police Officers attended this sixth annual conference.
Aim
To enable participants to understand why domestic abuse is a serious public health issue; identify indicators of domestic violence and abuse; identify opportunities for safe enquiry and know how to respond; critically reflect on ethical, legal, professional and interprofessional challenges for practitioners; and reflect on and explore opportunities for inter-professional working.
Method
Multi-disciplinary educators delivered formal presentations and facilitated interprofessional workshops.
Data from anonymised pre- and post- conference questionnaires distributed on the day, included quantitative questions using a Likert scale 1–5 and open and closed qualitative questions.
Results
In total, 75 out of a possible 121 participants completed both questionnaires (62%). The above aims were all met. In all questions participants gave higher scores after the conference indicating increased levels of knowledge and confidence. The qualitative comments highlighted the learning benefits from interprofessional group work. 100% (average score 4.5) agreed that facilitators fostered a supportive learning environment.
Conclusion
The conference provided a highly valued opportunity for useful interprofessional learning about domestic abuse. Results indicated that it increased participants’ knowledge and confidence about their own and others’ roles and responsibilities.
Cheryl Yardley, Christchurch Canterbury University
Karen Hynes, Christchurch Canterbury University
Andrew Charley, Health Education England Kent, Surrey & Sussex
Sari Sirkia-Weaver, Christchurch Canterbury University
Julie Critcher, Medway NHS Trust
Lorna Hughes, Christchurch Canterbury University
Emma Banks, Kent Police
Jane Arnott, Christchurch Canterbury University
Tim Woodhouse, Kent County Council
Anne Lyttle, Rising Sun Domestic Violence & Abuse Service
Address for correspondence Andrew Charley, Health Education England Kent, Surrey & Sussex
Email:a.charley{at}nhs.net
What do patients want? A qualitative exploration of patients’ needs and expectations regarding online access to their primary care record
DOI: 10.3399/bjgp20X711245
Background
Primary care records have traditionally served the needs and demands of clinicians rather than those of the patient. GP contracts in England state practices must promote and offer registered patients online access to their primary care record and research has shown benefits to both patients and clinicians of doing so. Despite this, we know little about patients’ needs and expectations regarding online access.
Aim
To explore patients’ views about accessing online primary care records and to find out how patients would like to interact with their records and what support they may need.
Method
Interviews and focus groups with a sample of 50 patients from a variety of socio-demographic backgrounds who were either; eligible for the NHS Health Check; had multimorbidities or were carers. Thematic analysis of data identified major themes impacting upon patients’ wishes and needs as well as highlighting population-specific issues.
Results
Participants highlighted a wide range of views about the benefits and drawbacks of accessing their records online. The majority of participants indicated that they would be more likely to access their online primary care record if improvements were made to the design, reliability and functionality of existing online record services. Carers found accessing online records particularly useful.
Conclusion
Consultation with patients and carers about their experiences of accessing online records; support needs and preferred functions can provide useful insights to inform the future design of online record services.
Gail Davidge, The University of Manchester
Caroline Sanders, The University of Manchester
Rebecca Hays, The University of Manchester
Rebecca Morris, The University of Manchester
Helen Atherton, The University of Warwick
Freda Mold, The University of Surrey
Brian McMillan, The University of Manchester
Address for correspondence Brian McMillan, The University of Manchester
Email:brian.mcmillan{at}manchester.ac.uk
MULTIPAP Study: Improving healthcare for patients with multimorbidity
DOI: 10.3399/bjgp20X711257
Background
The steady rise in multimorbidity entails serious consequences for our populations, challenges healthcare systems, and calls for specific clinical approaches of proven effectiveness. The MULTIPAP Study comprises three sequential projects (MULTIPAP and MULTIPAP Plus RCTs, and the MULTIPAP Cohort). Results of MULTIPAP RCT are presented.
Aim
To evaluate the effectiveness of a complex, patient-centred intervention in young-old patients with multimorbidity and polypharmacy.
Method
Pragmatic cluster-randomised clinical trial in a primary healthcare setting. GPs were randomly allocated to either conventional care or the MULTIPAP intervention based on the Ariadne Principles with two components: GPs e-training (that is, eMULTIPAP addresses specific, key concepts on multimorbidity, polypharmacy and shared decision-making) and GP–patient-centred interview. Young-old patients aged 65–74 years with multimorbidity and polypharmacy were included. Main outcome: difference in the Medication Appropriateness Index (MAI) after 6-month follow-up between groups. Secondary outcomes: MAI, quality of life, patient perception, health services use, treatment adherence and cost-effectiveness after 12-month follow-up.
Results
117 GPs from 38 Spanish primary health care recruited 593 patients randomly assigned to the intervention/control groups. Difference in MAI scores between groups in the intention-to-treat analysis after 6 months’ follow-up: −2.42 (−4.27 to −0.59), P = 0.009 (adjusted difference in mean MAI score −1.81(−3.35 to −0.27), P = 0.021). Secondary outcomes: not significant, including quality of life (adjusted difference in mean EQ-5D-5L (VAS) 2.94 (−1.39 to 7.28), P = 0.183, EQ-5D-5L (index) −0.006(−0.034 to 0.022), P = 0.689).
Conclusion
The intervention significantly improved medication appropriateness. The observed quality of life improvement was not significant. GPs e-training in multimorbidity has shown to be feasible and well accepted by the professionals. Future studies may test whether this format facilitates implementation.
Alexandra Prados-Torres, EpiChron Research Group on Chronic Diseases, Aragon Health Sciences Institute, Miguel Servet University Hospital, Zaragoza, Spain
Isabel del Cura-González, Primary Care Research Unit, Gerencia de Atención Primaria. Department of Preventive Medicine and Public Health, University Rey Juan Carlos, Madrid, Spain
Juan Daniel Prados-Torres, Multiprofesional Teaching Unit of Community and Family Atention ‘Distrito Atención Primaria Málaga-Guadalhorce’, Málaga, Spain.
Christiane Muth, Institute of General Practice, Johann Wolfgang Goethe University, Frankfurt/Main, Germany
Francisca Leiva-Fernández, Multiprofesional Teaching Unit of Community and Family Atention ‘Distrito Atención Primaria Málaga-Guadalhorce’, Andalusian Health Service, Málaga, Spain
Juan A Lopez-Rodriguez, Primary Care Research Unit, Gerencia de Atención Primaria. Department of Preventive Medicine and Public Health, University Rey Juan Carlos, General Ricardos Primary Health Care Centre, Madrid, Spain
Francisca González-Rubio, EpiChron Research Group on Chronic Diseases, Aragon Health Sciences Institute, Aragón; Miguel Servet University Hospital, Delicias-Sur Primary Care Health Centre, SALUD, Zaragoza, Spain.
Address for correspondence Alexandra Prados-Torres, EpiChron Research Group on chronic diseases, Aragon Health Sciences Institute, Miguel Servet University Hospital, Zaragoza, Spain
Email:sprados.iacs{at}aragon.es
GPs’ experience of safeguarding in care homes: what do they see and what do they do?
DOI: 10.3399/bjgp20X711269
Background
Abuse of older people in care homes is an on-going problem. GPs, as the most frequent practitioner group visiting care homes, have an important role in detecting and reporting abuse. However, there is little research about GPs’ experiences of working in care homes and how they work to safeguard residents.
Aim
To explore the challenges experienced by GPs working in this unique environment and how these impact on safeguarding.
Method
An online survey collected qualitative data about GPs’ experiences as visiting professionals to care homes, with an emphasis on safeguarding. A thematic analysis identified key themes.
Results
In total, 58 completed surveys were returned, with a range of practitioner experience represented (1–30 years). Approximately 70% were GP partners, with the remainder salaried and locum doctors. Over one third reported they had witnessed signs of definite or possible abuse within care homes. Emerging themes related to the complex care home context, in which residents had multiple health needs and GPs had to build multiple relationships with managers, carers, families, and residents. Difficulties in accessing information were reported; residents could not always provide information, GPs had to rely on others for information, and rarely had access to electronic records.
Conclusion
GP work in care homes is a complex and skilled role, in which GPs encounter evidence of poor care and abuse. Key themes in respect of barriers and facilitators of good care were highlighted. The reliance on others for information and the need to build relationships with staff/managers may raise tensions in respect of safeguarding practice.
Elisabeth Alton, East Riding of Yorkshire CCG
Caroline White, University of Hull
Address for correspondence Elisabeth Alton, East Riding of Yorkshire CCG
Email:elisabeth.alton{at}nhs.net
If GPs who teach medical students were assisted to be good role models might this influence the medical career the students choose?
DOI: 10.3399/bjgp20X711281
Background
Most patients are cared for in the community by GPs, and workforce planning for the UK NHS suggests that 50% of medical school graduates need to train as GPs. While there is pressure on medical schools to provide more student teaching in general practice, general practice must be prepared for this increase in workload and teachers should have appropriate training.
Aim
This study examined the influence that teachers as role models can have on the development and career choices of medical students and whether GPs who teach medical students might benefit from assistance in developing positive attributes.
Method
A literature search was carried out. Relevant papers were those that examined the influence of a doctor as teacher role model for medical students, both in assisting in professional development and clinical skills, and in influencing career choice.
Results
The review identified eleven papers. There was evidence of association between a student having an influential role model as teacher and choosing specialty training in that area, although evidence of a causative connection is less convincing. A recurring theme is the recommendation that teachers should be aware of the influence they can have as role models, both positive and negative.
Conclusion
As medical student teaching moves into general practice GPs who teach will need to be helped to understand and develop positive role model attributes, to promote general practice as an attractive career to the students. Further research needs to identify the extent of assistance required and whether medical schools are prepared for this extra responsibility.
Address for correspondence Jonathan White, University of Exeter
Email:jcwhite{at}doctors.org.uk
Quantifying empathy levels among UK undergraduate medical students: an online survey
DOI: 10.3399/bjgp20X711293
Background
Empathy is a key health care concept and refers to care that incorporates understanding of patient perspective’s, shared decision making, and consideration of the broader context in which illness is experience. Evidence suggests experiences of doctor empathy correlate with improved health outcomes and patient satisfaction. It has also been linked to job satisfaction, and mental wellbeing for doctors. To date, there is a paucity of evidence on empathy levels among medical students. This is critical to understand given that it is a key point at which perceptions and practices of empathy in the longer term might be formed.
Aim
To quantify the level of empathy among UK undergraduate medical students
Method
An anonymised cross-sectional online survey was distributed to medical students across three universities. The previously validated Davis’s Interpersonal Reactivity Index was used to quantify empathy. The survey also collected information on age, sex, ethnicity, year of medical school training and included a free-text box for ‘any other comments’.
Results
Data analysis is currently underway with high response rates. Mean empathy scores by age, sex, year of study and ethnic group are presented. A correlation analysis will examine associations between age and year of study, and mean empathy sores.
Conclusion
These data will help to provide a better understanding of empathy levels to inform the provision of future empathy training and medical school curriculum design. Given previous evidence linking experiences of empathy to better health outcomes, the findings may also be significant to future patient care
Sarah Garnett, University of Southampton
Hajira Dambha-Miller, University of Southampton
Beth Stuart, University of Southampton
Address for correspondence Hajira Dambha-Miller, University of Southampton
Email:hajiradambha{at}doctors.org.uk
Patients’, healthcare providers’, and health insurance employees’ preferences for knee and hip osteoarthritis care: a discrete choice experiment
DOI: 10.3399/bjgp20X711305
Background
Despite the wide range of treatment options for knee and hip osteoarthritis (KHOA), suboptimal care, low uptake and low adherence to treatment is widely seen. We need to gain insight into preferences for KHOA treatment.
Aim
To determine patients’, healthcare providers’ and healthcare insurance employees’ preferences for existing health care for KHOA.
Method
A survey containing a discrete choice experiment (DCE) was conducted. Patients with KHOA, healthcare providers (orthopaedists and GPs), and insurance employees had to choose scenarios that differed in six attributes: waiting times, out of pocket costs, travel distance, involved healthcare providers during consultation, length of consultation and access to specialist equipment. A (panel latent class) conditional logit model was used to determine the relative importance of the attributes and trade-offs that responders made, and to explore preference heterogeneity.
Results
A total of 648 patients completed the DCE. All six attributes played a significant role in patients’ choices. On average, out of pocket costs were deemed undesirable by patients. A GP with an orthopaedist during the consultation was preferred compared to a GP alone. Healthcare providers (n = 76) and insurance employees (n = 150) showed similar preferences, with respect to out of pockets costs being valued less important. Latent class analysis identified four classes of patients varying in their preferences.
Conclusion
Patients prefer less out of pocket costs and a GP with an orthopedists during consultation for KHOA care. Four subgroups of patients were identified that vary in preferences for KHOA care. These subgroups could provide opportunities to improve uptake, adherence and effectiveness of KHOA care.
Ilgin Arslan, Department of General Practice, Erasmus MC, University Medical Center, Rotterdam
Samare Huls, Department of Health Economics, Erasmus University, Rotterdam, The Netherlands
Esther de Bekker-Grob, Department of Health Economics, Erasmus University, Rotterdam, The Netherlands
Rianne Rozendaal, Department of General Practice, Erasmus MC, University Medical Center, Rotterdam
Sita Bierma-Zeinstra, Department of General Practice, Erasmus MC, University Medical Center, Rotterdam; Department of Orthopaedic Surgery, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
Dieuwke Schiphof, Department
Address for correspondence Ilgin Arslan, Department of General Practice, Erasmus MC, University Medical Center, Rotterdam Email: i.arslan{at}erasmusmc.nl
Chest discomfort at night and risk of acute coronary syndrome: cross-sectional study of telephone conversations
DOI: 10.3399/bjgp20X711317
Background
During telephone triage it is difficult to assign the adequate urgency to patients with chest discomfort. Considering the time of calling could be helpful.
Aim
To assess the risk of acute coronary syndrome (ACS) in certain time periods and whether sex influences this risk.
Method
Cross-sectional study of 1,655 recordings of telephone conversations of patients who called the out-of-hours services primary care (OHS-PC) for chest discomfort. Call time, patient characteristics, symptoms, medical history and urgency allocation of the triage conversations were collected. The final diagnosis of each call was retrieved at the patient’s general practice. Absolute numbers of patients with and without ACS were plotted and risks per hour were calculated. The risk ratio of ACS at night (0 am to 9 am) was calculated by comparing to the risk at other hours, and was adjusted for gender and age.
Results
The mean age of callers was 58.9 (SD ± 19.5) years, 55.5% were women and in total, 199 (12.0%) had an ACS. The crude risk ratio for an ACS at night was 1.80 (CI = 1.39 to 2.34, P<0.001); 2.33 (1.68 to 3.22, P<0.001) for men, and 1.29 (0.83 to 1.99, P = 0.256) for women. The adjusted risk ratio for ACS of all people at night was 1.82 (1.07 to 3.10, P = 0.039).
Conclusion
Patients calling the OHS-PC for chest discomfort between 0–9 am have almost twice a higher risk of ACS than those calling other hours, a phenomenon more evident in men than in women. At night, dispatching ambulances more ‘straightaway’ could be considered for these patients with chest discomfort.
Loes Wouters, Julius Center for Health Sciences and Primary Care
Dorien Zwart, Julius Center for Health Sciences and Primary Care
Carmen Erkelens, Julius Center for Health Sciences and Primary Care
Esther de Groot, Julius Center for Health Sciences and Primary Care
Roger Damoiseaux, Julius Center for Health Sciences and Primary Care
Arno Hoes, Julius Center for Health Sciences and Primary Care
Frans Rutten, Julius Center for Health Sciences and Primary Care
Address for correspondence Loes Wouters, Julius Center for Health Sciences and Primary Care,
Email:l.t.c.wouters-2{at}umcutrecht.nl
Missed acute coronary syndrome during telephone triage at out-of-hours primary care: lessons from a case-control study
DOI: 10.3399/bjgp20X711329
Background
Serious adverse events (SAE) at out-of-hours services in primary care (OHS-PC) are rare.
It most often concerns missed acute coronary syndromes (ACS). Root cause analyses highlighted errors in the triage process, but these analyses are hampered by hindsight bias.
Aim
To compare triage calls at the OHS-PC of missed ACS with matched controls with chest discomfort but without a missed ACS; and to assess predictors of missed ACS.
Method
A case-control study with triage recordings of calls of a missed ACS registered between 2013–2017. Controls were from the same period. Cases were matched 1:8 with controls based on age and gender. Clinical, patient and call characteristics were assessed, and 15 expert GPs rated the triage safety and quality, being blinded to the final diagnosis. We applied conditional logistic regression analysis.
Results
Fifteen missed ACS calls and 120 matched control calls were included. Cases used less cardiovascular medication (38.5% versus 64.1%, P = 0.05), and more often experienced retrosternal chest pain (63.3% versus 24.7%, P = 0.02) than controls. Consultation of the supervising GP (86.7% versus 49.2%, P = 0.02) occurred more often in cases than controls. Experts rated the triage of cases more often as ‘poor’ (33.3% versus 10.9%, P = 0.001), and ‘unsafe’ (73.3% versus 22.5%, P<0.001) than that of controls.
Conclusion
It seems nearly impossible to differentiate missed ACS at the OHS-PC from others with chest discomfort based on symptom presentation.
Carmen Erkelens, Julius Center for Health Sciences and Primary Care
Frans Rutten, Julius Center for Health Sciences and Primary Care
Loes Wouters, Julius Center for Health Sciences and Primary Care
Esther de Groot, Julius Center for Health Sciences and Primary Care
Roger Damoiseaux, Julius Center for Health Sciences and Primary Care
Arno Hoes, Julius Center for Health Sciences and Primary Care
Dorien Zwart, Julius Center for Health Sciences and Primary Care
Address for correspondence Carmen Erkelens, Julius Center for Health Sciences and Primary Care
Email:d.c.a.erkelens{at}umcutrecht.nl
The Moving Healthcare Professionals Programme
DOI: 10.3399/bjgp20X711341
Background
Healthcare professionals (HCPs) are estimated to see nearly 500 000 patients during their career. Evidence demonstrates that one in four patients would be more active if advised by their GP. However, there is a lack of engagement between HCPs and patients regarding the benefits of physical activity (PA). PA is not discussed with 80% of patients, with 75% of GPs feeling they lack knowledge to advise their patients.
Aim
Moving Healthcare Professionals Programme (MHPP) aims include increasing awareness and skills in PA for prevention and management of ill health; changing clinical practice in the promotion of activity; and evaluating impact to identify ‘what works’.
Method
GPs were recruited as Physical Activity Clinical Champions (PACCs) to deliver peer-to-peer training to HCPs nationally. Additionally, relationships were developed with undergraduate medical schools to embed PA into curriculum. A PA advice pad was developed as a local GP pilot, while the ‘Moving Medicine’ online resource was created.
Results
Over 22 000 HCPs were trained to date, with evaluation demonstrating an increase in knowledge, skills and confidence, and over 18 000 completions of our eLearning modules. PA coverage was expanded across the undergraduate curriculum at multiple medical schools, while feedback on the e-advice pad pilot has informed a further digital pilot. Additionally, there were >3000 monthly users of ‘Moving Medicine’.
Conclusion
This work demonstrated scope for significant improvements in HCP engagement in multiple clinical settings. Working with GPs has proved crucial to this success across various workstreams, with their participation a continued focus moving into Phase 2.
Michael Brannan, Public Health England, Physical Activity Team
Matt Hughes-Short, Public Health England, Physical Activity Team
Address for correspondence Matt Hughes-Short, Public Health England, Physical Activity Team
Email:matthew.hughesshort{at}phe.gov.uk
A qualitative evaluation of a prescribing e-learning package for general practice
DOI: 10.3399/bjgp20X711353
Background
The GMC PRACtiCe study identified a 1 in 20 error rate in prescriptions issued in general practice and identified a need for further training in prescribing. As a result, an e-Learning prescribing package was designed and launched to healthcare professionals through the Royal College of General Practitioners in January 2014.
Aim
This part of the study explored the longer-term impact on prescribing knowledge, attitudes and behaviours of practitioners completing the eLearning prescribing package.
Method
On completion of the e-Learning package, participants were asked to indicate their willingness to be contacted for a telephone interview. Semi-structured interviews were conducted which were audio recorded, transcribed verbatim and analysed using thematic analysis, aided by NVivo. Interviewees were invited to enter a prize draw to win Stockley’s Drug Interaction textbook (provided courtesy of the Royal Pharmaceutical Society).
Results
Of the 120 participants who expressed an interest in being followed up for interview, seven prescribers were interviewed in 2014 and 2015. Reasons for completing the course were explored, and interviewees gave examples of changes made to their prescribing practice as a result of completing the e-Learning. This included the adoption of specific strategies to enhance safe practice, and enacting enhanced vigilance in key areas such as renal function monitoring. Some changes to the course content and presentation were also recommended.
Conclusion
These interviews have highlighted the potential for using e-Learning for prescribing training and to achieve long-term changes in prescribing practice. However, further work is needed to generate substantive evidence of its impact on prescribing.
Richard Knox, University of Nottingham
Nde-Eshimuni Salema, University of Nottingham
Naomi Clement, University of Nottingham
Brian Bell, University of Nottingham
Gill Gookey, Rushcliffe CCG
Glen Swanick, University of Nottingham
Anthony Avery, University of Nottingham
Address for correspondence Richard Knox, University of Nottingham
Email:richard.knox{at}nottingham.ac.uk
Awareness and use of online appointment booking in general practice: analysis of GP Patient Survey data
DOI: 10.3399/bjgp20X711365
Background
General practices are required to provide online booking to patients in line with policy to digitise access. However, uptake of online booking by patients is currently low and there is little evidence about awareness and use by different patient groups.
Aim
To examine variability in awareness and use of online appointment booking in general practice.
Method
Secondary analysis of two questions from the GP Practice Survey data (2018) asking about awareness and use of online booking of appointments. Multivariable logistic regression was used to examine associations with age, gender, ethnicity, deprivation, the presence of a long-term condition, long-term sickness and being deaf.
Results
In total, 43.3% (277 278/647 064) of responders reported being aware of being able to book appointments online, while only 15% (93 671/641 073) reported doing so. There was evidence of variation by all factors considered, with strong deprivation gradients in both awareness and use (for example, most versus least deprived quintile OR for use: 0.63 (95% CI = 0.61 to 0.65). There was a reduction in awareness and use in patients >75 years of age. Patients with long-term conditions were more aware and more likely to use online booking.
Conclusion
While over 40% of patients know that they can book appointment online, the number that actually do so is far lower. With the constant push for online services within the NHS and the roll out of the NHS app, practices should be aware that not all patient groups will book appointments online and that other routes of access need to be maintained to avoid widening health inequalities.
Mayam Gomez-Cano, University of Exeter Medical School
Helen Atherton, The University of Warwick
John Campbell, University of Exeter Medical School
Abi Eccles, The University of Warwick
Jeremy Dale, The University of Warwick
Leon Poltawski, University of Exeter Medical School
Gary Abel, University of Exeter Medical School
Address for correspondence Gary Abel, University of Exeter Medical School,
Email:g.a.abel{at}exeter.ac.uk
Interpreter costs across clinical commissioning groups in England 2017–2018: a cross sectional survey using ‘freedom of information’ requests
DOI: 10.3399/bjgp20X711377
Background
Professional interpreters are considered to be the gold standard when meeting the needs of patients with limited English proficiency (LEP) in primary care. The models by which CCGs supply interpreting services (IS) vary. Many CCGs use external commercial IS, while other CCGs commission ‘not for profit’ services such as the Advocacy and Interpreting Service in Tower Hamlets, the Sussex Interpreting Service, and the decommissioned Sheffield Community Access and Interpreting Service. Research on comparative costs and needs of the LEP population is lacking.
Aim
To compare the costs of interpreting services between CCG’s in England.
Method
A cross-sectional study involving CCGs in England. A standardised request was sent to 195 CCGs inviting comment on how much the CCG spent (2017–2018) on IS. The data were plotted against a number of demographic variables (https://fingertips.phe.org.uk) and analysed using regression analysis.
Results
Survey response rate: 86% of CCGs (n = 169). Of those CCGs who responded, 39% (n = 66) did not hold IS cost data. NHS England spent £2 951 348.16 for IS services for the year 2017–2018. A positive correlation was noted with increased cost of interpreting services when plotted against increasing percentage BME or percentage birth to non-UK parents. However, there were wide variations around correlation of best fit indicating variation in spending between CCGs for similar populations.
Conclusion
Inter CCG variation in correlations between demographic variables and expenditure suggests further research is needed to determine how to optimise and resource safe and equitable IS across the UK population.
David Lehane, University of Sheffield
Philip Oliver, University of Sheffield
Caroline Mitchell, University of Sheffield
Christopher Burton, University of Sheffield
Address for correspondence David Lehane, University of Sheffield
Email:d.lehane{at}sheffield.ac.uk
Determinants of primary care workforce variation in England
DOI: 10.3399/bjgp20X711389
Background
The General Practice Forward View (GPFV) outlined how the government plans to attain a strengthened model of general practice. A key component of this proposal is an expansion of the workforce by employing a varied range of practitioners, in other words ‘skill mix’. A significant proportion of this investment focuses on increasing the number of ‘new’ roles such as clinical pharmacists, physiotherapists, physician associates, and paramedics.
Aim
The aim of this study is to examine what practice characteristics are associated with the current employment of these ‘new’ roles.
Method
The study uses practice level workforce data (2015–2019), publicly available from NHS Digital. The authors model FTE of specific workforce groups (for example, advanced nurse) as a function of deprivation, practice rurality, patient demographics (total list size and percentage of patients aged >65 years) and FTEs from other staff groups.
Results
Although analysis is ongoing, initial estimation suggests that the employment of ‘new’ roles has occurred in larger practices (in terms of list size), in practices with a higher proportion of patients living in deprived areas and practices with a larger proportion of patients aged >65 years. FTE for advanced nurses is negatively associated with GP FTE.
Conclusion
A negative correlation between advanced nurse FTE and GP FTE is potentially suggestive of substitution between roles, deliberate or otherwise. For example, practices may employ ‘new’ roles if they are unable to recruit GPs or they may recruit staff to free up GP time. Further work is needed to confirm these findings and to explore the reasons behind practice employment decisions.
Jon Gibson, University of Manchester
Sharon Spooner, University of Manchester
Matt Sutton, University of Manchester
Address for correspondence Jon Gibson, University of Manchester
Email:jon.m.gibson{at}manchester.ac.uk
Motivating factors behind skill mix change: results from a practice managers’ survey in England
DOI: 10.3399/bjgp20X711401
Background
The expansion of the primary care workforce by employing a varied range of practitioners (‘skill mix’) is a key component of the General Practice Forward View (GPFV). The extent of skill mix change and where that has occurred has been examined using publicly available practice level workforce data. However, such data does not provide information regarding specific motivating factors behind employment decisions for individual practices nor future workforce plans.
Aim
To identify key motivating factors behind practice workforce decisions and their future workforce plans.
Method
An online questionnaire was sent to practice managers in England. Data collection is ongoing; however, 1000 practices have responded to the survey so far. The questionnaire was composed of questions related to current workforce, motivating factors behind employment decisions, planned future workforce changes, financial assistance with employing staff (for example, HEE or CCG funding) and ideal workforce.
Results
Early results indicate that practices that have employed physician associates have done so to increase appointment availability (78% of practices) and release GP time (68%). Sixty-six per cent of practices who have employed pharmacists have received some form of financial assistance with 21% of practices still receiving assistance. When asked to construct an ideal workforce, ‘new’ roles accounted for 20% of that workforce on average, which is a significantly larger proportion than those roles currently account for.
Conclusion
Although data collection and analysis are ongoing, the results of the survey provide novel insights into the underlying motivating factors behind employment decisions, specifically for new roles such as pharmacists, PAs and paramedics.
Jon Gibson, University of Manchester
Sharon Spooner, University of Manchester
Matt Sutton, University of Manchester
Imelda McDermott, University of Manchester
Mhorag Goff, University of Manchester
Kath Checkland, University of Manchester
Damian Hodgson, University of Manchester
Anne McBride, University of Manchester
Mark Hann, University of Manchester
Address for correspondence Jon Gibson, University of Manchester
Email:jon.m.gibson{at}manchester.ac.uk
Time for change? A comparative analysis of GPs’ opinions on appointment length
DOI: 10.3399/bjgp20X711413
Background
The research on the benefits, disadvantages and factors that affect appointment length in general practice is fragmented. There is a need to draw the evidence together and who better to assess this than those on the front line.
Aim
To investigate GPs’ opinions on appointment length, including the factors that affect appointment length, its impact on doctors and the validity of increasing appointment length.
Method
A questionnaire was sent to six general practices in Bristol and was completed by 30 GPs (response rate = 100%). Analysis of current appointment length, satisfaction and the ideal length was undertaken, alongside thoughts about the advantages and disadvantages of longer appointments. Ethical approval was successfully sought from Student Research Ethics Committee.
Results
Most doctors have 10-minute appointments (n = 29); however, 90% (n = 27) wished for 15 minutes. Appointments overrunning was described as a constant problem and resulting in stress. Longer appointments were due to multiple problems in a single consultation, mental health and multimorbidity. There did not appear to be any variation in viewpoints with practices, clinician experience and session length. The benefits of a longer appointment were a greater ability to deal with complex conditions, improved decision making, stress reduction and time to talk about interventions. However, 93.3% (n = 28) of doctors were concerned that there would be less appointments available if appointment lengths increased.
Conclusion
Most doctors would like longer appointments. In light of the concern about appointment availability, there needs to be research into whether this would substantiate.
Katherine Murdoch, University of Bristol
Address for correspondence Katherine Murdoch, University of Bristol
Email:km14870{at}bristol.ac.uk
In situ deteriorating patient simulation in general practice
DOI: 10.3399/bjgp20X711425
Background
GP practices have limited access to medical emergency training and basic life support is often taught out of context as a skills-based event.
Aim
To develop and evaluate a whole team integrated simulation-based education, to enhance learning, change behaviours and provide safer care.
Method
Phase 1: 10 practices piloted a 3-hour programme delivering 40 minutes BLS and AED skills and 2-hour deteriorating patient simulation. Three scenarios where developed: adult chest pain, child anaphylaxis and baby bronchiolitis. An adult simulation patient and relative were used and a child and baby manikin. Two facilitators trained in coaching and debriefing used the 3D debriefing model. Phase 2: 12 new practices undertook identical training derived from Phase 1, with pre- and post-course questionnaires. Teams were scored on: team working, communication, early recognition and systematic approach. The team developed action plans derived from their learning to inform future response. Ten of the 12 practices from Phase 2 received an emergency drill within 6 months of the original session. Three to four members of the whole team integrated training, attended the drill, but were unaware of the nature of the scenario before. Scoring was repeated and action plans were revisited to determine behaviour changes.
Results
Every emergency drill demonstrated improved scoring in skills and behaviour.
Conclusion
A combination of: in situ GP simulation, appropriately qualified facilitators in simulation and debriefing, and action plans developed by the whole team suggests safer care for patients experiencing a medical emergency.
Joanna Lawrence, Brighton and Sussex Medical School
Petronelle Eastwick-Field, Health Education Thames Valley
Anne Maloney, Health Education England Thames Valley
Helen Higham, Health Education England Thames Valley
Address for correspondence Petronelle Eastwick-Field, Health Education Thames Valley
Email:petronelle1{at}hotmail.co.uk
GP views on the routine identification of older people living with frailty in primary care
DOI: 10.3399/bjgp20X711437
Background
To meet the challenges of an ageing population, the updated 2017/18 NHS GP contract requires primary care providers to use evidence-based frailty identification tools to risk-stratify all patients aged >65 years. Those patients flagged as moderately or severely frail should be clinically reviewed and if severe frailty is confirmed, providers have been asked to consider offering relevant interventions, with the overall aim of enabling these patients to live well for longer. However, there is limited knowledge about how this frailty contractual requirement is being operationalised in primary care.
Aim
To improve understanding of the barriers and facilitators GPs encounter when routinely identifying, risk-stratifying and providing interventions for people living with frailty in primary care.
Method
This was a two-part study: an initial survey via online questionnaire, with participants selected by maximum variation sampling to be followed up with a semi-structured telephone interview. All GPs working in the East Midlands region (Derbyshire, Leicestershire, Lincolnshire, Nottinghamshire, and Northamptonshire) were eligible to take part. The online questionnaire was analysed using descriptive statistics. Interview transcripts were analysed using framework analysis to identify key themes.
Results
In total, 188 GPs responded to the survey. Eighteen GPs were interviewed. Four themes were identified: 1) beliefs about stratification and pro-active identification of frailty; 2) frailty stratification tools; 3) managing complexity, resources and models of care; and 4) drivers of GP behaviour.
Conclusion
The study findings will inform the further development of NHS England policy on the frailty contractual requirement for primary care providers.
Ebrahim Mulla, University of Nottingham
Elizabeth Orton, University of Nottingham
Denise Kendrick, University of Nottingham
Address for correspondence Ebrahim Mulla, University of Nottingham
Email:e_mulla{at}hotmail.co.uk
Poster Presentations
Healthcare professionals’ perspectives on lung cancer screening in the UK: a qualitative study
DOI: 10.3399/bjgp20X711449
Background
Lung cancer screening with low-dose CT has been shown to decrease mortality. Low lung cancer survival rates in the UK, driven primarily by late-stage presentation, provide the impetus for implementing screening. Nascent guidance on screening in the UK recommends primary care case-finding. However, the potential impact and acceptability on primary care, and the opportunistic utilisation of other case-finding routes such as pharmacies, smoking cessation services and respiratory clinics, have not been fully explored.
Aim
To explore healthcare professionals’ views and perspectives about lung cancer screening and their preparedness and willingness to be involved in its implementation.
Method
A qualitative study was carried out with semi-structured interviews conducted with GPs, pharmacists and staff from smoking cessation services within Southwark and Lambeth and from respiratory clinics in Guy’s and St. Thomas’ NHS Trust in London in 2018. Sixteen participants were interviewed, and the interview transcripts were analysed thematically.
Results
Participants described lung cancer screening as an important diagnostic tool for capturing lung cancer at an earlier stage and in increasing survivorship. However, the majority expressed a lack of awareness and understanding, uncertainty and concerns about the validity of screening, its misuse and the potential impact on their patients and workload.
Conclusion
Study participants had mixed opinions about lung cancer screening and expressed their concerns about its implementation. Addressing these concerns by providing resources and effective and detailed guidelines for their use may lead to greater engagement and willingness to be involved in lung cancer screening.
Charikleia Margariti, King’s College London
Maria Kordowicz, King’s College London
Gillian Selman, Guy’s and St Thomas’ NHS Foundation Trust
Arjun Nair, University College London Hospitals NHS Trust
Yvonne Akande, Guy’s and St Thomas’ NHS Foundation Trust
Azhar Saleem, Lambeth Clinical Commissioning Group
Tiago Rua, King’s College London
Address for correspondence Charikleia Margariti, King’s College London
Email:xaroula88{at}hotmail.com
Achieving better quality care in general practice: are incentives the answer?
DOI: 10.3399/bjgp20X711461
Background
The introduction of financial incentives, such as the quality and outcomes framework (QOF), historically lead to improvements in standardising practice. However, with shifting demands on healthcare providers, are these schemes still enough to drive high-quality care?
Aim
To explore current incentives, intrinsic and extrinsic, their role and effectiveness in improving quality of care and how they are perceived by GPs.
Method
Mixed methods study using two systematic literature reviews including 44 papers and 18 semi-structured interviews with GPs.
Results
In the literature, QOF was associated with reduced socioeconomic inequalities, decreased mortality and improved outcomes. However, the absence of control groups and the simultaneous analysis of multiple indicators complicates the findings. GPs agreed with the literature and viewed financial incentives as beneficial, however, they felt the key driver in providing good-quality care was their intrinsic motivation. Financial incentives were found to contribute to depersonalised care, diluted provision of non-incentivised activities and hindered overall practice. The results from the second literature review were in keeping with the views of the participants. They illustrated the importance of managing factors contributing to physician burnout, reduced performance, and low job satisfaction, which can result in the provision of low-quality care.
Conclusion
Financial incentives have the potential to induce behaviour change, however, their use in quality improvement is limited when used alone. If used in an environment that nurtures intrinsic motivation, healthcare providers will be more driven to achieve a higher quality of care and will be better able to cope with shifting demands.
Kanwal Ahmed, Imperial College London
Salma Hashim, Imperial College London
Mariyam Khankhara, Imperial College London
Ilhan Said, Imperial College London
Amrita Shandakumar, Imperial College London
Sadia Zaman, Imperial College London
Andre Veiga, Imperial College London
Address for correspondence Kanwal Ahmed, Imperial College London
Email:ka2415{at}ic.ac.uk
2017 Cancer Prevalence Dashboard for London
DOI: 10.3399/bjgp20X711473
Background
As cancer incidence increases and survival improves, the number of people living with a cancer diagnosis is increasing. People living with cancer have 50% more contact with GPs 15 months after diagnosis than a population of similar age, sex and locality; 70% have another long-term condition.
Aim
To aid service providers’ understanding of the cancer prevalent population by creating a publicly available visualisation tool that both describes patients’ demographics and length of time lived with cancer, and compares counts of nationally registered cancer survivors to GP-maintained registers.
Method
Using National Cancer Registration and Analysis Service (NCRAS) data, prevalence rates and counts were generated for London patients diagnosed 1995–2017 and alive 31 December 2017, overall and for lower-level geographies. GP-recorded Quality and Outcomes Framework (QOF) prevalence at Clinical Commissioning Group (CCG) level was compared to NCRAS counts for the same period.
Results
On 31 December 2017, 231 740 (2.6%) people were living with cancer in London; 33% were diagnosed 5–9 years prior and 31% were diagnosed ≥10 years prior. Prevalence was higher in women (P<0.001) and dramatically increased with age for London (P<0.001); >12% of >75 year olds were living with a cancer diagnosis in every lower-level geography. Completeness of GP QOF cancer registers against NCRAS prevalence counts ranged from 75–108% across CCGs.
Conclusion
Local understanding of the cancer prevalent population is needed, with a concerted effort to interpret large discrepancies between QOF and NCRAS registers, which may arise from differences in coding practice. Ensuring patients are identified in primary care is a first key step to managing cancer as a long-term condition.
Amy Zalin, Public Health England and Transforming Cancer Services Team Partnership
Sophie Jose, Public Health England and Transforming Cancer Services Team Partnership
Jason Petit, Transforming Cancer Services Team — Healthy London Partnership
Liz Price, Transforming Cancer Services Team — Healthy London Partnership
Tania Anastasiadis, NHS Tower Hamlets CCG
Address for correspondence Amy Zalin, Public Health England and Transforming Cancer Services Team Partnership
Email:amy.zalin{at}phe.gov.uk
How do you diagnose asthma? A multiple case study design to understand and explain current use of national guidelines by primary care clinicians
DOI: 10.3399/bjgp20X711485
Background
Clinical guidelines for asthma are available to UK clinicians but implementation is not straightforward. Diagnostic and treatment inadequacy contribute to patient morbidity and mortality and lack of adherence to guidelines is a component of this.
Aim
This qualitative study sought to explore and understand the use of asthma guidelines by primary care clinicians in two geographically bounded regions of Wales.
Method
Multiple case study design was used. Data was collected using semi-structured interviews with a purposively sampled group of clinical staff from GP practices. Interview transcripts were thematically analysed to produce a detailed picture of practice.
Results
Asthma care in the studied areas operated as a social network of clinicians who often used guidelines as boundary objects. Practice and local service design was influenced and dependent on regular input from local secondary care providers. Clinicians looked to British Thoracic Society and Scottish Intercollegiate Guideline Network (BTS/SIGN) 2016 guidelines. There was limited use of National Institute for Health and Care Excellence (NICE) 2017 guidelines. Barriers to guideline recommended diagnostic asthma care included: lack of acceptability, financial costs and disempowerment of nursing staff.
Conclusion
The findings from this study replicate and reinforce the findings of previous work. It is striking and concerning that the thematic outcomes of this study bear a strong resemblance to that which was demonstrated over a decade ago. The guideline-implementation gap in asthma diagnostics will likely persist unless there is significant restructuring, financial investment and greater empowerment of nursing staff in primary care.
Fiona Hares, Betsi Cadwaladr University Health Board
Daniel Menzies, Glan Clwyd Hospital
Paul Brocklehurst, Bangor University
Sion Williams, Bangor University
Address for correspondence Fiona Hares, Betsi Cadwaladr University Health Board
Email:fionahares{at}doctors.org.uk
The prevalence of musculoskeletal presentations in general practice: an epidemiological study
DOI: 10.3399/bjgp20X711497
Background
It is estimated that 28.9% (17.8 million) of the UK population live with a musculoskeletal (MSK) condition. They are a major cause of morbidity, and a significant reason for presentation to primary care.
Aim
The primary aim of this study was to determine the prevalence of MSK conditions presenting for consultation in general practice. The secondary aim was to determine specifically which MSK conditions present most frequently in general practice.
Method
A total of 545 consultations were reviewed at an urban community general practice, which included evaluating morning consultations over a 1-week period taken from each of January, April, July and October 2018. This encompassed all morning consultations from all GPs present. The number of MSK consultations were recorded and, within that, the different presentations and their management plan.
Results
A total of 115 of all consultations were regarding an MSK presentation yielding an overall prevalence of 21.1%. The commonest MSK presentations included the lumbosacral spine (18.3%) and the knee (17.4%). Re-presentations of original condition accounted for 73.9% of all MSK consultations. Steroid injections were administered in 33% of knee related consultations.
Conclusion
This study demonstrates that MSK presentations account for a large proportion of GP workload. There are no current mandatory training requirements in orthopaedics as part of the GP curriculum. Structured MSK education for GPs is important and would reduce the burden of re-presentations, particularly that of the lumbosacral spine and knee. Competency in joint injection is also a valuable skill for GPs.
Ruairi Keavy, South Tyneside and Sunderland NHS Foundation Trust
Address for correspondence Ruairi Keavy, South Tyneside and Sunderland NHS Foundation Trust
Email:ruairi.keavy{at}nhs.net
A scoping review of community holistic interventions for older people with multimorbidity
DOI: 10.3399/bjgp20X711509
Background
In many areas, new regional community-based services have been established to provide holistic care to patients with high physical, mental and social needs. Older people represent a group with multimorbidity and high healthcare needs that may benefit from holistic care, although uncertainty remains whether such an approach is effective.
Aim
To review evidence for community holistic interventions in older people with multimorbidity.
Method
The authors screened studies referenced by an earlier Cochrane Review and Academy of Medical Sciences report, both of which looked at interventions and populations more broadly, and their own searches of Medline, EMBASE, trial registration databases and hand-searching of journals since 2015. The authors included controlled community-based studies of holistic interventions with data for people aged at least 60 years.
Results
Studies found (five published, two ongoing) were heterogeneous. The only significant improvement relating to physical or mental outcomes occurred in self-rated health scores, seen in two studies. One consisting entirely of diabetics showed developing a self-management plan improved self-rated health (P = 0.023), and Mental Component Summary (P = 0.03). The other used a multidisciplinary-team-guided personal care plan and found self-rated overall health improved (P = 0.02). Three studies looked at service usage, only one seeing a benefit, and only in the second year.
Conclusion
Community-based holistic interventions for people with multimorbidity tended to focus on disease management or medication modification, and resulted in few significant benefits, almost entirely in self-rated health measures. Research into interventions focused on those with the highest needs, for example, multimorbidity with frailty; high number of comorbidities may be more likely to demonstrate meaningful benefits.
Timothy Smith, University of Central Lancashire
Tahera Patel, University of Central Lancashire
Asangaedem Akpan, University of Liverpool
Andrew Clegg, University of Central Lancashire
Dame Caroline Watkins, University of Central Lancashire
Catherine Elizabeth Lightbody, University of Central Lancashire
Umesh Chauhan, University of Central Lancashire
Address for correspondence Timothy Smith, University of Central Lancashire
Email:tsmith10{at}uclan.ac.uk
Continuing professional development for GPs in Myanmar: a pilot programme
DOI: 10.3399/bjgp20X711521
Background
The quality of general practice in Myanmar is currently highly variable. No formalised system of revalidation yet exists and so engagement with continuing professional development (CPD) activities and motivation to further one’s own knowledge is sporadic.
Aim
To train GPs in three key areas; 1) recording CPD activities and maintaining a portfolio logbook; 2) reflecting on learning; and 3) what a future formalised CPD credit system may involve.
Method
Sixty-one GPs were recruited in March 2019 and given training on the above. Logbooks were issued, which were completed by the GPs while attending a simultaneous 3-month ‘GP CPD Refresher’ course, organised by the GP Society of Myanmar. The logbooks were then marked and individualised feedback given before issuing CPD accredited certificates.
Results
All GPs agreed the pilot helped them to better understand how to maintain a CPD logbook and the importance of doing so (retention rate = 67%). All GPs also reported they would now be more likely to continue to keep a portfolio. Finally, all GPs surveyed felt a credit reward system, used as tangible evidence of CPD participation, would positively influence their future engagement with CPD.
Conclusion
Improving general practice is a key component in helping Myanmar develop its healthcare system; one step required is making engagement with CPD compulsory for the revalidation of clinicians. This pilot has highlighted existing inadequacies within current training of GPs, as well as the potential benefits of implementing a CPD credit reward system.
Kerran Kandola, NHS Thames Valley and Wessex Leadership Academy
Myint Oo, General Practitioners Society of Myanmar
Address for correspondence Kerran Kandola, NHS Thames Valley and Wessex Leadership Academy
Email:kerran91{at}googlemail.com
Antibiotic resistance of uropathogenic Escherichia coli and ESBL prevalence in general practice patients over 10 years
DOI: 10.3399/bjgp20X711533
Background
Bacterial susceptibility to antibiotics changes over time. Knowledge of the susceptibility is important for antibiotic treatment guidelines in general practices.
Aim
To determine the antibiotic-susceptibility of E. coli from uncomplicated UTI among women in general practices in the Netherlands and to compare the results with those collected in 2004 and 2009.
Method
Urine samples were collected from women with symptoms of uncomplicated UTI, in 30 sentinel GP practices of the Nivel Primary Care database. Patient characteristics, E. coli susceptibility and ESBL prevalence were analysed.
Results
In total, 689 samples were collected. E. coli was the most isolated uropathogen (83%). Antibiotic susceptibility was stable over time except for ciprofloxacin (96%, 97% and 94% in 2004, 2009 and 2014, respectively; P<0.05). The susceptibility to co-amoxiclav was 88%, 87% and 92% in 2004, 2009 and 2014, respectively. The prevalence of ESBL producing E. coli increased from 0.1% in 2004, to 2.2% in 2014 (P<0.05). Susceptibility for co-trimoxazole was the highest in the West (88%) and the lowest in the North (72%, P = 0.021). Ciprofloxacin susceptibility was related to antibiotic use in the past 3 months (97% no use versus 90% use, P = 0.002) and those aged >70 years (P = 0.005). In 2014, prescription of fosfomycin increased compared to 2009 (14.3% versus 5.6%) at the expense of co-amoxiclav, co-trimoxazole and ciprofloxacin (P<0.05).
Conclusion
The antibiotic susceptibility percentages to the agents tested were stable over the 10-year period, except for ciprofloxacin as was the prevalence of ESBL producing E. coli. Surveillance with regular intervals is warranted.
Antoinette van Driel, Erasmus University Medical Center
Address for correspondence Antoinette van Driel, Erasmus University Medical Center
Email:antoinet20{at}hotmail.com
Cancer treatment decisions for people living with dementia: experiences of family carers
DOI: 10.3399/bjgp20X711545
Background
Dementia and cancer are both diseases associated with older age. The National Cancer Data Audit in England found that 4.4% of people diagnosed with cancer also had cognitive impairment. Decisions about cancer treatment can be very complex when someone already has dementia. Often someone’s closest relative may be asked to make decisions on their behalf. Little is known about the psychosocial impact that this has on carers, or what their support needs are during this time.
Aim
To explore the experiences of family carers who have been involved in making cancer treatment decisions on behalf of a relative with dementia, in particular identifying challenges and support needs.
Method
The authors are conducting semi-structured interviews with carers of people with dementia who have been involved in making decisions about cancer treatment on their behalf. Data is being thematically analysed using an inductive approach. Two researchers will independently verify themes.
Results
The authors expect to have completed 14–18 interviews and will report their preliminary findings. Family carers experience many difficulties in the context of cancer and dementia, including lack of support when coping with the aftereffects of cancer treatment, lack of awareness among healthcare professionals regarding the authority granted by a lasting power of attorney and the anxiety created by feeling responsible for identifying cancer recurrence.
Conclusion
This study will highlight that supporting someone with dementia through cancer treatment, and having to make decisions about it on their behalf, creates unique challenges for carers. Currently there is a significant lack of support for those facing this distressing experience.
Catherine Hynes, University of Sheffield
Caroline Mitchell, University of Sheffield
Lynda Wyld, University of Sheffield
Address for correspondence Catherine Hynes, University of Sheffield
Email:c.hynes{at}sheffield.ac.uk
Exploring patient preference regarding interpreter use in primary care
DOI: 10.3399/bjgp20X711557
Background
Effective communication is considered an essential component of delivering health care. Trained, professional interpreters are the gold standard for overcoming language barriers with those with limited English proficiency (LEP). However, LEP patients often use unqualified interpreters such as family members and friends. Existing literature explores the rationale behind choosing different interpreters, but rarely from the patient perspective.
Aim
To explore the patient perspective on the type of interpreter best suited for primary care consultations.
Method
Participants self-identified as having LEP were recruited from four GP practices in areas of Sheffield with high proportions of black and minority ethnic (BME) residents. The participants were from Urdu-, Arabic-, or Romani-speaking ethnic groups. Semi-structured interpreted interviews were recorded, transcribed, and analysed thematically with independent verification of emergent themes. Interviews continued to data saturation.
Results
All participants expressed a preference for face-to-face interpreters. Urdu and Arabic participants highlighted the importance of using an interpreter with the same dialect; Roma participants were passionate about the need for qualified Roma interpreters. Most participants also identified trust and sex as important factors. However, interpreter preference varied between participants: some valued the continuity of family members, whereas others favoured the professionalism and linguistic accuracy associated with qualified interpreters.
Conclusion
This study identified conflicts between patient preferences and guidance for healthcare professionals; all of the participants disliked telephone interpreting, and many recognised the benefits of untrained interpreters. The study highlights the complexities of interpreter preference in primary care and suggests that the decision should be flexible, and patient centred.
Heather Steele, University of Sheffield
David Lehane, University of Sheffield
Elizabeth Walton, University of Sheffield
Caroline Mitchell, University of Sheffield
Address for correspondence David Lehane, University of Sheffield
Email:d.lehane{at}sheffield.ac.uk
A case study evaluation of a community multidisciplinary team in South East England using a mixed-method approach
DOI: 10.3399/bjgp20X711569
Background
Community multidisciplinary teams (MDTs) represent a model of integrated care comprising health, social care, and the voluntary sector where members work collaboratively to coordinate care for those patients most at risk.
Aim
The evaluation will answer the question, ‘What are the enablers and what are the restrictors to the embedding of the case study MDT into the routine practice of the health and social care teams involved in the project?’
Method
The MDT was evaluated using a mixed-method approach with normalisation process theory as a methodological tool. Both quantitative and qualitative data were gathered through a questionnaire consisting of the NoMAD survey followed by free-form questions.
Results
The concepts of the MDT were generally clear, and participants could see the potential benefits of the programme, though this was found to be lower in GPs. Certain professionals, particularly mental health and nursing professionals, found it difficult to integrate the MDT into normal working patterns because of a lack of resources. Participants also felt there was a lack of training for MDT working. A lack of awareness of evidence supporting the programme was shown particularly within management, GP, and nursing roles.
Conclusion
Specific recommendations have been made in order to improve the MDT under evaluation. These include adjustments to IT systems and meeting documentation, continued education as to the purpose of the MDT, and the engagement of GPs to enable better buy-in. Recommendations were made to focus the agenda with specialist attendance when necessary, and to expand the MDT remit, particularly in mental health and geriatrics.
Jessica Wyatt Muscat, South Kent Coast CC
Address for correspondence Jessica Wyatt Muscat, South Kent Coast CC
Email:jessica.wyatt-muscat{at}nhs.net
Opioid crisis in primary care? An audit of high-dose opioid prescribing at Bangholm GP Practice
DOI: 10.3399/bjgp20X711581
Background
Opioids are effective analgesics for acute and palliative pain, but there is no evidence base for long-term pain relief. They also carry considerable risks such as overdose and dependence. Despite this, they are increasingly prescribed for chronic pain. In the UK, opioid prescribing more than doubled between 1998 and 2018.
Aim
An audit at Bangholm GP Practice to understand the scale of high-strength opioid prescribing. The aim of the audit was to find out if indications, length of prescription, discussion, and documentation at initial consultation and review process were consistent with best-practice guidelines.
Method
A search on Scottish Therapeutics Utility for patients prescribed an average daily dose of opioid equivalent ≥50 mg morphine between 1 July 2019 and 1 October 2019, excluding methadone, cancer pain, or palliative prescriptions. The Faculty of Pain Medicine’s best-practice guidelines were used.
Results
Demographics: 60 patients (37 females), average age 62, 28% registered with repeat opioid prescription, 38% comorbid depression. Length of prescription: average 6 years, 57% >5 years, 22% >10 years. Opioid: 52% tramadol, 23% on two opioids. Indications: back pain (42%), osteoarthritis (12%), fibromyalgia (10%). Initial consultation: 7% agreed outcomes, 35% follow-up documented. Review: 56% 4-week, 70% past year.
Conclusion
Opioid prescribing guidelines are not followed. The significant issues are: long-term prescriptions for chronic pain, especially back pain; new patients registering with repeat prescriptions; and no outcomes of treatment agreed, a crucial message is the goal is pain management rather than relief. Changes have been introduced at the practice: a patient information sheet, compulsory 1-month review for new patients on opioids, and in-surgery pain referrals.
Charlotte Greene, King’s College London, GKT School of Medicine
Alice Pearson, King’s College London, GKT School of Medicine
Address for correspondence Charlotte Greene, King’s College London, GKT School of Medicine
Email:charlotte.greene{at}kcl.ac.uk
Inequalities in suicide rates associated with deprivation in England from 2004 to 2019
DOI: 10.3399/bjgp20X711593
Background
Although addressing inequality has been a public and political priority for decades, inequalities in health, wealth, and other societal domains persist in England. In Ireland, rates of suicide are twice as high in the most deprived decile of society compared with the least deprived. Trends in the association between deprivation and suicide in England are unclear.
Aim
To describe the relationship between deprivation and suicide in England in 2019 and analyse trends in this relationship over time.
Method
Data on rate of suicide and Index of Multiple Deprivation (IMD) for each local authority in England for 2018 and 2004 were obtained from the Office for National Statistics’ publicly available databases. The mean suicide rate for each quintile of deprivation was calculated, and means compared using ANOVA. The correlation coefficients between IMD and suicide rate were calculated for both 2004 and 2019. Steiger’s test was used to compare coefficients over time.
Results
In 2019, the suicide rate in the least deprived quintile was 8.7 per 100 000 person-years, compared with 8.3 in 2004. This increased across each quintile to 11.1 suicides per 100 000 person-years in the most deprived quintile in 2019 (ANOVA: P<0.001), and to 11.7 in 2004 (ANOVA: P<0.001). The correlation coefficient between IMD and suicide rate in 2004 was 0.43, compared with 0.33 in 2019. Steiger’s test demonstrated no significant difference between coefficients over time (P = 0.16).
Conclusion
Suicide is associated with deprivation in England. Despite significant research and policy effort, there has been no improvement in this association between 2004 and 2019.
Sam Hodgson, University of Southampton
Jack Hodgson, NHS Digital
Address for correspondence Sam Hodgson, University of Southampton
Email:samcbhodgson{at}gmail.com
Blood tests in general practice: the use of routine data to characterise venous blood testing in North West London, 2016–2018
DOI: 10.3399/bjgp20X711605
Background
Laboratory testing is an integral diagnostic tool, contributing to 70% of diagnoses in the NHS today. Its use has been steadily increasing despite estimates that ≤40% of blood tests ordered are unnecessary. Understanding blood-testing patterns is a fundamental step to tackling overuse.
Aim
To characterise the volume, type, and per patient frequency (PPF) of venous blood testing reported in general practice in North West London, 2016–2018.
Method
Following ethics clearance, aggregate data of blood tests reported in general practice in North West London between 2016 and 2018 were extracted from the Discover database. Non-venous blood test codes and codes not used within the designated time period were excluded. Codes reporting the same analyte were aggregated. Overall volume and PPF were calculated per analyte.
Results
Three hundred and thirty-six individual analytes were reported and grouped into 35 recognised panels or groupings. Blood testing increased by 16.5% over the 3-year period. Full blood count, urea and electrolytes, liver function tests, and lipid profile accounted for 80.4% of all venous blood tests. Requests for HbA1c increased by 52.8% and non-HDL cholesterol by 148.7%, whereas glucose decreased by 13.3% and urea by 15.7%. The PPF remained unchanged over the 3-year period at 1.29 blood tests per person per year. The coagulation assay had the highest PPF at 3.0.
Conclusion
Routine general practice data revealed important trends in blood testing. Trends uncovered can inform innovative and targeted solutions to reduce unnecessary blood testing.
Marize Bakhet, Imperial College London
Zia Ul-Haq, Imperial College Health Partners
Tahereh Kamalati, Imperial College Health Partners
Amanda Lucas, Imperial College Health Partners
Azeem Majeed, Imperial College London
Austen El-Osta, Imperial College London
Address for correspondence Marize Bakhet, Imperial College London
Email:m.bakhet{at}imperial.ac.uk
Management of gout and adherence to current guidelines in general practice surgery
DOI: 10.3399/bjgp20X711617
Background
Gout is one of the most common inflammatory joint diseases in the UK managed by GPs. The recent (2017) guideline of the British Society for Rheumatology (BSR) changed the recommendation for urate-lowering therapy (ULT) and now advises it after the first episode of gout, whereas it previously recommended after the second one. Moreover, the BSR now also recommends screening and management of risk factors of gout.
Aim
To audit contemporary management of gout and adherence to the new BSR guideline in a large GP practice.
Method
The audit identified all patients diagnosed with gout between 1 July 2017 and 1 May 2019. Pharmacological gout management, lifestyle advice, and management of risk factors were assessed, including body mass index (BMI), systemic blood pressure (BP), and HbA1c.
Results
The audit included 104 patients, 26.9% female, mean age 63.8 years at the age of diagnosis. Uric acid was raised in all patients (mean 469 um/L). Most patients (68%) had abnormal BMI (mean 30.4), whereas BP, cholesterol, and HbA1C were normal in the majority of patients (in 78%, 75%, and 90%, respectively); however, all of these parameters were normal in just 17% of patients. Lifestyle advice was given to 46 (44.2%) patients while allopurinol was prescribed, and overall in 21 (20.2%) patients. More patients were managed with colchicine (40.2%) and naproxen (56.7%).
Conclusion
Most patients diagnosed with a first gout attack have risk factors of gout and require their management. Overall, allopurinol is prescribed in a fifth of patients, which may be related to patients’ preferences, strict adherence to lifestyle modification only, or presence of contraindications to allopurinol. This requires, however, further assessment.
Agnes Kempny, Hartley Corner Surgery
Jamie Martin, Hartley Corner Surgery
Address for correspondence Agnes Kempny, Hartley Corner Surgery
Email:agnieszka.kempny{at}gmail.com
Evaluation of a novel anxiety and trauma intervention at the Edinburgh Fringe
DOI: 10.3399/bjgp20X711629
Background
Anxiety and psychological trauma are common presentations in general practice and may lead to long-term prescribing and/or time-consuming talking therapies.
Aim
To assess the efficacy and acceptability of short ‘Gazetherapy’ interventions.
Method
‘The Anxiety Experiment’ was delivered as a show at the Edinburgh Fringe Festival from 1–25 August 2019. Gazetherapy interventions were explained using props to describe polyvagal theory and cranial nerve and cerebellar/hippocampus anatomy and function. BabyGaze (reducing anxiety in the moment), da Vinci Gaze (attenuating stress), and Accessory Gaze (resolving simple trauma) were delivered to audiences of between six and 51 people during <10 minutes of the 50-minute presentation. Subjects were given a card bearing a QR code to link to an online survey containing validated short screening questionnaires: GAD-2 for probable anxiety disorder and PC-PTSD for probable post-traumatic stress disorder (PTSD).
Results
Efficacy: 73 (9.8%) attendees completed the survey, of whom 39% screened positive for anxiety and 26% screened positive for PTSD. Those screening negative in both tests (52%) were designated a control group, with 36% of them feeling better after the presentation. Fifty-nine per cent of probable anxiety ‘cases’ and 68% of probable PTSD cases felt better after the presentation; none felt worse. Acceptability: 95% reported a ‘definite’ or ‘probable’ intent to use the techniques in the future, with 5% (all non-cases) stating that they probably would not. No responder said they would definitely not use the techniques.
Conclusion
The acceptability and effectiveness of a new therapeutic approach were demonstrated by presenting them in a show at the Edinburgh Fringe.
Andrew Ashworth, sessional GP
Address for correspondence Andrew Ashworth, sessional GP
Email:drandy{at}me.com
Appropriate secondary prevention of stroke and transient ischaemic attack with antithrombotics: an audit in general practice
DOI: 10.3399/bjgp20X711641
Background
Stroke is a major cause of death and disability worldwide. Major advances have occurred in secondary prevention of stroke/transient ischaemic attack (TIA) during the past three decades. Primary care is a critical point of contact with patients in the implementation of secondary prevention, with the majority of patients with past stroke/TIA being managed in the community.
Aim
To assess current practice at the New Queen Street and Stanground Surgeries, Peterborough, in reference to the National Institute for Health and Care Excellence guidelines on secondary prevention of stroke/TIA.
Method
An audit at the above practices was undertaken by searching the SystmOne computer system for adult patients with previous stroke/TIA (311), excluding those with haemorrhagic stroke and those on aspirin. The patient records of the remaining group (37) were investigated to find whether they were on appropriate antithrombotic therapy and, if not, why.
Results
Of post-stroke/TIA patients, 234/236 were receiving antithrombotic therapy unless contraindicated. For those not on antithrombotics, risk of bleeding was the reason given in 10/13 of cases, though many of these patients did not have active bleeding (exact number unclear due to poor documentation). In 2/13 cases there was no documented reason given and informed dissent in one of the 13 cases.
Conclusion
It was found that both practices implemented the guidelines to a satisfactory degree. However, to further improve secondary prevention outreach, bleeding risk should be assessed using a tool such as S2TOP-BLEED before withholding antithrombotic therapy, as, on balance, antithrombotic therapy may still be preferable. In addition, accurate and detailed documentation of the indications/contraindications to anticoagulation is paramount for such assessment.
Isabelle Williams, University of Cambridge
William Smith, University of Cambridge
Edward Nash, University of Cambridge
Ajay Patel, New Queen Street and Stanground Surgeries
Address for correspondence Isabelle Williams, University of Cambridge
Email:ijmw2{at}cam.ac.uk
A pilot project on the management of osteoporosis in primary care: results of the audit cycle
DOI: 10.3399/bjgp20X711653
Background
Osteoporosis is a major public health problem with the ageing population in the UK. However, there is no known national algorithm for the management of osteoporosis in primary care. Therefore, a treatment pathway was developed in secondary care for patients in the community.
Aim
This audit cycle investigates whether patients at a GP practice with a population of 14 000 have been appropriately identified, coded as osteoporosis, treated, and have followed the recommended pathway.
Method
A search of the practice clinical system was undertaken for three groups of patients coded as: patients currently on the existing osteoporosis register; patients with a code of ‘osteoporosis’ or ‘fragility fracture’ but not prescribed an osteoporosis treatment; and patients currently prescribed an osteoporosis treatment with no coding for ‘osteoporosis’ or ‘fragility fracture’. The words ‘osteoporosis’, ‘fragility fracture’, ‘QOF’, and all individual drug names were used in the search engine.
Results
The completed audit cycle shows an increase in the proportion of patients following the local guidelines pathway, from 75% in 2018 to 81% in 2019, emphasising the importance of having a guideline for GPs to follow in order to optimise treatment and prevent future fragility fractures.
Conclusion
This is a pilot project to assess the ability to identify patients who have osteoporosis and review their treatment pathway. The results are promising as the analysed data indicate that GP practice lists can be used to identify and treat high-risk patients for osteoporosis and assess the adherence to the pathway. Using the pathway, GPs can more efficiently diagnose and manage patients.
Sindhuja Jothimurugan, Barts and the London School of Medicine and Dentistry
Subramanian Jothimurugan, Maylands Healthcare
Deepali Sanganee, Maylands Healthcare
Thushani Wickramaratne, Barking, Havering and Redbridge University Hospitals NHS Trust
Myo Lynn, Barking, Havering and Redbridge University Hospitals NHS Trust
Address for correspondence Sindhuja Jothimurugan, Barts and the London School of Medicine and Dentistry
Email:s.jothimurugan{at}smd14.qmul.ac.uk
Should diverticulitis be managed in primary care? An audit on the management of diverticulitis in primary care
DOI: 10.3399/bjgp20X711665
Background
The prevalence of diverticulosis and acute diverticulitis is increasing in developed countries. For those with diverticulosis the lifetime risk of developing acute diverticulitis is about 4–25%. Mild, uncomplicated diverticulitis can be, and often is, managed safely in a primary care setting, avoiding unnecessary admission.
Aim
To evaluate management of suspected diverticulitis in primary care against standards set by the National Institute for Health and Care Excellence (NICE) and review admission rates following primary care management.
Method
An electronic search on EMIS Web using Read codes ‘diverticulitis’, ‘diverticulosis’, and ‘diverticular disease’, with a specified period of 2017–2019. All consultations with suggestions of an infective flare of diverticular disease were included in the study. Clinical data from the consultations were extracted and retrospectively audited.
Results
A total of 64 patients were identified with diverticular disease or diverticulosis. Of those, 42% (n = 27) presented to primary care with presenting complaints suspicious of diverticulitis. A total of 64 consultations were reviewed, as several patients presented more than once in the study period. Of the consultations reviewed, 12.5% (n = 8) resulted in referral to the surgical assessment unit. Antibiotics were prescribed after 68.4% (n = 39) of consultations. Bloods for inflammatory markers were performed after 19.3% (n = 11) of consultations. Only 3.5% (n = 2) of patients were reviewed within the recommended 48-hour timeframe. Only 3.5% (n = 2) of patients subsequently deteriorated and required admission.
Conclusion
The management of diverticulitis in this primary care centre is not fully concordant with NICE guidelines. There is a need to improve adherence, in particular antibiotic regimen when deciding to prescribe antibiotics.
Miraen Kiandee, University Hospital North Midlands
Rajani Sripada, Tean Surgery
Address for correspondence Miraen Kiandee, University Hospital North Midlands
Email:miraen.mk{at}gmail.com
Multiple risk behaviour intervention to prevent depression in primary care
DOI: 10.3399/bjgp20X711677
Background
Primary care is the ideal setting for promotion and prevention intervention. Multiple risk behaviour interventions present several advantages over single-risk lifestyle interventions. Multiple risk behaviour interventions could be easily implemented in primary care to prevent non-communicable disease and depression.
Aim
To test the effectiveness of a multiple risk behaviour intervention to promote Mediterranean diet, physical activity, and/or smoking cessation in people attending Spanish primary health care with incidence of depression and symptoms of depression.
Method
This was a secondary analysis of the EIRA study that aims to test the effectiveness of a multiple risk behaviour intervention to promote healthy lifestyles. Twenty-six primary care centres were randomised to receive multiple risk behaviour intervention or usual care. The multiple risk behaviour intervention included individual sessions, group sessions, communitarian activities, and SMS reception. Participants were followed for 10–14 months. The primary outcomes of this study were incidence of depression and reductions of depressive symptoms.
Results
Three thousand and sixty-seven participants were included. Females accounted for 45.13% and 93.88% were Spanish. Age varied between 45 and 75 years old. The effectiveness of the intervention will be calculated using the Patient Health Questionnaire (PHQ-9) and the Composite International Diagnostic Interview (CIDI) depression section. Linear and logistic regression will be used to create predictive models.
Conclusion
Primary care is the most accessible service in the health system for patients. Hence primary care is the ideal setting for health education, promotion, and prevention interventions. This study will provide high-quality evidence about the effectiveness of multiple risk behaviour interventions over depression prevention.
Irene Gómez-Gómez, Universidad Loyola Andalucía
Patricia Moreno-Peral, Network for Prevention and Health Promotion in Primary Care
Tomás López, Network for Prevention and Health Promotion in Primary Care
Ana Clavería, Network for Prevention and Health Promotion in Primary Care
Barbara Oliván, Network for Prevention and Health Promotion in Primary Care
Ruth Marti, Network for Prevention and Health Promotion in Primary Care
Joan Llobera, Network for Prevention and Health Promotion in Primary Care
Jose-Angel Maderuelo-Fernández, Network for Prevention and Health Promotion in Primary Care
Emma Motrico, Universidad Loyola Andalucía
Address for correspondence Irene Gómez-Gómez, Universidad Loyola Andalucía
Email:igomezg{at}uloyola.es
Association between screen-time and school performance of secondary school children in Karachi, Pakistan
DOI: 10.3399/bjgp20X711689
Background
Electronic media are playing a negative role in people’s lives and yet people are unaware of the hazardous effect.
Aim
To show that screen-time of >1 hour had detrimental associations with school performance.
Method
A population-based, cross-sectional survey of 363 students, mean age 14.2 years (grades 5–8), from both government and private-sector schools in Karachi was conducted. A total of 363 students (210 males [57.9%] and 153 females [42.1%]) were included in the study. Of these students, 193 (53.2%) belonged to government schools and 173 (46.8%) to private schools. A questionnaire form was filled in. Weekday, weekend television, and video game screen-time was looked at. The main outcome was self-report of school performance (grades A, B, and C). Ordinal logistic regression analysis was used to test the independent effects of each variable, adjusting for demographics, child personality, and parenting style.
Results
Television content measurement showed that 69 (19%) students watched sports channels regularly while 30 (8.3%) and 3 (0.8%) watched educational and action programmes, respectively. The viewers of entertainment TV programmes (268 [73.8%]) and news programmes (159 [43.8%]) were in the majority. In terms of school grades, 154 students (42.4%) attained grade A, 180 students (49.6%) scored grade B, and 29 (8%) obtained grade C. Data showed no association between increased screen-time of ≤1 hour (weekdays as well as weekends) with poor school performance (P=0.46 and P=0.58, respectively).
Conclusion
Screen-time of ≤1 hour does not have any detrimental associations with poor school performance.
Kashan Niazi, Sulaiman Al Rajhi Colleges
Address for correspondence Kashan Niazi, Sulaiman Al Rajhi Colleges
Email:kashy1981{at}gmail.com
Revolutionising participants’ health and wellbeing through neuro-reprogramming via the Slimpod® app: a randomised controlled trial
DOI: 10.3399/bjgp20X711701
Background
Obesity is a global pandemic that threatens the health of the population and the sustainability of publicly funded health care. This randomised controlled trial addresses the gap in the literature surrounding unconscious persuasion and its use in weight loss and weight management. The Slimpod® tool is unlike any of those currently available on the market. Using breakthrough research in ‘nudge’ thinking, it is designed to retrain an adult’s habitual and emotional response to foodstuffs. This therapeutic model allows unconscious thought to be shaped into a manner more consistent with a healthy lifestyle. Candidates can then take control of their eating behaviours to induce a holistic state of wellbeing.
Aim
To assess the effectiveness of an audio unconscious-persuasion weight loss/weight management intervention (Slimpod®) compared with audio relaxation (control).
Method
Eighty-two overweight adults were randomised to intervention (n = 41) and control groups (n = 41). Weight was assessed at trial commencement, mid-trial (12 weeks), and trial end (24 weeks). Secondary outcomes were assessed using the Eating Self-Efficacy Scale (ESES), Exercise Confidence Scale (ECS), and Quality of Life Index Generic Version III (QLI-G3) at the start and end of the trial.
Results
Reports found a statistically significant difference in mean weight loss between intervention group (1.7 kg at 12 weeks and 4.3 kg at 24 weeks) versus control (0.6 kg and 1.2 kg respectively) at P<0.001. ESES scores showed greater self-efficacy (P = 0.008) in intervention at 24 weeks. No significant differences in ESES negative affect sub-scale score or ECS were observed.
Conclusion
Slimpod® was effective at reducing weight and increasing eating self-efficacy in overweight adults.
Richard Kyle, School of Health and Social Care, Edinburgh Napier University
Stephen Jones, Independent Statistical Consultant
Sandra Roycroft-Davis, Wellpods International
Address for correspondence Sandra Roycroft-Davis, Wellpods International
sandra{at}thinkingslimmer.com
Evaluating the relational continuity of care of four GP practices, one of which uses personalised lists
DOI: 10.3399/bjgp20X711713
Background
Continuity of care is a fading type of care because GPs are working more flexibly and at reduced working hours. The GP Contract gave a financial incentive to provide prompt GP appointments, but to the detriment of continuity of care. Increased patient demand for appointments has seemingly led to patients favouring ‘any’ appointment with a GP rather than ‘an appointment with the same GP’. Continuity of care in general practice is associated with greater patient satisfaction and is the preferred type of care for patients with chronic disease or psychological problems. In the Northeast of England there is a multi-partner GP practice that operates a true personalised list system. Other GP practices in the area do offer a degree of continuity of care, but this has not been measured.
Aim
To measure and compare the relational continuity of care index of four matched GP practices, one of which operates a personalised list.
Method
A written protocol enabled the authors to extract comparable anonymised data from four GP practices over a year (January to December 2019). Two standardised indexes of continuity of care (UPC and SLICC) were calculated and compared.
Results
Continuity of care was consistently higher with personalised lists. UPC index results show that all GP practices provide surprisingly high continuity of care, albeit not with patients’ assigned GPs. Higher monthly UPC scores versus overall scores indicate patients are receiving continuity of care in relation to their condition.
Conclusion
Continuity of care is still observed in GP practices that do not have personalised lists.
Riaan Swanepoel, North Tyneside CCG
Address for correspondence Riaan Swanepoel, North Tyneside CCG
Email:riaanswanepoel{at}nhs.net
Decision making on clinical care choices including end-of-life decision making for older adults in an acute care setting
DOI: 10.3399/bjgp20X711725
Background
The Scottish Government’s vision for older people is that ‘Older people are valued as an asset; their voices are heard and they are supported to enjoy full and positive lives.’ In the health and social care setting in Scotland it is increasingly recognised that there is a need for careful planning of care for older patients with complex comorbidities, and that this should involve the patient where possible via a process of shared decision making (SDM).
Aim
To establish what future planning for healthcare decision making and end-of-life care was undertaken in the care of the older patients in a secondary care facility, and how much they participate in this process.
Method
An audit was conducted across four wards in the care of the older patient setting in a hospital for older patients in Scotland. Over a 2-week period, all patients’ charts (n = 82) were reviewed, and evidence was examined on whether the following documents were in place: a do not resuscitate order; an escalation of medical care plan; and an assessment of capacity/incapacity.
Results
The majority of patients (55%) had a resuscitation plan in place. An Incapacity Statement was also in place for the majority of patients who required it (90%). The escalation of medical care plan was only completed for a minority of patients, mainly those on the palliative care ward.
Conclusion
Plans for decision making around resuscitation were reasonably well developed. However, planning for other, more complex, future medical care needs was less well defined or explored with older patients.
Sinead O’Reilly, Ayrshire and Arran NHS Trust
Address for correspondence Sinead O’Reilly, Ayrshire and Arran NHS Trust
Email:sineadoreilly3112{at}gmail.com
- © British Journal of General Practice 2020