ResearchPad - 1696 https://www.researchpad.co Default RSS Feed en-us © 2020 Newgen KnowledgeWorks <![CDATA[Patients’ views on involving general practice in bowel cancer screening: a South Australian focus group study]]> https://www.researchpad.co/article/elastic_article_12554 To explore patients’ experiences of bowel cancer screening and its promotion, and perspectives on possible input from general practice for improving screening rates.DesignQualitative focus group study underpinned by a phenomenological approach.SettingThree general practice clinics in metropolitan South Australia.ParticipantsThirty active general practice patients, aged 50–74 years (60% female) who were eligible for the National Bowel Cancer Screening Program.FindingsFactors affecting screening were described, with particular concerns regarding the nature of the test, screening process and culture. There were mixed views on the role for general practice in bowel cancer screening; some participants appreciated the current process and viewed screening as out of scope of primary care services, while others were in support of general practice involvement. Roles for general practice were proposed that comprised actions across the continuum from providing information through to reminders and the provision and collection of screening kits. With a view that multifaceted strategies are required to encourage participation, community-based solutions were suggested that centred on improving screening culture and education.ConclusionsThere was a view among participants that general practice could play a useful role in supporting the uptake of the National Bowel Cancer Screening Program, however participants saw a need for multiple strategies at different levels and under different jurisdictions. ]]> <![CDATA[Independent medical evaluation of general practitioners’ follow-up of sick-listed patients: a cross-sectional study in Norway]]> https://www.researchpad.co/article/elastic_article_9110 The study was designed to examine the sufficiency of general practitioners’ (GPs) follow-up of patients on sick leave, assessed by independent medical evaluators.DesignCross-sectional studySettingPrimary health care in the Western part of Norway. The study reuses data from a randomised controlled trial—the Norwegian independent medical evaluation trial (NIME trial).ParticipantsThe intervention group in the NIME trial: Sick-listed workers having undergone an independent medical evaluation by an experienced GP at 6 months of unremitting sick leave (n=937; 57% women). In the current study, the participants were distributed into six exposure groups defined by gender and main sick leave diagnoses (women/musculoskeletal, men/musculoskeletal, women/mental, men/mental, women/all other diagnoses and men/all other diagnoses).Outcome measureThe independent medical evaluators assessment (yes/no) of the sufficiency of the regular GPs follow-up of their sick-listed patients.ResultsEstimates from generalised linear models demonstrate a robust association between men with mental sick leave diagnoses and insufficient follow-up by their regular GP first 6 months of sick leave (adjusted relative risk (RR)=1.8, 95% CI=1.15–1.68). Compared with the reference group, women with musculoskeletal sick leave diagnoses, this was the only significant finding. Men with musculoskeletal diagnoses (adjusted RR=1.4, 95% CI=0.92–2.09); men with other diagnoses (adjusted RR=1.0, 95% CI=0.58–1.73); women with mental diagnoses (adjusted RR=1.2, 95% CI=0.75–1.77) and women with other diagnoses (adjusted RR=1.3, 95% CI=0.58–1.73).ConclusionsAssessment by an independent medical evaluator showed that men with mental sick leave diagnoses may be at risk of insufficient follow-up by their GP. Efforts should be made to clarify unmet needs to initiate relevant actions in healthcare and work life. Avoiding marginalisation in work life is of the utmost importance.Trial registration number NCT02524392; Post-results. ]]> <![CDATA[Recognition of anxiety disorders in children: a cross-sectional vignette-based survey among general practitioners]]> https://www.researchpad.co/article/N274f3076-312b-403c-a48f-17e7349a14fe To quantify general practitioners’ (GPs) sensitivity to anxiety disorders (ADs) when confronted with the range of symptoms common to children with ADs. Also, to explore GPs’ conscious preferences and implicit tendencies for referral of children with ADs to mental healthcare.Design and settingIn a cross-sectional vignette-based survey, all attendees of a Dutch continuing medical education conference for primary care physicians were presented with subtitled audio fragments of five vignettes that we constructed to mimic symptom presentation of children with ADs in general practice. We asked attendees to select per vignette the most plausible diagnoses and most adequate referral option, and for their general referral preferences when they suspect each of the most common mental health problems.ParticipantsA sample of 229 GPs, resulting in a total of 1128 vignette evaluations.Main outcome measureGPs’ selection rate of ADs in the five vignettes compared with a benchmark provided by mental health professionals (MHPs).ResultsOverall, recognition of ADs was less likely in GPs compared with MHPs (OR=0.26, 95% CI 0.15 to 0.46). GPs varied in their recognition of anxiety, with 44.1% not once selecting anxiety as the probable presenting problem. When asked explicitly, 63.9% of the GPs reported that they would refer a child to mental healthcare when they suspect probable ADs. By contrast, only 12.0% of the GPs who recognised anxiety in the vignettes actually selected that referral option.ConclusionA significant fraction of GPs did not notice the depicted symptoms as anxiety. Despite the widespread prevalence of ADs, GPs seem to overlook anxiety already in their early diagnostic opinion. Improving GPs’ familiarity with initial symptom presentation, ADs’ base-rate, relevance and impact yields potential for timely recognition. ]]> <![CDATA[Knowledge and perspectives of the new National Cervical Screening Program: a qualitative interview study of North Queensland women—‘I could be that one percent’]]> https://www.researchpad.co/article/N88f64b2d-25a5-4184-883f-c16a665cc1ab

Objectives

To investigate women’s understanding and attitudes towards the National Cervical Screening Program (NCSP) and to explore methods to improve screening participation.

Design

Semi-structured face-to-face interviews were conducted through convenience and snowball sampling. Thematic analysis occurred using the interpretivist framework.

Setting

A private general practice in North Queensland.

Participants

Women between the ages of 18 and 74 who attended the general practice were eligible to participate. Fourteen women between 20 and 58 years old were interviewed.

Results

Participants were concerned that the new NCSP would miss cancer due to longer screening intervals and reliance on primary human papilloma virus (HPV) testing. They believed that young women are at increased risk of cervical cancer, due to perceived HPV vaccine ineffectiveness and parent objection to vaccination. Most participants were not agreeable to self-sampling and preferred their doctor to perform screening. Personal and practitioner beliefs influenced a woman’s screening participation. Personal factors include being healthy for themselves and their family, previous abnormal smears and family history of cancer. Emphasis was placed on feeling ‘comfortable’ with their practitioner which included patient rapport and gender preference. Proposed methods to improve cervical screening included education programmes, advertising campaigns, general practitioner interventions and improving accessibility.

Conclusions

It is apparent that women are hesitant about the new NCSP. However, when provided with additional information they were more amenable to the changes. This highlights the need to improve awareness of cervical screening and the new NCSP.

]]>
<![CDATA[Primary care patient and practitioner views of weight and weight-related discussion: a mixed-methods study]]> https://www.researchpad.co/article/N2305c980-dd39-4965-b9b0-53b4789a54a4

Objective

To understand the beliefs that primary care practitioners (PCPs) and patients with overweight and obesity have about obesity and primary care weight management in Scotland.

Setting

Seven National Health Service (NHS) Scotland primary care centres.

Participants

A total of 305 patients and 14 PCPs (12 general practitioners; two practice nurses) participated.

Design and methodology

A cross-sectional mixed-methods study. PCPs and patients completed questionnaires assessing beliefs about obesity and primary care weight communication and management. Semi-structured interviews were conducted with PCPs to elaborate on questionnaire topics. Quantitative and qualitative data were synthesised to address study objectives.

Results

(1) Many patients with overweight and obesity did not accurately perceive their weight or risk of developing weight-related health issues; (2) PCPs and patients reported behavioural factors as the most important cause of obesity, and medical factors as the most important consequence; (3) PCPs perceive their role in weight management as awareness raising and signposting, not prevention or weight monitoring; (4) PCPs identify structural and patient-related factors as barriers to weight communication and management, but not PCP factors.

Conclusions

Incongruent and/or inaccurate beliefs held by PCPs and patient may present barriers to effective weight discussion and management in primary care. There is a need to review, standardise and clarify primary care weight management processes in Scotland. Acknowledging a shared responsibility for obesity as a disease may improve outcomes for patients with overweight and obesity.

]]>
<![CDATA[Tackling frailty at primary care: evaluation of the effectiveness of a multicomponent intervention through a randomised controlled trial: study protocol]]> https://www.researchpad.co/article/N3c96de30-731c-461d-83ed-7cacc10cf283

Introduction

This project focuses on how frailty is addressed in primary healthcare (PHC) and will evaluate the effectiveness of a multifactorial intervention (considering the appropriateness of the pharmaceutical prescription, the nutritional care provided and the exercise intervention) for persons with frailty, in terms of improving their functional capacity and reducing the incidence of adverse events related to frailty. The final evaluation will be made at 12 months’ follow-up.

Methods and analysis

Pragmatic multicentre cluster randomised controlled clinical trial, single blind with two arms: multifactorial intervention in PHC versus usual follow-up. The randomisation unit is the patient list and the analysis unit is the patient. In addition, a cost-effectiveness study and a qualitative study will be carried out, the latter based on semistructured interviews and focus groups. Two hundred persons (100 per study branch) all aged ≥70 years, presenting frailty, but functionally independent and resident in the community, will be recruited. A baseline evaluation will be carried out prior to the intervention, with follow-up at 6 and 12 months. The main study variables considered will be functional capacity and incidence of adverse events; the secondary variables considered will be the patients’ sociodemographic characteristics, nutritional status, level of physical activity and drug consumption, together with data on comorbidity, cognitive and affective status and health-related quality of life. Data will be analysed according to the intention-to-treat principle using a 5% significance level.

Ethics and dissemination

The study will at all times be conducted in strict accordance with the provisions of the Declaration of Helsinki and with the national legislation regulating patients’ autonomy. All patients recruited will be asked to provide written informed consent before taking part in the clinical trial. On completion of the study, the principal investigator expects to publish the results of this research in a peer-reviewed open access scientific journal.

Trial registration number

ISRCTN17143761.

]]>
<![CDATA[Nutrition competence of primary care physicians in Saudi Arabia: a cross-sectional study]]> https://www.researchpad.co/article/N83b9ede6-6240-414a-bf34-1bd26dc2e43c

Objectives

Primary care physicians have an opportunity to support healthy dietary behaviours of patients by providing nutrition care. However, it is unclear whether primary care physicians in the Kingdom of Saudi Arabia (KSA) are sufficiently competent in nutrition. This study aimed to assess the nutrition competence of primary care physicians in KSA and identify whether nutrition competence is associated with the provision of nutrition care to patients living with diet-related chronic disease.

Design

A cross-sectional study.

Setting

Chronic disease clinics across 48 primary care centres under the Ministry of Health in the city of Jeddah, KSA.

Participants

90 primary care physicians completed the survey (response rate: 98%). General practitioners and family medicine residents, specialists, and consultants actively working in chronic disease clinics between February and May 2019 were included.

Primary and secondary outcome measures

Primary outcome measure was nutrition competence of primary care physicians measured via the validated nutrition competence (NUTCOMP) questionnaire.

Results

Primary care physicians perceived themselves as competent in nutrition care but their reported provision of nutrition care was limited. Confidence in their nutrition knowledge and skills elicited the lowest mean scores of 25.8 (±5.4) out of 35 and 29 (±5.2) out of 40, respectively. The reported provision of nutrition care was closely correlated with physicians’ confidence in their nutrition knowledge (r=0.57) and communication (r=0.52). Three factors were identified as predicting whether physicians provide nutrition care to patients: confidence in counselling about nutrition (p<0.001), having previous nutrition education (p=0.005) and a higher professional qualification (p=0.008).

Conclusions

Primary care physicians felt confident in providing nutrition care to patients living with diet-related chronic disease. Primary care physicians would benefit from higher levels of nutrition knowledge and skills to effectively support patients to improve their dietary behaviours and health conditions, leading to a positive impact on public health.

]]>
<![CDATA[Diagnostic property of direct referral from general practitioners to contrast-enhanced thoracoabdominal CT in patients with serious but non-specific symptoms or signs of cancer: a retrospective cohort study on cancer prevalence after 12 months]]> https://www.researchpad.co/article/N0e4298fc-fe41-483c-adb8-5042c77fb771

Objectives

To describe the diagnostic properties of thoracoabdominal contrast-enhanced CT (ceCT), when general practitioners (GPs) managed referral to ceCT through the non-specific symptoms or signs of cancer-cancer patient pathway (NSSC-CPP).

Design

Retrospective cohort study including patients from a part of Denmark.

Setting

Department of Internal Medicine at a university hospital.

Participants

In total, 529 patients underwent ceCT.

Primary and secondary outcomes

Our primary objective was to estimate the negative and positive likelihood ratios for being diagnosed with cancer within 1 year after ceCT. Our secondary outcomes were prevalence and final diagnoses of malignancy (including temporal trends since implementation of NSSC-CPP in 2012), the prevalence of revision of CT scans and referral patterns based on ceCT results.

Results

In total, 529 subjects underwent ceCT and malignancy was identified in 104 (19.7%) patients; 101 (97.1%) during initial workup and 3 patients during the subsequent 12 months follow-up.

Eleven patients had a false-negative ceCT, and revision classified the ceCT as ‘probable/possible malignancy’ in eight (73%) patients. The negative predictive value was 98% and positive predictive value 63%. Negative and positive likelihood ratios for malignancy was 0.1 and 7.9, respectively.

Conclusion

Our study shows that ceCT as part of GP-coordinated workup has a low negative likelihood ratio for identifying malignancy; this is important since identifying patients for further workup is vital.

]]>
<![CDATA[Evaluation of community pharmacists’ readiness to implement the Falsified Medicines Directive (Directive 2011/62/EC): an English cross-sectional survey with geospatial analysis]]> https://www.researchpad.co/article/Nc4dc4526-7d81-4993-bcec-83b8aed39a40

Objectives

To evaluate the readiness to implement the Falsified Medicines Directive (FMD) by community pharmacies in England. Eight secondary objectives were assessed.

Setting

Community/retail pharmacies.

Participants

We invited pharmacists from 501 pharmacies to complete a survey. Non-contractors, non-pharmacists or pharmacists practising abroad were excluded. We randomly selected addresses, ensuring that they were nationally representative.

Interventions

We mailed the survey in October 2018 with a single follow-up in January 2019. Respondents were invited to provide self-reported answers. A prepaid self-addressed envelope was provided. We received favourable ethical approval.

Results

102 responses (20.44% response rate) were received. Readiness to implement was poor: 4 (3.9%) said very much, while 40 (39.2%) said not at all and 29 (28.4%) said not really. Increased workload and reduced profitability were anticipated, accompanied with improved patient safety. Prevalence of ‘substandard and falsified (SF) medical products’ was estimated at 1%–5%, with erectile dysfunction at greatest risk of falsification. Different packaging would raise suspicions. Five (4.9%) had identified SFs (p<0.001 one-sample binomial test). Of these, three (2.9%) informed the medicines agency. None had been involved in any public health campaigns. Confidence and self-efficacy was low. Strategies to reduce SFs reaching the public are described. Pharmacist’s role in combating SFs was elucidated. SFs were identified in deprived areas 4 (9%) more often than in affluent areas 1 (2%).

Conclusions

Many pharmacies are not ready to implement FMD, potentially not capturing anticipated benefits of the directive, with greatest risk of harm in deprived area. We further validated a confidence scale. Limited public health campaigns may result in a lack of awareness among pharmacy professionals and patients. Limited awareness of technologies to identify falsified medicines exist, though further training is welcome. A worrying trend of under-reporting maybe prevalent. A larger sample study using this survey would be valuable.

]]>
<![CDATA[Relationship between general practice capitation funding and the quality of primary care in England: a cross-sectional, 3-year study]]> https://www.researchpad.co/article/N2792066e-9b1d-4b15-b172-ea478dc40142

Objective

To explore the relationship between general practice capitation funding and quality ratings based on general practice inspections.

Design

Cross-sectional study pooling 3 years of primary care administrative data.

Setting

UK primary care.

Participants

7310 practices (95% of all practices) in England which underwent Care Quality Commission (CQC) inspections between November 2014 and December 2017.

Main outcome measures

CQC ratings. Ordered logistic regression methods were used to predict the relationship between practice capitation funding and CQC ratings in each of five domains of quality: caring, effective, responsive, safe and well led, together with an overall practice rating.

Results

Higher capitation funding per patient was significantly associated with higher CQC ratings across all five quality domains: caring (OR 1.14, 95% CI 1.04 to 1.23), effective (OR 1.08, 95% CI 1.00 to 1.16), responsive (OR 1.09, 95% CI 1.02 to 1.17), safe (OR 1.11, 95% CI 1.05 to 1.18), well led (OR 1.13, 95% CI 1.06 to 1.20) and overall rating (OR 1.13, 95% CI 1.06 to 1.19).

Conclusion

Higher capitation funding was consistently associated with higher ratings across all CQC domains and in the overall practice rating. This study suggests that measured dimensions of the quality of care are related to the underlying capitation funding allocated to each general practice, implying that additional capitation funding may be associated with higher levels of primary care quality.

]]>
<![CDATA[Fever control interventions versus placebo, sham or no intervention in adults: a protocol for a systematic review with meta-analysis and Trial Sequential Analysis]]> https://www.researchpad.co/article/Nebb8683d-251c-412e-936c-c08f45edabad

Introduction

Fever is an integral part of the inflammatory response and has therefore likely a physiological role in fighting infections. Nevertheless, whether fever in itself is beneficial or harmful in adults is unknown. This protocol for a systematic review aims at identifying the beneficial and harmful effects of fever control interventions in adults.

Methods and analysis

This protocol for a systematic review was conducted following the recommendations of Cochrane, GRADE and the eight-step assessment suggested by Jakobsen and colleagues for better validation of meta-analytical results in systematic reviews. We plan to include all relevant randomised clinical trials comparing any fever control intervention with placebo, sham or no intervention in adults. We plan to search CENTRAL, MEDLINE, Embase, LILACS, BIOSIS, CINAHL, Scopus and Web of Science Core Collection to identify relevant trials. Any eligible trial will be assessed and classified as either at high risk of bias or low risk of bias, and our primary conclusions will be based on trials at low risk of bias. We will perform our meta-analyses of the extracted data using Review Manager 5.3 and Trial Sequential Analysis. For all our outcomes, we will create a ‘Summary of Findings’ table based on GRADE assessments of the certainty of the evidence.

Ethics and dissemination

No formal approval or review of ethics is required for this systematic review as individual patient data will not be included. This systematic review has the potential to highlight (1) whether one should believe fever to be beneficial, harmful or neither in adults; (2) the existing knowledge gaps on this topic; and (3) whether the recommendations from guidelines and daily clinical practice are correct. These results will be disseminated through publication in a leading peer-reviewed journal.

PROSPERO registration number

CRD42019134006

]]>
<![CDATA[Pharmacist-led adherence support in general practice: a qualitative interview study of adults with asthma]]> https://www.researchpad.co/article/N7e698372-13c0-4c9e-9946-04f6067dfb4b

Objectives

The National Health Service (NHS) in England recently introduced general practice pharmacists (GPPs) to provide medication-focused support to both patients and the general practice team. This healthcare model may benefit people with asthma, who currently receive suboptimal care and demonstrate low medication adherence. This study aimed to explore the perspectives of adults with asthma on the potential for pharmacist-led adherence support delivered in general practice, with a focus on how these perspectives are formed.

Design and setting

The study was conducted in the United Kingdom (UK) utilising a qualitative interview methodology. Participants were invited to partake in a telephone-based semistructured interview, followed by an online questionnaire for demographic details and asthma history. Qualitative data were analysed using thematic analysis.

Participants

Participants (n=17) were adults with asthma in the UK with a prescription for an inhaled corticosteroid. Participants did not have previous experience with GPPs and were asked to provide their views on a proposed GPP-led service.

Results

Participant perspectives of GPPs were determined by trust in pharmacists, perceived gaps in asthma care and the perceived strain on the NHS. Trust was based on pharmacists’ perceived clinical competency, established over time, and gauged through a ‘benchmarking’ process. GPP’s fit in current asthma care was assessed based on potential role overlap with other healthcare professionals, continuity of care and medication-related support needs. Participants navigated the NHS based on a perceived hierarchy of healthcare professionals (general practitioners on top, nurses, then pharmacists), and this influenced their perspectives of GPPs.

Conclusion

While the GPP scheme shows promise based on the perspectives of people with asthma, the identified barriers to optimal patient engagement and service implementation will need to be addressed for the service to be effective.

]]>
<![CDATA[Can implementation failure or intervention failure explain the result of the 3D multimorbidity trial in general practice: mixed-methods process evaluation]]> https://www.researchpad.co/article/Ncea78f69-777f-4419-b054-a73044fc807e

Objectives

During a cluster randomised trial, (the 3D study) of an intervention enacting recommended care for people with multimorbidity, including continuity of care and comprehensive biennial reviews, we examined implementation fidelity to interpret the trial outcome and inform future implementation decisions.

Design

Mixed-methods process evaluation using cross-trial data and a sample of practices, clinicians, administrators and patients. Interviews, focus groups and review observations were analysed thematically and integrated with quantitative data about implementation. Analysis was blind to trial outcomes and examined context, intervention adoption, reach and maintenance, and delivery of reviews to patients.

Setting

Thirty-three UK general practices in three areas.

Participants

The trial included 1546 people with multimorbidity. 11 general practitioners, 14 nurses, 7 administrators and 38 patients from 9 of 16 intervention practices were sampled for an interview.

Results

Staff loss, practice size and different administrative strategies influenced implementation fidelity. Practices with whole administrative team involvement and good alignment between the intervention and usual care generally implemented better. Fewer reviews than intended were delivered (49% of patients receiving both intended reviews, 30% partially reviewed). In completed reviews >90% of intended components were delivered, but review observations and interviews with patients and clinicians found variation in style of component delivery, from ‘tick-box’ to patient-centred approaches. Implementation barriers included inadequate skills training to implement patient-centred care planning, but patients reported increased patient-centredness due to comprehensive reviews, extra time and being asked about their health concerns.

Conclusions

Implementation failure contributed to lack of impact of the 3D intervention on the trial primary outcome (quality of life), but so did intervention failure since modifiable elements of intervention design were partially responsible. When a decisive distinction between implementation failure and intervention failure cannot be made, identifying potentially modifiable reasons for suboptimal implementation is important to enhance potential for impact and effectiveness of a redesigned intervention.

Trial registration number

ISRCTN06180958

]]>
<![CDATA[Understanding the delayed prescribing of antibiotics for respiratory tract infection in primary care: a qualitative analysis]]> https://www.researchpad.co/article/5b29dc43463d7e28b15c8c76

Objective

To identify general practitioner (GP) views and understanding on the use of delayed prescribing in primary care.

Design

Qualitative semistructured telephone interview study.

Setting

Primary care general practices in England.

Participants

32 GPs from identified high-prescribing and low-prescribing general practices in England.

Method

Semistructured telephone interviews were conducted with GPs identified from practices within clinical commissioning groups with the highest and lowest prescribing rates in England. A thematic analysis of the data was conducted to generate themes.

Results

All GPs had a good understanding of respiratory tract infection (RTI) management and how the delayed prescribing approach could be used in primary care. However, GPs highlighted factors that were influential as to whether delayed prescribing was successfully carried out during the consultation. These included the increase in evidence of antimicrobial resistance, and GPs' prior experiences of using delayed prescribing during the consultation. The patient–practitioner relationship could also influence treatment outcomes for RTI, and a lack of an agreed prescribing strategy within and between practices was considered to be of significance to GPs. Participants expressed that a lack of feedback on prescribing data at an individual and practice level made it difficult to know if delayed prescribing strategies were successful in reducing unnecessary consumption. GPs agreed that coherent and uniform training and guidelines would be of some benefit to ensure consistent prescribing throughout the UK.

Conclusions

Delayed prescribing is encouraged in primary care, but is not always implemented successfully. Greater uniformity within and between practices in the UK is needed to operationalise delayed prescribing, as well as providing feedback on the uptake of antibiotics. Finally, GPs may need further guidance on how to answer the concerns of patients without interpreting these questions as a demand for antibiotics, as well as educating the patient about antimicrobial resistance and supporting a good patient–practitioner relationship.

]]>
<![CDATA[Definition of whole person care in general practice in the English language literature: a systematic review]]> https://www.researchpad.co/article/5c39468cd5eed0c484a37e03

Objectives

The importance of ‘whole person’ or ‘holistic’ care is widely recognised, particularly with an increasing prevalence of chronic multimorbidity internationally. This approach to care is a defining feature of general practice. However, its precise meaning remains ambiguous. We aimed to determine how the term ‘whole person’ care is understood by general practitioners (GPs), and whether it is synonymous with ‘[w]holistic’ and ‘biopsychosocial’ care.

Design

Systematic literature review.

Methods

MEDLINE, PubMed, EMBASE, CINAHL, PsycINFO, Web of Science, Proquest Dissertations and Theses, Science.gov (Health and Medicine database), Google Scholar and included studies’ reference lists were searched with an unlimited date range. Systematic or literature reviews, original research, theoretical articles or books/book chapters; specific to general practice; relevant to the research question; and published in English were included. Included literature was critically appraised, and data were extracted and analysed using thematic synthesis.

Results

Fifty publications were included from 4297 non-duplicate records retrieved. Six themes were identified: a multidimensional, integrated approach; the importance of the therapeutic relationship; acknowledging doctors’ humanity; recognising patients’ individual personhood; viewing health as more than absence of disease; and employing a range of treatment modalities. Whole person, biopsychosocial and holistic terminology were often used interchangeably, but were not synonymous.

Conclusions

Whole person, holistic and biopsychosocial terminology are primarily characterised by a multidimensional approach to care and incorporate additional elements described above. Whole person care probably represents the closest representation of the basis for general practice. Health systems aiming to provide whole person care need to address the challenge of integrating the care of other health professionals, and maintaining the patient–doctor relationship central to the themes identified. Further research is required to clarify the representativeness of the findings, and the relative importance GPs’ assign to each theme.

PROSPERO registration number

CRD42017058824.

]]>
<![CDATA[The performance of seven QPrediction risk scores in an independent external sample of patients from general practice: a validation study]]> https://www.researchpad.co/article/5ba6e51240307c489cbf7a21

Objectives

To validate the performance of a set of risk prediction algorithms developed using the QResearch database, in an independent sample from general practices contributing to the Clinical Research Data Link (CPRD).

Setting

Prospective open cohort study using practices contributing to the CPRD database and practices contributing to the QResearch database.

Participants

The CPRD validation cohort consisted of 3.3 million patients, aged 25–99 years registered at 357 general practices between 1 Jan 1998 and 31 July 2012. The validation statistics for QResearch were obtained from the original published papers which used a one-third sample of practices separate to those used to derive the score. A cohort from QResearch was used to compare incidence rates and baseline characteristics and consisted of 6.8 million patients from 753 practices registered between 1 Jan 1998 and until 31 July 2013.

Outcome measures

Incident events relating to seven different risk prediction scores: QRISK2 (cardiovascular disease); QStroke (ischaemic stroke); QDiabetes (type 2 diabetes); QFracture (osteoporotic fracture and hip fracture); QKidney (moderate and severe kidney failure); QThrombosis (venous thromboembolism); QBleed (intracranial bleed and upper gastrointestinal haemorrhage). Measures of discrimination and calibration were calculated.

Results

Overall, the baseline characteristics of the CPRD and QResearch cohorts were similar though QResearch had higher recording levels for ethnicity and family history. The validation statistics for each of the risk prediction scores were very similar in the CPRD cohort compared with the published results from QResearch validation cohorts. For example, in women, the QDiabetes algorithm explained 50% of the variation within CPRD compared with 51% on QResearch and the receiver operator curve value was 0.85 on both databases. The scores were well calibrated in CPRD.

Conclusions

Each of the algorithms performed practically as well in the external independent CPRD validation cohorts as they had in the original published QResearch validation cohorts.

]]>
<![CDATA[Do GPs know their patients with cancer? Assessing the quality of cancer registration in Dutch primary care: a cross-sectional validation study]]> https://www.researchpad.co/article/5b03c125463d7e6d1b8f6a74

Objectives

To assess the quality of cancer registry in primary care.

Design and setting

A cross-sectional validation study using linked data from primary care electronic health records (EHRs) and the Netherlands Cancer Registry (NCR).

Population

290 000 patients, registered with 120 general practitioners (GPs), from 50 practice centres in the Utrecht area, the Netherlands, in January 2013.

Intervention

Linking the EHRs of all patients in the Julius General Practitioners’ Network database at an individual patient level to the full NCR (∼1.7 million tumours between 1989 and 2011), to determine the proportion of matching cancer diagnoses. Full-text EHR extraction and manual analysis for non-matching diagnoses.

Main outcome measures

Proportions of matching and non-matching breast, lung, colorectal and prostate cancer diagnoses between 2007 and 2011, stratified by age category, cancer type and EHR system. Differences in year of diagnosis between the EHR and the NCR. Reasons for non-matching diagnoses.

Results

In the Primary Care EHR, 60.6% of cancer cases were registered and coded in accordance with the NCR. Of the EHR diagnoses, 48.9% were potentially false positive (not registered in the NCR). Results differed between EHR systems but not between age categories or cancer types. The year of diagnosis corresponded in 80.6% of matching coded diagnoses. Adding full-text EHR analysis improved results substantially. A national disease registry (the NCR) proved incomplete.

Conclusions

Even though GPs do know their patients with cancer, only 60.6% are coded in concordance with the NCR. Reusers of coded EHR data should be aware that 40% of cases can be missed, and almost half can be false positive. The type of EHR system influences registration quality. If full-text manual EHR analysis is used, only 10% of cases will be missed and 20% of cases found will be wrong. EHR data should only be reused with care.

]]>
<![CDATA[Patient-reported gout attack frequency and allopurinol use in general practice in the Netherlands: a prospective observational cohort study protocol]]> https://www.researchpad.co/article/5c19b18dd5eed0c484c4d5a7

Introduction

Gout is the most common inflammatory arthritis in the Dutch general practice population and is often managed with long-term uric acid lowering treatment. The clinical relevance of this treatment in preventing gout attacks is unclear.

Primary research question

What is the frequency of self-reported gout attacks and what is the effect of allopurinol use in patients diagnosed with gout in general practice?

Methods and analysis

Adult patients with a diagnostic consultation code for gout in the year 2013, 2014 or 2015 will be invited to participate in this prospective observational cohort study. Patients with a limited life expectancy will be excluded. Baseline measurements will include blood pressure, body mass index and a blood sample (estimated glomerular filtration rate, serum uric acid, cholesterol (low-density lipoprotein (LDL) and high-density lipoprotein), glucose (fasting)). At the 2-year follow-up, patients will receive questionnaires every 3 months. The questionnaires at baseline, 12 months and 24 months assess the frequency of gout attacks, the presence of tophi, comorbidity, medication use, quality of life, diet and lifestyle. The questionnaires in between only assess the frequency of gout attacks and medication use for gout. Descriptive statistics will be used to calculate the mean frequency of self-reported gout attacks during the 2-year follow-up. The propensity score for each patient being offered allopurinol is estimated and used to match patients with and without allopurinol treatment. We will compare the frequency of gout attacks in these groups using multilevel Poisson regression analyses. With this type of analysis, we can calculate the corrected estimated effect of allopurinol on gout attack frequency.

Ethics and dissemination

The research protocol was approved by the Medical Ethical Committee of the Erasmus Medical Centre in Rotterdam. The knowledge generated by this study will be transferred to the Dutch College of General Practitioners, conferences and to (inter)national peer-reviewed journals.

Trial registration number

NTR6329; Pre-results.

]]>
<![CDATA[Unplanned admissions and the organisational management of heart failure: a multicentre ethnographic, qualitative study]]> https://www.researchpad.co/article/5af273d6463d7e3f7d53d0ac

Objectives

Heart failure is a common cause of unplanned hospital admissions but there is little evidence on why, despite evidence-based interventions, admissions occur. This study aimed to identify critical points on patient pathways where risk of admission is increased and identify barriers to the implementation of evidence-based interventions.

Design

Multicentre, longitudinal, patient-led ethnography.

Setting

National Health Service settings across primary, community and secondary care in three geographical locations in England, UK.

Participants

31 patients with severe or difficult to manage heart failure followed for up to 11 months; 9 carers; 55 healthcare professionals.

Results

Fragmentation of healthcare, inequitable provision of services and poor continuity of care presented barriers to interventions for heart failure. Critical points where a reduction in the risk of current or future admission occurred throughout the pathway. At the beginning some patients did not receive a formal clinical diagnosis, in addition patients lacked information about heart failure, self-care and knowing when to seek help. Some clinicians lacked knowledge about diagnosis and management. Misdiagnoses of symptoms and discontinuity of care resulted in unplanned admissions. Approaching end of life, patients were admitted to hospital when other options including palliative care could have been appropriate.

Conclusions

Findings illustrate the complexity involved in caring for people with heart failure. Fragmented healthcare and discontinuity of care added complexity and increased the likelihood of suboptimal management and unplanned admissions. Diagnosis and disclosure is a vital first step for the patient in a journey of acceptance and learning to self-care/monitor. The need for clinician education about heart failure and specialist services was acknowledged. Patient education should be seen as an ongoing ‘conversation’ with trusted clinicians and end-of-life planning should be broached within this context.

]]>
<![CDATA[Early real-world evidence of persistence on oral anticoagulants for stroke prevention in non-valvular atrial fibrillation: a cohort study in UK primary care]]> https://www.researchpad.co/article/5b047a0c463d7e232cc2fd86

Objectives

To examine the characteristics and persistence in patients newly initiated with oral anticoagulants (OACs) for stroke prevention in non-valvular atrial fibrillation (NVAF).

Design

Cohort study in Clinical Practice Research Datalink.

Setting

UK primary care.

Participants

15 242 patients with NVAF newly prescribed apixaban, rivaroxaban, dabigatran or vitamin K antagonists (VKAs) between 1 December 2012 and 31 October 2014. 13 089 patients were OAC naïve.

Outcome measures

Patient characteristics and risk of non-persistence compared to apixaban using Cox regression models over the entire follow-up and using a time-partitioned approach to handle non-proportional hazards.

Results

Among the OAC naïve patients, VKAs were most common (78.1%, n=10 218), followed by rivaroxaban (12.1%, n=1589), dabigatran (5.7%, n=741) and apixaban (4.1%, n=541). High baseline stroke risk (CHA2DS2VASc ≥2) ranged from 80.2% (dabigatran) to 88.4% (apixaban and rivaroxaban). History of stroke and bleeding was the highest among apixaban (23.7% and 31.6%) and lowest among VKA patients (15.9% and 27.5%). Across the entire follow-up period, adjusting for differences in characteristics, there was no evidence of a difference in non-persistence between VKA and apixaban (HR 0.92 (95% CI 0.68 to 1.23)). Non-persistence was higher with dabigatran (HR 1.67 (1.20 to 2.32)) and rivaroxaban (HR 1.41 (1.02 to 1.93)) than apixaban. Using the partitioned approach, non-persistence was lower with VKA (HR 0.33 (0.22 to 0.48)), and higher with dabigatran (HR 1.65 (1.08 to 2.52)) compared to apixaban in the first 2 months of follow-up. After 2 months, non-persistence was higher with VKA (HR 1.70 (1.08 to 2.66)) and dabigatran (HR 2.10 (1.30 to 3.41)). Pooling OAC naïve and experienced patients, non-persistence was also higher with rivaroxaban compared to apixaban after 2 months of follow-up (HR 1.69 (1.19 to 2.39)).

Conclusions

Observed differential prescribing of OACs can result in channelling bias in comparative effectiveness research. Persistence patterns changed over follow-up time, but there are indications of improved persistence rates with apixaban over other OACs in the UK. A larger study with longer follow-up is needed to corroborate findings. This study is registered on ClinicalTrials.gov (NCT02488421).

]]>