The effect of a distance-learning programme on patient self-management of Lower Urinary Tract Symptoms (LUTS) in general practice: a randomised controlled trial

Synthesis of Existent Oncology Curricula for Primary Care Providers: A Scoping Review With a Global Equity Lens

PURPOSE

Global increases in cancer, coupled with a shortage of cancer specialists, has led to an increasing role for primary care providers (PCP) in cancer care. This review aimed to examine all extant cancer curricula for PCPs and to analyze the motivations for curriculum development.

METHODS

A comprehensive literature search was conducted from inception to October 13, 2021, with no language restrictions. The initial search yielded 11,162 articles and 10,902 articles underwent title and abstract review. After full-text review, 139 articles were included. Numeric and thematic analyses were conducted and education programs were evaluated using Bloom's taxonomy.

RESULTS

Most curricula were developed in high-income countries (HICs), with 58% in the United States. Cancer-specific curricula focused on HIC priority cancers, such as skin/melanoma, and did not represent the global cancer burden. Most (80%) curricula were developed for staff physicians and 73% focused on cancer screening. More than half (57%) of programs were delivered in person, with a shift toward online delivery over time. Less than half (46%) of programs were codeveloped with PCPs and 34% did not involve PCPs in the program design and development. Curricula were primarily developed to improve cancer knowledge, and 72 studies assessed multiple outcome measures. No studies included the top two levels of Bloom's taxonomy of learning (evaluating; creating).

CONCLUSION

To our knowledge, this is the first review to assess the current state of cancer curricula for PCPs with a global focus. This review shows that extant curricula are primarily developed in HICs, do not represent the global cancer burden, and focus on cancer screening. This review lays a foundation to advance the cocreation of curricula that are aligned to the global cancer burden.

Development of an online personalized self-management intervention for men with uncomplicated LUTS

Aims

To develop an online platform to facilitate evidence‐based self‐management of lower urinary tract symptoms (LUTS) in men.

Methods

Using the PubMed database (search until January 2017) and relevant guidelines, we reviewed evidence for the self‐management of LUTS and identified suitable components for the intervention. Next, we built an algorithm that provided individualized advice based on patient characteristics and symptoms for use on an online platform. Men with LUTS tested the usability of the intervention and provided feedback. Finally, we surveyed urologists and general practitioners to identify potential areas for improvement of the intervention.

Results

We identified nine self‐help interventions from 48 eligible publications. These were as follows: information and education about LUTS, pelvic floor muscle training, bladder training, urethral milking, double voiding, caffeine management, alcohol management, fluid management, and exercise advice. The level of evidence for each item was low due to the paucity of research available. Six men with LUTS reported difficulties understanding and completing the frequency‐volume chart online. The 158 surveyed physicians agreed (≥50% positive ratings) on the inclusion of seven advice items, but not for double voiding and fluid management. Respondents noted that some advice should be provided to all men with LUTS, while other advice should only be presented to certain groups. Some recommendations for additions were offered.

Conclusions

Despite a lack of evidence for the self‐management advice, physicians agreed with most of the included advice. The online platform needs further development. Therefore, adjustments will be made and we will assess its impact in future studies.

Physical activity for lower urinary tract symptoms secondary to benign prostatic obstruction

BACKGROUND

Lower urinary tract symptoms caused by benign prostatic obstruction (LUTS/BPO) represents one of the most common clinical complaints in men. Physical activity might represent a viable first-line intervention for treating LUTS/BPO.

OBJECTIVES

To assess the effects of physical activity for lower urinary tract symptoms caused by benign prostatic obstruction (LUTS/BPO).

SEARCH METHODS

We performed a comprehensive search of multiple databases (CENTRAL, MEDLINE, Embase, Web of Science, LILACS, ClinicalTrials.gov, and WHO ICTRP); checked the reference lists of retrieved articles; and handsearched abstract proceedings of conferences with no restrictions on the language of publication or publication status from database inception to 6 November 2018.

SELECTION CRITERIA

We included published and unpublished randomised controlled and controlled clinical trials that included men diagnosed with LUTS/BPO. We excluded studies in which medical history suggested non-BPO causes of LUTS or prior invasive therapies to physical activity or that used electrical stimulation.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study eligibility, extracted data, and assessed the risk of bias of included studies. We assessed primary outcomes (symptom score for LUTS; response rate, defined as 20% improvement in symptom score; withdrawal due to adverse events) and secondary outcomes (change of medication use; need for an invasive procedure; postvoid residual urine). We assessed the quality of the evidence using the GRADE approach.

MAIN RESULTS

We included six studies that randomised 652 men over 40 years old with moderate or severe LUTS. The four different comparisons were as follows:Physical activity versus watchful waitingTwo RCTs randomised 119 participants. The interventions included tai chi and pelvic floor exercise. The evidence was overall of very low quality, and we are uncertain about the effects of physical activity on symptom score for LUTS (mean difference (MD) -8.1, 95% confidence interval (CI) -13.2 to -3.1); response rate (risk ratio (RR) 1.80, 95% CI 0.81 to 4.02; 286 more men per 1000, 95% CI 68 fewer to 1079 more); and withdrawal due to adverse events (RR 1.00, 95% CI 0.59 to 1.69; 0 fewer men per 1000, 95% CI 205 fewer to 345 more).Physical activity as part of self-management programme versus watchful waitingTwo RCTs randomised 362 participants. Pelvic floor exercise was one of multiple intervention components. The evidence was of very low quality, and we are uncertain about the effects of physical activity for symptom score for LUTS (MD -6.2, 95% CI -9.9 to -2.5); response rate (RR 2.36, 95% CI 1.32 to 4.21; 424 more men per 1000, 95% CI 100 more to 1000 more); and withdrawal due to adverse events (risk difference 0.00, 95% CI -0.05 to 0.06; 65 fewer men per 1000, 95% CI 65 fewer to 65 fewer).Physical activity as part of weight reduction programme versus watchful waitingOne RCT randomised 130 participants. An unclear type of intense exercise was one of multiple intervention components. The evidence was of very low quality, and we are uncertain about the effects for symptom score for LUTS (MD -1.1, 95% CI -3.5 to 1.3); response rate (RR 1.20, 95% CI 0.74 to 1.94; 67 more men per 1000, 95% CI 87 fewer to 313 more); and withdrawal due to adverse events (RR 1.63, 95% CI 1.03 to 2.57; 184 more men per 1000, 95% CI 9 more to 459 more).Physical activity versus alpha-blockersOne RCT randomised 41 participants to pelvic floor exercise or alpha-blockers. The evidence was of very low quality, and we are uncertain about the effects for symptom score for LUTS (MD 2.8, 95% CI -0.9 to 6.4) and response rate (RR 0.80, 95% CI 0.55 to 1.15; 167 fewer men per 1000, 95% CI 375 fewer to 125 more). The evidence was of low quality for withdrawal due to adverse events; the effects for this outcome may be similar between interventions (RR 0.86, 95% CI 0.06 to 12.89; 7 fewer men per 1000, 95% CI 49 fewer to 626 more).

AUTHORS' CONCLUSIONS

We rated the quality of the evidence for most of the effects of physical activity for LUTS/BPO as very low. We are therefore uncertain whether physical activity affects symptom scores for LUTS, response rate, and withdrawal due to adverse events. Our confidence in the estimates was lowered due to study limitations, inconsistency, indirectness, and imprecision. Additional high-quality research is necessary.

The role of primary care in early detection and follow-up of cancer

Primary care providers have important roles across the cancer continuum, from encouraging screening and accurate diagnosis to providing care during and after treatment for both the cancer and any comorbid conditions. Evidence shows that higher cancer screening participation rates are associated with greater involvement of primary care. Primary care providers are pivotal in reducing diagnostic delay, particularly in health systems that have long waiting times for outpatient diagnostic services. However, so-called fast-track systems designed to speed up hospital referrals are weakened by significant variation in their use by general practitioners (GPs), and affect the associated conversion and detection rates. Several randomized controlled trials have shown primary care-led follow-up care to be equivalent to hospital-led care in terms of patient wellbeing, recurrence rates and survival, and might be less costly. For primary care-led follow-up to be successful, appropriate guidelines must be incorporated, clear communication must be provided and specialist care must be accessible if required. Finally, models of long-term cancer follow-up are needed that provide holistic care and incorporate management of co-morbid conditions. We discuss all these aspects of primary care, focusing on the most common cancers managed at the GP office-breast, colorectal, prostate, lung and cervical cancers.

Interventions to reduce primary care delay in cancer referral: a systematic review

BACKGROUND

Reducing delay in the primary care part of the cancer care pathway is likely to improve cancer survival. Identifying effective interventions in primary care would allow action by primary healthcare professionals and local commissioners to reduce delay.

AIM

To identify interventions that reduce primary care delay in the referral of patients with cancer to secondary care.

DESIGN AND SETTING

Systematic review in primary care.

METHOD

Eight electronic databases were searched using terms for primary care, cancer, and delay. Exclusion criteria included screening and the 2-week-wait referral system. Reference lists of relevant papers were hand searched. The quality of each paper was assessed using predefined criteria, and checked by a second reviewer.

RESULTS

Searches identified 1798 references, of which 22 papers were found to meet the criteria. Interventions concerning education, audit and feedback, decision support software and guideline use, diagnostic tools, and other specific skills training were identified. Most studies reported a positive effect on their specified outcomes, although no study measured a direct effect on reducing delay.

CONCLUSION

There was no evidence that any intervention directly reduced primary care delay in the diagnosis of cancer. Limited evidence suggests that complex interventions, including audit and feedback and specific skills training, have the potential to do so.

Improving initial management of lower urinary tract symptoms in primary care: Costs and patient outcomes

OBJECTIVE

Guidelines for primary care management of lower urinary tract symptoms in older men recommend shared decision making regarding the choice of treatment. In this study we aimed to determine the costs and patient outcomes of an implementation strategy designed to enhance uptake of these guidelines.

MATERIAL AND METHODS

The intervention comprised a distance learning programme for general practitioners, comprising evidence-based information, assessment of learning needs, a knowledge test and patient education materials. The control group only received the written guidelines. A cluster randomized trial in 187 older male patients compared costs and outcomes in the two study groups. A healthcare perspective was taken in the economic evaluation, with a 3-month time horizon. The primary health outcome was patient-reported urinary symptoms at 3 months. Costs relating to the distance learning package and the healthcare provided were considered, using undiscounted standardized prices.

RESULTS

Patient-reported urinary symptoms at 3 months did not differ between the study groups: 66% and 61% with moderate symptoms and 7% and 11% with severe symptoms in the intervention and control groups, respectively. The mean total costs per patient were euro28.15 lower in the intervention group (euro93.11) compared to the control group (euro121.26), mainly because of a lower number of referrals to the urologist. A bootstrap analysis showed an incremental cost-effectiveness ratio of euro111.98 (95% CI -euro423 to +euro329).

CONCLUSIONS

The distance learning programme did not change health outcomes, but it reduced costs in the first 3 months after an initial consultation compared to written guidelines. Studies with a longer follow-up period are needed.

Do elderly patients feel more enabled if they had been actively involved in primary care consultations?

OBJECTIVE

This study aimed to determine whether older patients' enablement was associated with their evaluation of the level of their involvement in primary care consultations.

METHODS

Secondary analysis of data from an international cross-sectional study in seven European countries (n=625 patients). Patient enablement, preference for involvement in the consultation and evaluation of involvement in the consultation were measured with validated questionnaires. Random coefficient linear modelling was used to identify factors associated with patient enablement.

RESULTS

The overall mean patient enablement score was 5.5 (theoretical range: 0-12; higher score indicated more enablement). Enablement was higher in patients who reported more positive compared to those reporting less positive evaluations of involvement (B=1.660; p<0.001). The impact of evaluation on enablement was higher in patients with a high preference for involvement compared to those with lower preference for involvement (B=0.743; p=0.015).

CONCLUSION

Positive evaluations of involvement in primary care were associated with higher enablement in older patients, and even more if the patient had a high preference for involvement.

PRACTICE IMPLICATIONS

Involving older patients actively may enhance their enablement, a particularly important goal for patients who have one or more chronic conditions.

Effects of distance learning on clinical management of LUTS in primary care: a randomised trial

AIM

To determine the effect of a distance learning programme on general practice management of men with lower urinary tract symptoms (LUTS).

METHODS

A cluster randomised controlled trial was performed. General practitioners (GPs) were randomised to a distance learning programme accompanied with educational materials or to a control group only receiving mailed clinical guidelines on LUTS. Clinical management was considered as outcome.

RESULTS

Sixty-three GPs registered care management of 187 patients older than 50 years attending the practice because of LUTS. The intervention group showed a lower referral rate to a urologist (OR: 0.08 (95% CI: 0.02-0.40)), but no effect on PSA testing or prescription of medication. PSA testing tended to be requested more frequently by intervention group GPs. Secondary analysis showed patients in the intervention group received more educational materials (OR: 75.6 (95% CI: 13.60-419.90)).

CONCLUSIONS

The educational programme had impact on clinical management without changing PSA testing. Distance learning is an promising method for continuing education.

PRACTICE IMPLICATIONS

Activating distance learning packages are a potentially effective method for improving professional performance. Emotional matters as PSA testing probably need a more complex approach.