Dilemmas of medical overuse in general practice - A focus group study

Use of primary healthcare services before and after specialized rehabilitation and its relation to changes in health and functioning: a longitudinal cohort study

OBJECTIVE

To examine patients' use of primary healthcare (PHC) before and after specialized rehabilitation and its relation with self-reported health and functioning.

DESIGN

Longitudinal cohort study.

PARTICIPANTS

451 rehabilitation patients.

METHODS

Register data were used to measure the frequency of visits to the general practitioner (GP) and physiotherapist (PT) in PHC 3 years before and after rehabilitation. Patients reported health (EQ-VAS) and functioning (SF-36) before rehabilitation and at 1 and 3 years after. Data are described for the total study cohort and subgroups with musculoskeletal disease (MSD) and cardiovascular disease (CVD).

RESULTS

There was an increase in GP and PT visits preceding rehabilitation and a gradual decrease thereafter. An exception was GP visits among patients with CVD, with few diagnosis-specific visits before but an increase after. Lower levels of health and functioning tended to be related to more frequent GP and PT visits. An indication of clinically important improvement was found among those with frequent GP visits in the MSD subgroup, and among those with 1-2 GP visits in the CVD subgroup.

CONCLUSIONS

The diverse relationship between health and functioning, and the use of PHC services at follow-up, may imply that additional factors besides healthcare use explain long-term improvement following rehabilitation.

To neutrally offer or strongly recommend? General practitioners' perspectives on screening for gestational diabetes according to the national guideline in Norway

OBJECTIVE

To explore general practitioners' experiences and reflections on how the current Norwegian guideline for screening for gestational diabetes affects their clinical practice.

DESIGN

A qualitive study in which data were collected through semi-structured focus group interviews and analyzed thematically.

SETTING AND SUBJECTS

Five focus groups conducted in 2020 among GPs in Norway; three interviews took place face-to-face and two were held digitally. The total number of participants was 31.

RESULTS

GPs acknowledged the potential benefits of more extensive screening, but had concerns about the medicalization of pregnancy, stating that some women experienced considerable anxiety. The GPs expressed doubts about the guideline's evidence base but differed in how they interpreted what the guideline was asking them to do. Some offered eligible women the opportunity to be screened, while other set up a screening appointment without consulting the women first. For some, fear of incrimination made them recommend screening without being convinced that it was the right thing for the patient.

CONCLUSIONS

It is unclear whether the guideline for gestational diabetes requires GPs to recommend screening to pregnant women or if they should provide neutral information about the availability of screening. This ambiguity should be addressed, and the guideline evaluated against the core principles of general practice.

Norwegian general practitioners' and radiologists' perspectives on the referral, justification, and unnecessary imaging-a survey

AIM

This study aimed to survey general practitioners' (GPs) and radiologists' perspectives on referrals, imaging justification, and unnecessary imaging in Norway.

MATERIALS AND METHODS

The survey covered access to imaging, responsibilities, attitudes toward justification assessment, referral process, and demographics using multiple choice questions, statements to report agreement with using the Likert scale and one open question.

RESULTS

Forty radiologists and 58 GPs attending national conferences completed a web-based survey, with a 20/15% response rate, respectively. Both radiologists (97%) and GPs (100%) considered avoiding unnecessary examinations essential to their role in the healthcare service. Still, 91% of GPs admitted that they referred to imaging they thought was not helpful, while about 60% of the radiologists agreed that unnecessary imaging was conducted in their workplace. GPs reported pressure from patients and patients having private insurance as the most common reasons for doing unnecessary examinations. In contrast, radiologists reported a lack of clinical information and the inability to discuss patient cases with the GPs as the most common reasons.

CONCLUSION

This study adds to our understanding of radiologists' and GPs' perspectives on unnecessary imaging and referrals. Better guidelines and, even more importantly, better communication between the referrer and the radiologist are needed. Addressing these issues can reduce unnecessary imaging and improve the quality and safety of care.

To reveal disease or to promote function - that is the question

Medicine faces challenges that indicate that it may not be sustainable. A descriptive disease concept is apt to what philosopher of science Ian Hacking called "looping effects", which can explain why health care is faced with insatiable demands. Diseases are not only indifferent objects with an objective existence in the biology of individuals. They are often interactive identities that have attractive properties. We suggest a shift in medical practice where descriptive perspectives are complemented with functional perspectives to enable clinicians better to help people from merging with dysfunctional disease identities.

Process evaluation of a tailored nudge intervention to promote appropriate care and treatment of older patients at the end-of-life

BACKGROUND

Non-beneficial treatment affects a considerable proportion of older people in hospital, and some will choose to decline invasive treatments when they are approaching the end of their life. The Intervention for Appropriate Care and Treatment (InterACT) intervention was a 12-month stepped wedge randomised controlled trial with an embedded process evaluation in three hospitals in Brisbane, Australia. The aim was to increase appropriate care and treatment decisions for older people at the end-of-life, through implementing a nudge intervention in the form of a prospective feedback loop. However, the trial results indicated that the expected practice change did not occur. The process evaluation aimed to assess implementation using the Consolidated Framework for Implementation Research, identify barriers and enablers to implementation and provide insights into the lack of effect of the InterACT intervention.

METHODS

Qualitative data collection involved 38 semi-structured interviews with participating clinicians, members of the executive advisory groups overseeing the intervention at a site level, clinical auditors, and project leads. Online interviews were conducted at two times: implementation onset and completion. Data were coded to the Consolidated Framework for Implementation Research and deductively analysed.

RESULTS

Overall, clinicians felt the premise and clinical reasoning behind InterACT were strong and could improve patient management. However, several prominent barriers affected implementation. These related to the potency of the nudge intervention and its integration into routine clinical practice, clinician beliefs and perceived self-efficacy, and wider contextual factors at the health system level.

CONCLUSIONS

An intervention designed to change clinical practice for patients at or near to end-of-life did not have the intended effect. Future interventions targeting this area of care should consider using multi-component strategies that address the identified barriers to implementation and clinician change of practice.

TRIAL REGISTRATION

Australia New Zealand Clinical Trial Registry (ANZCTR), ACTRN12619000675123p (approved 06/05/2019).

Presenting a Comprehensive Definition of Unnecessary Healthcare Services and Their Drivers: A Systematic Review and Meta-synthesis

Background

Providing unnecessary healthcare services is a major common problem in every health system. The scope and cause of healthcare services must be identified in order to be managed and controlled. Finding the most complete definition of the problem and its causes are the goals of this meta-synthesis.

Methods

A comprehensive search strategy was performed using a wide range of keywords and databases. Based on the defined inclusion and exclusion criteria, 22 articles were selected for content analysis and meta-synthesis. The Graneheim and Lundman method was used for content analysis. The MAXQDA software Version 18.2.0 was used for the first round of content analysis. Content analysis and meta-synthesis were used to comprehensively define the term "unnecessary healthcare services" and find the etiologic factors driving healthcare providers to unnecessary healthcare services.

Results

The term "unnecessary healthcare services" is defined as "overproviding healthcare services that could be harmful, low-value, insufficient, and inappropriate." The etiologic pattern of unnecessary healthcare services shows intrinsic and extrinsic factors as a driving force for unnecessary healthcare services.

Conclusion

A multilayer strategy for efficient management and prevention of unnecessary healthcare services is appropriate due to the multifaceted character of these services. This approach consists of the modification of the intrinsic factors and extrinsic drivers.

Factors affecting patient decisions to undergo testing for cancer symptoms: an exploratory qualitative study in Australian general practice

BACKGROUND

Patients presenting to their GP are often concerned their symptoms may be due to cancer. However, there is a lack of evidence on the factors that influence patient decisions to undergo investigation for suspected cancer in the general practice setting.

AIM

To identify the factors influencing patient decisions to undertake investigations for suspected cancer in general practice.

DESIGN & SETTING

An exploratory qualitative, semi-structured interview study of patients attending rural and metropolitan general practices in Victoria, Australia.

METHOD

A purposive sample of 15 general practice patients aged ≥40 years participated. Thematic analysis of transcripts drew on interpretative description methodology and shared decision-making (SDM) theory.

RESULTS

Cancer-related concerns such as 'cancer worry' prompt patients to seek investigations from their GP. Participants prefer that their symptoms are investigated regardless of cancer risk. The perceived 'best test' provides the most reassurance. Trust and SDM enhance dialogue between patients and GPs about diagnostic testing strategies. Deterrents to testing included out-of-pocket costs, waiting time, travel time, and competing work and family demands.

CONCLUSION

There may be a mismatch between efforts to rationalise investigation use and patient preferences for investigation. SDM that incorporates patient concerns, facilitators, and barriers to testing may ensure appropriate and timely investigation of cancer symptoms.

Prediction of heart failure 1 year before diagnosis in general practitioner patients using machine learning algorithms: a retrospective case-control study

OBJECTIVES

Heart failure (HF) is a commonly occurring health problem with high mortality and morbidity. If potential cases could be detected earlier, it may be possible to intervene earlier, which may slow progression in some patients. Preferably, it is desired to reuse already measured data for screening of all persons in an age group, such as general practitioner (GP) data. Furthermore, it is essential to evaluate the number of people needed to screen to find one patient using true incidence rates, as this indicates the generalisability in the true population. Therefore, we aim to create a machine learning model for the prediction of HF using GP data and evaluate the number needed to screen with true incidence rates.

DESIGN, SETTINGS AND PARTICIPANTS

GP data from 8543 patients (-2 to -1 year before diagnosis) and controls aged 70+ years were obtained retrospectively from 01 January 2012 to 31 December 2019 from the Nivel Primary Care Database. Codes about chronic illness, complaints, diagnostics and medication were obtained. Data were split in a train/test set. Datasets describing demographics, the presence of codes (non-sequential) and upon each other following codes (sequential) were created. Logistic regression, random forest and XGBoost models were trained. Predicted outcome was the presence of HF after 1 year. The ratio case:control in the test set matched true incidence rates (1:45).

RESULTS

Sole demographics performed average (area under the curve (AUC) 0.692, CI 0.677 to 0.706). Adding non-sequential information combined with a logistic regression model performed best and significantly improved performance (AUC 0.772, CI 0.759 to 0.785, p<0.001). Further adding sequential information did not alter performance significantly (AUC 0.767, CI 0.754 to 0.780, p=0.07). The number needed to screen dropped from 14.11 to 5.99 false positives per true positive.

CONCLUSION

This study created a model able to identify patients with pending HF a year before diagnosis.

GP strategies to avoid imaging overuse. A qualitative study in Norwegian general practice

OBJECTIVES

The aim of the study was to identify general practitioners' (GPs) strategies to avoid unnecessary diagnostic imaging when encountering patients with such expectations and to explore how patients experience these strategies.

DESIGN, SETTING AND SUBJECTS

We conducted a qualitative study that combined observations of consultations and interviews with GPs and patients. A total of 24 patients visiting nine different GPs in two Norwegian urban areas were included in the study. Of these, 12 consultations were considered suitable for studying GP strategies and were therefore selected for a more thorough analysis.

MAIN OUTCOME MEASURES

GPs' communication strategies to avoid unnecessary medical imaging and patients' experiences with such strategies.

RESULTS

Five categories of strategies were identified: (1) wait and see - or suggest an alternative; (2) the art of rejection; (3) seek support from a professional authority; (4) partnership and shared decision-making and (5) reassurance, normalisation and recognition. The GPs often used multiple strategies. Factors related to a long-term doctor-patient relationship seemed to influence both communication and how both parties experienced the decision. Three important factors were evident: the patient trusted the doctor, the doctor knew the patient's medical history and the doctor knew the patient as a person. The patients seemed to be generally satisfied with the outcomes of the consultations.

CONCLUSION

GPs largely combine different strategies when meeting patients' expectations of diagnostic imaging that are not strictly medically indicated. Continuity of the doctor-patient relationship with good personal knowledge and trust between doctor and patient appeared crucial for patients to accept the doctors' decisions.Key pointsGPs usually combine a broad range of strategies to avoid unnecessary medical imagingThe patients appeared generally satisfied regardless of the strategy the strategy used by the GPs and even where their referral request were rejectedFactors related to a long-term doctor-patient relationship appeared decisive.

Efficiency over thoroughness in laboratory testing decision making in primary care: findings from a realist review

Background

Existing research demonstrates significant variation in test-ordering practice, and growth in the use of laboratory tests in primary care. Reviews of interventions designed to change test-ordering practice report heterogeneity in design and effectiveness. Improving understanding of clinicians’ decision making in relation to laboratory testing is an important means of understanding practice patterns and developing theory-informed interventions.

Aim

To develop explanations for the underlying causes of patterns of variation and increasing use of laboratory tests in primary care, and make recommendations for future research and intervention design.

Design & setting

Realist review of secondary data from primary care.

Method

Diverse evidence, including data from qualitative and quantitative studies, was gathered via systematic and iterative searching processes. Data were synthesised according to realist principles to develop explanations accounting for clinicians’ decision making in relation to laboratory tests.

Results

A total of 145 documents contributed data to the synthesis. Laboratory test ordering can fulfil many roles in primary care. Decisions about tests are incorporated into practice heuristics and tests are deployed as a tool to manage patient interactions. Ordering tests may be easier than not ordering tests in existing systems. Alongside high workloads and limited time to devote to decision making, there is a common perception that laboratory tests are relatively inconsequential interventions. Clinicians prioritise efficiency over thoroughness in decision making about laboratory tests.

Conclusion

Interventions to change test-ordering practice can be understood as aiming to preserve efficiency or encourage thoroughness in decision making. Intervention designs and evaluations should consider how testing decisions are made in real-world clinical practice.

Knowledge of and support for cancer patient pathways among general practitioners and other physicians - a study from Sweden

OBJECTIVE

To investigate the expertise in and support of the implemented new method of cancer patient pathways (CPPs) among general practitioners (GPs) and other working physicians in Sweden.

DESIGN

A survey in the form of 10 knowledge-based multiple-choice questions (MCQs) and two general questions about CPPs.

SETTING

Physicians from two different regions in Sweden answered the survey between December 2018 and January 2019.

SUBJECTS

GPs in primary care compared to other physicians. 155 participants completed the survey and the response rate was 65%.

MAIN OUTCOME MEASURES

Physicians' self-estimated knowledge of CPPs in general and opinion of CPPs effect on mortality and morbidity. Their scores on 10 different MCQs. Scores were analysed in subgroups related to the physicians medical specialty and experience.

RESULTS

A majority of all physicians (63%) felt that they had insufficient knowledge regarding the procedure of CPPs, and the average score from the MCQs was 3.8 out of 10 correct answers. The results showed that GPs performed significantly better than specialists from other disciplines.

CONCLUSIONS

The low percentage of correctly answered MCQs shows that the information about the entry part of CPPs needs to be improved. The study demonstrates a support for the system with CPPs because the physicians believed in its' positive effects on morbidity and mortality, however, it also reveals a lack of self-estimated knowledge about the system with CPPs.Key pointsCancer patient pathways (CPPs) is a newly implemented method in Sweden that aims to equalize cancer care and reduce the time to diagnosis and treatment.The proficiency of when to initiate an investigation according to a specific CPP seems low. General practitioners (GPs) performed significantly better on knowledge-based questions than other specialists did.Physicians rated their knowledge as insufficient regarding the procedure of CPPs.A clear majority of physicians believed that CPPs promotes a lower mortality and morbidity in cancer.

GP's perspectives on laboratory test use for monitoring long-term conditions: an audit of current testing practice

BACKGROUND

We have shown previously that current recommendations in UK guidelines for monitoring long-term conditions are largely based on expert opinion. Due to a lack of robust evidence on optimal monitoring strategies and testing intervals, the guidelines are unclear and incomplete. This uncertainty may underly variation in testing that has been observed across the UK between GP practices and regions.

METHODS

Our objective was to audit current testing practices of GPs in the UK; in particular, perspectives on laboratory tests for monitoring long-term conditions, the workload, and how confident GPs are in ordering and interpreting these tests. We designed an online survey consisting of multiple-choice and open-ended questions that was promoted on social media and in newsletters targeting GPs practicing in UK. The survey was live between October-November 2019. The results were analysed using a mixed-methods approach.

RESULTS

The survey was completed by 550 GPs, of whom 69% had more than 10 years of experience. The majority spent more than 30 min per day on testing (78%), but only half of the respondents felt confident in dealing with abnormal results (53%). There was a high level of disagreement for whether liver function tests and full blood counts should be done 'routinely', 'sometimes', or 'never' in patients with a certain long-term condition. The free text comments revealed three common themes: (1) pressures that promote over-testing, i.e. guidelines or protocols, workload from secondary care, fear of missing something, patient expectations; (2) negative consequences of over-testing, i.e. increased workload and patient harm; and (3) uncertainties due to lack of evidence and unclear guidelines.

CONCLUSION

These results confirm the variation that has been observed in test ordering data. The results also show that most GPs spent a significant part of their day ordering and interpreting monitoring tests. The lack of confidence in knowing how to act on abnormal test results underlines the urgent need for robust evidence on optimal testing and the development of clear and unambiguous testing recommendations. Uncertainties surrounding optimal testing has resulted in an over-use of tests, which leads to a waste of resources, increased GP workload and potential patient harm.

Doctors' characteristics and the use of long consultations at out-of-hours services 2008-2017: a registry-based follow-up study in Norway

Objective: The aim was to analyse whether there was a change in percentage of long consultations over a 10-year period, and whether individual doctors changed their use of time as they got more experience and specialisation during the same period. Design and setting: This is a registry based study encompassing all consultations in primary care out-of-hours service in Norway in 2008 and 2017. Subjects: For both years all doctors were included in cross sectional analyses. In addition, doctors who participated both years were included in a separate follow-up analysis. Main outcome measures: Long consultations (>20 min) were identified by a time fee in the claims' database. Results: There were 4610 doctors in 2008 and 5620 in 2017, 904 participated both years. In 2008 a time fee was claimed in 38% of consultations, in 2017 in 47%. Older doctors made less use of the time fee, as did doctors who had many consultations, regular general practitioners, and general practice specialists. The general practitioners who participated both years increased their use of the time fee from 33% to 38% of consultations. Those who specialised in general practice during the 10-year period increased their use of the time fee from 34% to 37%. Conclusions: Experienced doctors have fewer long consultations than inexperienced doctors. Over years there is a strong trend towards increasing the use of time fee during out-of-hours consultations. This trend is only partly offset by increasing the experience of the doctors. KEY POINTS Although consultation length may be associated with patient satisfaction there is also a cost-efficiency aspect to be taken into account •Percentage long consultations out-of-hours increased from 38% in 2008 to 47% in 2017 •Experienced doctors had fewer long consultations •Experience only partly offset the trend towards more long consultations.