Complex consultations in primary care: a tool for assessing the range of health problems and issues addressed in general practice consultations

Agreement between patient's description of abdominal symptoms of possible upper gastrointestinal cancer and general practitioner consultation notes: a qualitative analysis of video-recorded UK primary care consultation data

INTRODUCTION

Abdominal symptoms are common in primary care but infrequently might be due to an upper gastrointestinal (UGI) cancer. Patients' descriptions may differ from medical terminology used by general practitioners (GPs). This may affect how information about abdominal symptoms possibly due to an UGI cancer are documented, creating potential missed opportunities for timely investigation.

OBJECTIVES

To explore how abdominal symptoms are communicated during primary care consultations, and identify characteristics of patients' descriptions that underpin variation in the accuracy and completeness with which they are documented in medical records.

METHODS AND ANALYSIS

Primary care consultation video recordings, transcripts and medical records from an existing dataset were screened for adults reporting abdominal symptoms. We conducted a qualitative content analysis to capture alignments (medical record entries matching patient verbal and non-verbal descriptions) and misalignments (symptom information omitted or differing from patient descriptions). Categories were informed by the Calgary-Cambridge guide's 'gathering information' domains and patterns in descriptions explored.

RESULTS

Our sample included 28 consultations (28 patients with 18 GPs): 10 categories of different clinical features of abdominal symptoms were discussed. The information GPs documented about these features commonly did not match what patients described, with misalignments more common than alignments (67 vs 43 instances, respectively). Misalignments often featured patients using vague descriptors, figurative speech, lengthy explanations and broad hand gestures. Alignments were characterised by patients using well-defined terms, succinct descriptions and precise gestures for symptoms with an exact location. Abdominal sensations reported as 'pain' were almost always documented compared with expressions of 'discomfort'.

CONCLUSIONS

Abdominal symptoms that are well defined or communicated as 'pain' may be more salient to GPs than those expressed vaguely or as 'discomfort'. Variable documentation of abdominal symptoms in medical records may have implications for the development of clinical decision support systems and decisions to investigate possible UGI cancer.

Factors affecting the documentation of spoken safety-netting advice in routine GP consultations: a cross-sectional study

BACKGROUND

Previous studies have reported how often safety-netting is documented in medical records, but it is not known how this compares with what is verbalised and what factors might influence the consistency of documentation.

AIM

To compare spoken and documented safety-netting advice and to explore factors associated with documentation.

DESIGN AND SETTING

A cross-sectional study, using an existing GP consultations archive.

METHOD

Observational coding involving classifying and quantifying medical record entries and comparison with spoken safety-netting advice in 295 video-/audio-recorded consultations. Associations were tested using logistic regression.

RESULTS

Two-thirds of consultations (192/295) contained spoken safety-netting advice that applied to less than half of the problems assessed (242/516). Only one-third of consultations (94/295) had documented safety-netting advice, which covered 20.3% of problems (105/516). The practice of GPs varied widely, from those that did not document their safety-netting advice to those that nearly always did so (86.7%). GPs were more likely to document their safety-netting advice for new problems (P = 0.030), when only a single problem was discussed in a consultation (P = 0.040), and when they gave specific rather than generic safety-netting advice (P = 0.007). In consultations where multiple problems were assessed (n = 139), the frequency of spoken and documented safety-netting advice decreased the later a problem was assessed.

CONCLUSION

GPs frequently do not document the safety-netting advice they have given to patients, which may have medicolegal implications in the event of an untoward incident. GPs should consider how safely they can assess and document more than one problem in a single consultation and this risk should be shared with patients to help manage expectations.

Measuring the complexity of general practice consultations: a Delphi and cross-sectional study in English primary care

BACKGROUND

The complexity of general practice consultations may be increasing and varies in different settings. A measure of complexity is required to test these hypotheses.

AIM

To develop a valid measure of general practice consultation complexity applicable to routine medical records.

DESIGN AND SETTING

Delphi study to select potential indicators of complexity followed by a cross-sectional study in English general practices to develop and validate a complexity measure.

METHOD

The online Delphi study over two rounds identified potential indicators of consultation complexity. The cross-sectional study used an age-sex stratified random sample of patients and general practice face-to-face consultations from 2013/2014 in the Clinical Practice Research Datalink. The authors explored independent relationships between each indicator and consultation duration using mixed-effects regression models, and revalidated findings using data from 2017/2018. The proportion of complex consultations in different age-sex groups was assessed.

RESULTS

A total of 32 GPs participated in the Delphi study. The Delphi panel endorsed 34 of 45 possible complexity indicators after two rounds. After excluding factors because of low prevalence or confounding, 17 indicators were retained in the cross-sectional study. The study used data from 173 130 patients and 725 616 face-to-face GP consultations. On defining complexity as the presence of any of these 17 factors, 308 370 consultations (42.5%) were found to be complex. Mean duration of complex consultations was 10.49 minutes, compared to 9.64 minutes for non-complex consultations. The proportion of complex consultations was similar in males and females but increased with age.

CONCLUSION

The present consultation complexity measure has face and construct validity. It may be useful for research, management and policy, and for informing decisions about the range of resources needed in different practices.

The content and conduct of GP consultations for dermatology problems: a cross-sectional study

Background

Skin complaints are common in primary care, and poor outcomes in long-term conditions are often due to low adherence to treatment. Shared decision making and self-management support may help, yet there is little understanding of patient involvement or the support provided by GPs.

Aim

To describe the content of primary care consultations for skin problems, including shared decision making practice, delivery of self-management advice, and follow-up.

Design and setting

Cross-sectional study of video-recorded UK adult GP consultations and linked data.

Method

A coding tool was developed and applied to all consultations with skin problems. Shared decision making was assessed using the observer OPTION⁵ scale.

Results

A total of 45/318 consultations (14.2%) related to one or more skin problems, which were discussed alongside other problems in 71.1% (32/45) of consultations. Of the 100 different problems discussed in these consultations, 51 were dermatological. The mean amount of time spent on skin problems in the consultations was 4 minutes 16 seconds. Medication was recommended for 66.7% (34/51) of skin problems, with low shared decision making (mean OPTION⁵ score = 10.7). Self-management advice (verbal only) was given for 47.1% (24/51) of skin problems. Most skin problems (84.3%; 43/51) were not referred to secondary care; 32.6% (14/43) of the skin problems not referred were seen again in primary care within 12 weeks, of which 35.7% (5/14) follow-up appointments were not planned.

Conclusion

In this study, skin problems were usually presented alongside other complaints and resulted in a medication recommendation. Shared decision making was uncommon and self-management advice not consistently given, with re-attendance for the same problem common. GPs’ training should reflect how frequently skin problems are seen and seek to improve patient involvement in decision making and support self-management.

Safety netting in routine primary care consultations: an observational study using video-recorded UK consultations

BACKGROUND

Safety-netting advice is information shared with a patient or their carer designed to help them identify the need to seek further medical help if their condition fails to improve, changes, or if they have concerns about their health.

AIM

To assess when and how safety-netting advice is delivered in routine GP consultations.

DESIGN AND SETTING

This was an observational study using 318 recorded GP consultations with adult patients in the UK.

METHOD

A safety-netting coding tool was applied to all consultations. Logistic regression for the presence or absence of safety-netting advice was compared between patient, clinician, and problem variables.

RESULTS

A total of 390 episodes of safety-netting advice were observed in 205/318 (64.5%) consultations for 257/555 (46.3%) problems. Most advice was initiated by the GP (94.9%) and delivered in the treatment planning (52.1%) or closing (31.5%) consultation phases. Specific advice was delivered in almost half (47.2%) of episodes. Safety-netting advice was more likely to be present for problems that were acute (odds ratio [OR] 2.18, 95% confidence interval [CI] = 1.30 to 3.64), assessed first in the consultation (OR 2.94, 95% CI = 1.85 to 4.68) or assessed by GPs aged ≤49 years (OR 2.56, 95% CI = 1.45 to 4.51). Safety-netting advice was documented for only 109/242 (45.0%) problems.

CONCLUSION

GPs appear to commonly give safety-netting advice, but the contingencies or actions required on the patient's part may not always be specific or documented. The likelihood of safety-netting advice being delivered may vary according to characteristics of the problem or the GP. How to assess safety-netting outcomes in terms of patient benefits and harms does warrant further exploration.

Development of a tool for coding safety-netting behaviours in primary care: a mixed-methods study using existing UK consultation recordings

BACKGROUND

Safety netting is recommended in a variety of clinical settings, yet there are no tools to record clinician safety-netting communication behaviours.

AIM

To develop and assess the inter-rater reliability (IRR) of a coding tool designed to assess safety-netting communication behaviours in primary care consultations.

DESIGN AND SETTING

A mixed-methods study using an existing dataset of video-and audio-recorded UK primary care consultations.

METHOD

Key components that should be assessed in a coding tool were identified using the published literature and relevant guidelines. An iterative approach was utilised to continuously refine and generate new codes based on the application to real-life consultations. After the codebook had been generated, it was applied to 35 problems in 24 consultations independently by two coders. IRR scores were then calculated.

RESULTS

The tool allows for the identification and quantification of the key elements of safety-netting advice including: who initiates the advice and at which stage of the consultation; the number of symptoms or conditions the patient is advised to look out for; what action patients should take and how urgently; as well as capturing how patients respond to such advice plus important contextual codes such as the communication of diagnostic uncertainty, the expected time course of an illness, and any follow-up plans. The final tool had substantial levels of IRR with the mean average agreement for the final tool being 88% (κ = 0.66).

CONCLUSION

The authors have developed a novel tool that can reliably code the extent of clinician safety-netting communication behaviours.

The elicitation and management of multiple health concerns in GP consultations

OBJECTIVE

To describe the nature of patient concerns and to explore if, when and how they are addressed by GPs in the UK.

METHODS

Detailed coding and descriptive analysis of 185 video recordings from the EPaC study (Elicitation of Patient Concerns, EPaC) RESULTS: An average of 2.1 concerns were raised per consultation and the most common concerns were musculoskeletal, administrative (e.g. test results and medication related issues), and skin symptoms. GPs who had been trained as part of the EPaC intervention to solicit for additional concerns in the opening phase of the consultation did so 92.6% of the time. In contrast, those in the control arm did so only 7% of the time. However, the particular formulation of the GP soliciting question does not seem to be associated with the likelihood of the patient volunteering an additional concern.

CONCLUSIONS

GP consultations are complex encounters in which multiple concerns are dealt with across a wide range of disease areas. GPs can be trained to solicit for problems/concerns early in the consultation.

PRACTICE IMPLICATIONS

Soliciting for additional concerns is not routinely done. But very brief training can substantially help in eliciting concerns early in the consultation, which may help with organising the consultation.

The 'One in a Million' study: creating a database of UK primary care consultations

BACKGROUND

Around 1 million primary care consultations happen in England every day. Despite this, much of what happens in these visits remains a 'black box'.

AIM

To create an archive of videotaped consultations and linked data based on a large sample of routine face-to-face doctor-patient consultations with consent for use in future research and training.

DESIGN AND SETTING

Cross-sectional study in 12 general practices in the west of England, UK.

METHOD

Up to two GPs from each practice took part in the study. Over 1 to 2 days, consecutive patients were approached until up to 20 eligible patients for each GP consented to be videotaped. Eligible patients were aged ≥18 years, consulting on their own behalf, fluent in English, and with capacity to consent. GP questionnaires were self-administered. Patient questionnaires were self-administered immediately pre-consultation and post-consultation, and GPs filled in a checklist after each recording. A follow-up questionnaire was sent to patients after 10 days, and data about subsequent related consultations were collected from medical records 3 months later.

RESULTS

Of the 485 patients approached, 421 (86.8%) were eligible. Of the eligible patients, 334 (79.3%) consented to participate and 327 consultations with 23 GPs were successfully taped (307 video, 20 audio-only). Most patients (n = 300, 89.8%) consented to use by other researchers, subject to specific ethical approval.

CONCLUSION

Most patients were willing to allow their consultations to be videotaped, and, with very few exceptions, to allow recordings and linked data to be stored in a data repository for future use for research and training.

Depth of the patient-doctor relationship and content of general practice consultations: cross-sectional study

BACKGROUND

Patient-doctor continuity is valued by both parties, yet the effect of the depth of the patient-doctor relationship on the content of consultations in general practice is unknown.

AIM

To assess whether differences in the depth of relationship between a patient and their GP affects the length of consultations, and the number and type of problems and issues raised during a consultation.

DESIGN AND SETTING

Cross-sectional study in 22 GP practices in the UK.

METHOD

GP consultations (n = 229) were videotaped and the number of problems and aspects of those problems and issues identified. Patients completed the Patient-Doctor Depth of Relationship (PDDR) and General Practice Assessment Questionnaire-communication (GPAQc) scales. Associations were explored using multivariable linear and logistic regression.

RESULTS

Complete data were available on 190 participants consulting 30 GPs. In unadjusted analysis, patients with a deep relationship with their GP discussed more problems (mean 2.8) and issues (mean 4.7) compared with those with a moderate (2.4 problems; 4.0 issues) or shallow (2.3 problems; 3.8 issues) relationship. Patients with deep relationships had consultations that were on average 118 seconds (95% CI = 1 to 236) longer than those with shallow relationships. Adjustment for participant and GP factors attenuated these relationships, although the main trends persisted.

CONCLUSION

A greater number of problems and issues may be raised in a consultation when patients have a deeper relationship with their GP. Over several clinical encounters each year, this may be associated with significant benefits to patients and efficiencies in GP consultations and warrants further investigation.