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Chilvers H, Bates P. Remote prescribing consultations: exploring the principles of effective practice. Nurs Stand 2024; 39:77-81. [PMID: 38764389 DOI: 10.7748/ns.2024.e12290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/12/2024] [Indexed: 05/21/2024]
Abstract
There has been a rapid increase in remote patient consultations, including remote prescribing - partly in response to the coronavirus disease 2019 (COVID-19) pandemic, but also as part of the move towards a 'digital first' NHS. There are various benefits associated with remote prescribing, such as convenience for patients and judicious use of healthcare resources. However, it is also associated with several risks, for example the use of inappropriate medicines or doses if the prescriber does not have full access to the patient's records. This article considers some of the benefits and challenges of remote prescribing, and discusses the main principles of effective practice in relation to patient safety, informed consent and documentation.
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Affiliation(s)
- Helen Chilvers
- School of Health and Social Care, College of Social Science, University of Lincoln, Lincoln, England
| | - Paul Bates
- School of Health and Social Care, College of Social Science, University of Lincoln, Lincoln, England
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Neill S, Bayes N, Thompson M, Croxson C, Roland D, Lakhanpaul M. Helping parents know when to seek help for an acutely ill child: Evidence based co-development of a mobile phone app using complex intervention methodology. Int J Med Inform 2024; 187:105459. [PMID: 38640593 DOI: 10.1016/j.ijmedinf.2024.105459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 04/11/2024] [Accepted: 04/15/2024] [Indexed: 04/21/2024]
Abstract
BACKGROUND Acute illness accounts for the majority of episodes of illness in children under five years of age and is the age group with the highest consultation rate in general practice in the UK. The number of children presenting to emergency care is also steadily increasing, having risen beyond pre-pandemic numbers. Such high, and increasing, rates of consultation have prompted concerns about parents' level of knowledge and confidence in caring for their children when they are ill, and particularly when and how to seek help appropriately. AIM The ASK SNIFF collaboration research programme identified parents' need for accurate and accessible information to help them know when to seek help for a sick child in 2010. This paper presents the resulting programme of research which aimed to co-develop an evidence-based safety netting intervention (mobile app) to help parents know when to seek help for an acutely ill child under the age of five years in the UK. METHODS Our programme used a collaborative six step process with 147 parent and 324 health professional participants over a period of six years including: scoping existing interventions, systematic review, qualitative research, video capture, content identification and development, consensus methodology, parent and expert clinical review. RESULTS Our programme has produced evidence-based content for an app supported by video clips. Our collaborative approach has supported every stage of our work, ensuring that the end result reflects the experiences, perspectives and expressed needs of parents and the clinicians they consult. CONCLUSION We have not found any other resource which has used this type of approach, which may explain why there is no published evaluation data demonstrating the impact of existing UK resources. Future mobile apps should be designed and developed with the service users for whom they are intended.
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Affiliation(s)
- Sarah Neill
- School of Nursing and Midwifery, Faculty of Health, University of Plymouth, Plymouth, UK.
| | - Natasha Bayes
- Faculty of Health, University of Northampton, Northampton, UK.
| | - Matthew Thompson
- Department of Family Medicine, University of Washington, Seattle, USA.
| | - Caroline Croxson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, UK.
| | - Damian Roland
- Paediatric Emergency Medicine Leicester Academic (PEMLA) Group, Children's Emergency Department, Leicester Royal Infirmary, Leicester, UK; SAPPHIRE Group, Health Sciences, Leicester University, Leicester, UK.
| | - Monica Lakhanpaul
- UCL Population, Policy and Practice Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, University College London, London WC1N 1EH, UK; Community Paediatrics, Whittington Health NHS, London N19 5NF, UK.
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Hannah R, Chavasse RJPG, Paton JY, Walton E, Roland D, Foster S, Lyttle MD. Emergency department discharge practices for children with acute wheeze and asthma: a survey of discharge practice and review of safety netting instructions in the UK and Ireland. Arch Dis Child 2024; 109:536-542. [PMID: 38627029 DOI: 10.1136/archdischild-2023-326247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 03/31/2024] [Indexed: 06/21/2024]
Abstract
OBJECTIVE Recovery from acute wheeze and asthma attacks should be supported with safety netting, including treatment advice. We evaluated emergency department (ED) discharge practices for acute childhood wheeze/asthma attacks to describe variation in safety netting and recovery bronchodilator dosing. DESIGN Two-phase study between June 2020 and September 2021, comprising (1) Departmental discharge practice survey, and (2) Analysis of written discharge instructions for caregivers. SETTING Secondary and tertiary EDs in rural and urban settings, from Paediatric Emergency Research in the UK and Ireland (PERUKI). MAIN OUTCOME MEASURES Describe practice and variation in discharge advice, treatment recommendations and safety netting provision. RESULTS Of 66/71 (93%) participating sites, 62/66 (93.9%) reported providing written safety netting information. 52/66 (78.8%) 'nearly always' assessed inhaler/spacer technique; routine medication review (21/66; 31.8%) and adherence (16/66; 21.4%) were less frequent. In phase II, 61/66 (92.4%) submitted their discharge documents; 50/66 (81.9%) included bronchodilator plans. 11/66 (18.0%) provided Personalised Asthma Action Plans as sole discharge information. 45/50 (90%) provided 'fixed' bronchodilator dosing regimes; dose tapering was common (38/50; 76.0%). Median starting dose was 10 puffs 4 hourly (27/50, 54.0%); median duration was 4 days (29/50, 58.0%). 13/61 (21.3%) did not provide bronchodilator advice for acute deterioration; where provided, 42/48 (87.5%) recommended 10 puffs immediately. Subsequent dosages varied considerably. Common red flags included inability to speak (52/61, 85.2%), inhalers not lasting 4 hours (51/61, 83.6%) and respiratory distress (49/61, 80.3%). CONCLUSIONS There is variation in bronchodilator dosing and safety netting content for recovery following acute wheeze and asthma attacks. This reflects a lack of evidence, affirming need for further multicentre studies regarding bronchodilator recovery strategies and optimal safety netting advice.
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Affiliation(s)
- Romanie Hannah
- Children's Emergency Department, Royal Alexandra Children's Hospital, Brighton, UK
| | - Richard J P G Chavasse
- Respiratory Paediatrics, St George's University Hospitals NHS Foundation Trust, London, UK
| | - James Y Paton
- School of Medicine, College of Medical, Veterinary, and Life Sciences, University of Glasgow, Glasgow, UK
| | - Emily Walton
- Children's Emergency Department, Royal Alexandra Children's Hospital, Brighton, UK
| | - Damian Roland
- SAPPHIRE Group, Health Sciences, University of Leicester, Leicester, UK
- Paediatric Emergency Medicine Leicester Academic (PEMLA) Group, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Steven Foster
- Children's Emergency Department, Royal Hospital for Children, Glasgow, UK
| | - Mark D Lyttle
- Emergency Department, Bristol Royal Hospital for Children, Bristol, UK
- Research in Emergency Care Avon Collaborative Hub (REACH), University of the West of England, Bristol, UK
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Sources of diagnostic delay for people with Crohn's disease and ulcerative colitis: Qualitative research study. PLoS One 2024; 19:e0301672. [PMID: 38857292 PMCID: PMC11164383 DOI: 10.1371/journal.pone.0301672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 03/20/2024] [Indexed: 06/12/2024] Open
Abstract
OBJECTIVE An improved understanding of the causes and experience of diagnostic delay in Inflammatory Bowel Disease (IBD). METHODS Framework analysis of semi-structured interviews with 20 adults with IBD. RESULTS Participants' prior knowledge of normal bowel function/IBD was limited. Symptoms were sometimes misattributed to mild/transient conditions or normalised until intolerable. Family pressures, work, education, mistrust of doctors, fear and embarrassment could exacerbate delays. Poor availability of face-to-face appointments deterred people from seeing a GP. Patients feared that by the time they got to see their GP, their symptoms would have resolved. Patients instead self-managed symptoms, but often regretted not seeking help earlier. Limited time in consultations, language barriers, embarrassment, and delays in test results subsequently delayed specialist referrals. GPs misattributed symptoms to other conditions due to atypical or non-specific presentations, leading to reduced trust in health systems. Patients complained of poor communication, delays in accessing test results, appointments, and onward referrals-all associated with clinical deterioration. GPs were sometimes unable to 'fast-track' patients into specialist care. Consultations and endoscopies were often difficult experiences for patients, especially for non-English speakers who are also less likely to receive information on mental health support and the practicalities of living with IBD. CONCLUSIONS The framework analysis demonstrates delay in the diagnosis of IBD at each stage of the patient journey. RECOMMENDATIONS Greater awareness of IBD amongst the general population would facilitate presentation to healthcare services through symptom recognition by individuals and community advice. Greater awareness in primary care would help ensure IBD is included in differential diagnosis. In secondary care, greater attention to the wider needs of patients is needed-beyond diagnosis and treatment. All clinicians should consider atypical presentations and the fluctuating nature of IBD. Diagnostic overshadowing is a significant risk-where other diagnoses are already in play the risk of delay is considerable.
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Affiliation(s)
- AWARE-IBD Diagnostic Delay Working Group
- Sheffield CTRU, University of Sheffield, Regent Court, Sheffield, United Kingdom
- The Medical School, The University of Sheffield, Sheffield, United Kingdom
- Academic Unit of Medical Education, The Medical School, The University of Sheffield, Sheffield, United Kingdom
- Sheffield Inflammatory Bowel Disease Centre, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
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Quinn S, Ferguson L, Read D, Richards N. "The great escape": how an incident of elopement gave rise to trauma informed palliative care for a patient experiencing multiple disadvantage. BMC Palliat Care 2024; 23:61. [PMID: 38419002 PMCID: PMC10900545 DOI: 10.1186/s12904-024-01374-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 02/02/2024] [Indexed: 03/02/2024] Open
Abstract
BACKGROUND This case report from Scotland, UK illustrates how unresolved traumatic experiences across the life course can affect a patient's engagement with palliative care and offers insights into the flexibility and adaptations necessary for taking a trauma informed approach to care for an individual experiencing multiple disadvantage. Trauma informed care is a cornerstone in the pursuit of equitable palliative care, particularly for those facing multiple disadvantage, as it acknowledges the impact of past traumas on current healthcare experiences, and fosters an environment of understanding, acceptance, and tailored support to alleviate suffering in the final stages of life. CASE PRESENTATION "M" was a veteran with a history of homelessness, living with end stage anal cancer and symptoms consistent with post-traumatic stress disorder, although he never received a formal diagnosis. M exhibited complex behaviours perceived to be related to his history of trauma, including his decision to elope from the hospice, reluctance to accept personal care from nurses, and unpredictability. These behaviours posed a significant challenge to his palliative care team, both in the hospice and at home. An individualised and flexible approach to care delivery was eventually adopted, which included a 'safety-netting' approach and care delivery outside of the hospice. M was ultimately supported to remain at home until a week before he died. CONCLUSION M's case underscores the necessity of adopting a trauma informed approach to palliative care, particularly for patients with a history of trauma and multiple disadvantage. The case highlights the importance of understanding and respecting a patient's past traumas, promoting safety and autonomy, and ensuring flexibility in care delivery.
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Affiliation(s)
- Sam Quinn
- End of Life Studies Group, University of Glasgow, Dumfries Campus, Dumfries and Galloway, Scotland, DG1 4ZL, UK.
| | - Libby Ferguson
- Marie Curie Scotland, 133 Balornock Road, Stobhill, Glasgow, Scotland, G21 3US, UK
| | | | - Naomi Richards
- End of Life Studies Group, University of Glasgow, Dumfries Campus, Dumfries and Galloway, Scotland, DG1 4ZL, UK
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Cox C, Hatfield T, Fritz Z. How and why do doctors communicate diagnostic uncertainty: An experimental vignette study. Health Expect 2024; 27:e13957. [PMID: 38828702 PMCID: PMC10774830 DOI: 10.1111/hex.13957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 12/14/2023] [Accepted: 12/16/2023] [Indexed: 06/05/2024] Open
Abstract
BACKGROUND Diagnostic uncertainty is common, but its communication to patients is under-explored. This study aimed to (1) characterise variation in doctors' communication of diagnostic uncertainty and (2) explore why variation occurred. METHODS Four written vignettes of clinical scenarios involving diagnostic uncertainty were developed. Doctors were recruited from five hospitals until theoretical saturation was reached (n = 36). Participants read vignettes in a randomised order, and were asked to discuss the diagnosis/plan with an online interviewer, as they would with a 'typical patient'. Semi-structured interviews explored reasons for communication choices. Interview transcripts were coded; quantitative and qualitative (thematic) analyses were undertaken. RESULTS There was marked variation in doctors' communication: in their discussion about differential diagnoses, their reference to the level of uncertainty in diagnoses/investigations and their acknowledgement of diagnostic uncertainty when safety-netting. Implicit expressions of uncertainty were more common than explicit. Participants expressed both different communication goals (including reducing patient anxiety, building trust, empowering patients and protecting against diagnostic errors) and different perspectives on how to achieve these goals. Training in diagnostic uncertainty communication is rare, but many felt it would be useful. CONCLUSIONS Significant variation in diagnostic uncertainty communication exists, even in a controlled setting. Differing communication goals-often grounded in conflicting ethical principles, for example, respect for autonomy versus nonmaleficence-and differing ideas on how to prioritise and achieve them may underlie this. The variation in communication behaviours observed has important implications for patient safety and health inequalities. Patient-focused research is required to guide practice. PATIENT OR PUBLIC CONTRIBUTION In the design stage of the study, two patient and public involvement groups (consisting of members of the public of a range of ages and backgrounds) were consulted to gain an understanding of patient perspectives on the concept of communicating diagnostic uncertainty. Their feedback informed the formulations of the research questions and the choice of vignettes used.
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Affiliation(s)
- Caitríona Cox
- The Healthcare Improvement Studies (THIS) InstituteUniversity of CambridgeCambridgeUK
| | - Thea Hatfield
- The Healthcare Improvement Studies (THIS) InstituteUniversity of CambridgeCambridgeUK
| | - Zoë Fritz
- The Healthcare Improvement Studies (THIS) InstituteUniversity of CambridgeCambridgeUK
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Zhou T, Salman D, McGregor A. mHealth Apps for the Self-Management of Low Back Pain: Systematic Search in App Stores and Content Analysis. JMIR Mhealth Uhealth 2024; 12:e53262. [PMID: 38300700 PMCID: PMC10870204 DOI: 10.2196/53262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 12/06/2023] [Accepted: 12/21/2023] [Indexed: 02/02/2024] Open
Abstract
BACKGROUND With the rapid development of mobile health (mHealth) technology, many health apps have been introduced to the commercial market for people with back pain conditions. However, little is known about their content, quality, approaches to care for low back pain (LBP), and associated risks of use. OBJECTIVE The aims of this research were to (1) identify apps for the self-management of LBP currently on the market and (2) assess their quality, intervention content, theoretical approaches, and risk-related approaches. METHODS The UK iTunes and Google Play stores were initially searched for apps related to the self-management of LBP in May 2022. A repeat search in June 2023 was conducted to ensure that any relevant new apps developed in the last year were incorporated into the review. A total of 3 keywords recommended by the Cochrane Back and Neck Group were used to search apps "low back pain," "back pain," and "lumbago." The quality of the apps was assessed by using the 5-point Mobile App Rating Scale (MARS). RESULTS A total of 69 apps (25 iOS and 44 Android) met the inclusion criteria. These LBP self-management apps mainly provide recommendations on muscle stretching (n=51, 73.9%), muscle strengthening (n=42, 60.9%), core stability exercises (n=32, 46.4%), yoga (n=19, 27.5%), and information about LBP mechanisms (n=17, 24.6%). Most interventions (n=14, 78%) are consistent with the recommendations in the National Institute for Health and Care Excellence (NICE) guidelines. The mean (SD) MARS overall score of included apps was 2.4 (0.44) out of a possible 5 points. The functionality dimension was associated with the highest score (3.0), whereas the engagement and information dimension resulted in the lowest score (2.1). Regarding theoretical and risk-related approaches, 18 (26.1%) of the 69 apps reported the rate of intervention progression, 11 (15.9%) reported safety checks, only 1 (1.4%) reported personalization of care, and none reported the theoretical care model or the age group targeted. CONCLUSIONS mHealth apps are potentially promising alternatives to help people manage their LBP; however, most of the LBP self-management apps were of poor quality and did not report the theoretical approaches to care and their associated risks. Although nearly all apps reviewed included a component of care listed in the NICE guidelines, the model of care delivery or embracement of care principles such as the application of a biopsychosocial model was unclear.
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Affiliation(s)
- Tianyu Zhou
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - David Salman
- Department of Primary Care and Public Health, Imperial College London, London, United Kingdom
| | - Alison McGregor
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
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Morgan S. Alone: General Practice. Br J Gen Pract 2024; 74:74. [PMID: 38272688 PMCID: PMC10824357 DOI: 10.3399/bjgp24x736245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2024] Open
Affiliation(s)
- Simon Morgan
- Australian GP and medical educator. @DrSimonMorgan
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Burvenich R, Heytens S, De Sutter A, Struyf T, Toelen J, Verbakel JY. Towards an international consensus on safety netting advice for acutely ill children presenting to ambulatory care: a modified e-Delphi procedure. Arch Dis Child 2024; 109:93-99. [PMID: 38123917 DOI: 10.1136/archdischild-2023-326370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 11/28/2023] [Indexed: 12/23/2023]
Abstract
OBJECTIVE Develop a consensus on the content and form of safety netting advice (SNA) for parents of acutely ill children. DESIGN Four-round modified e-Delphi using online questionnaires and feedback among clinical and research experts. SETTING Ambulatory care in high-income countries. PARTICIPANTS Forty-one experts from 13 countries: 3 emergency physicians, 15 general practitioners, 4 nurses and 19 paediatricians. RESULTS The experts defined the content of SNA as advice on the normal, expected disease course of the provisional diagnosis, diagnostic uncertainty, alarm signs that indicate the need for medical help and information on where and how to find such help. Regarding the form of the SNA, the experts agree that a reliable source should give SNA verbally with paper or digital written or video/image resources at every appropriate healthcare encounter in a short and simple empowering fashion, specific to the child's situation and seek confirmatory feedback from parents. CONCLUSIONS SNA needs to contain advice on the expected disease course, alarm signs and where and how to find help. It should be given verbally with written resources by a reliable healthcare professional or digital platform. Short, simple and specific, SNA needs to empower the parent whose understanding of the advice should be checked. The effectiveness of SNA resources coproduced by parents and experts should be assessed in different settings and those providing SNA require up-to-date and reliable training.
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Affiliation(s)
- Ruben Burvenich
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Stefan Heytens
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - An De Sutter
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Thomas Struyf
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Jaan Toelen
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Jan Y Verbakel
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
- NIHR Community Healthcare Medtech and IVD cooperative, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Blok GCGH, Berger MY, Ahmeti AB, Holtman GA. What is important to the GP in recognizing acute appendicitis in children: a delphi study. BMC PRIMARY CARE 2023; 24:217. [PMID: 37872491 PMCID: PMC10591392 DOI: 10.1186/s12875-023-02167-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 09/30/2023] [Indexed: 10/25/2023]
Abstract
BACKGROUND For diagnostic research on appendicitis in registration data, insight is needed in the way GPs generate medical records. We aimed to reach a consensus on the features that GPs consider important in the consultation and medical records when evaluating a child with suspected appendicitis. METHODS We performed a three-round Delphi study among Dutch GPs selected by purposive sampling. An initial feature list was created based on a literature search and features in the relevant Dutch guideline. Finally, using a vignette describing a child who needed later reassessment, we asked participants to complete an online questionnaire about which consultation features should be addressed and recorded. RESULTS A literature review and Dutch guideline yielded 95 consultation features. All three rounds were completed by 22 GPs, with the final consensus list containing 26 symptoms, 29 physical assessments and signs, 2 additional tests, and 8 further actions (including safety-netting, i.e., informing the patient about when to contact the GP again). Of these, participants reached consensus that 37 should be actively addressed and that 20 need to be recorded if findings are negative. CONCLUSIONS GPs agreed that negative findings do not need to be recorded for most features and that records should include the prognostic and safety-netting advice given. The results have implications in three main domains: for research, that negative findings are likely to be missing; for medicolegal purposes, that documentation cannot be expected to be complete; and for clinical practice, that safety-netting advice should be given and documented.
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Affiliation(s)
- Guus C G H Blok
- Department of General Practice and Elderly Care Medicine, University Medical Center Groningen, University of Groningen, PO Box 196, Groningen, 9700 AD, The Netherlands
| | - Marjolein Y Berger
- Department of General Practice and Elderly Care Medicine, University Medical Center Groningen, University of Groningen, PO Box 196, Groningen, 9700 AD, The Netherlands
| | - Arjan B Ahmeti
- Department of General Practice and Elderly Care Medicine, University Medical Center Groningen, University of Groningen, PO Box 196, Groningen, 9700 AD, The Netherlands
| | - Gea A Holtman
- Department of General Practice and Elderly Care Medicine, University Medical Center Groningen, University of Groningen, PO Box 196, Groningen, 9700 AD, The Netherlands.
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Fernholm R, Wannheden C, Trygg Lycke S, Riggare S, Pukk Harenstam K. Patients' and clinicians' views on the appropriate use of safety-netting advice in consultations-an interview study from Sweden. BMJ Open 2023; 13:e077938. [PMID: 37798020 PMCID: PMC10565180 DOI: 10.1136/bmjopen-2023-077938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 09/14/2023] [Indexed: 10/07/2023] Open
Abstract
BACKGROUND A promising approach to manage clinical uncertainty and thereby reduce the risk of preventable diagnostic harm is to use safety-netting advice (ie, communicating structured information to patients about when and where to reconsult healthcare). AIM To explore clinicians' and patients' views on when and how safety-netting can be successfully applied in primary-care and emergency-care settings. DESIGN AND SETTING An exploratory qualitative research design; we performed focus groups and interviews in a Swedish setting. PARTICIPANTS Nine physicians working in primary or emergency care and eight patients or caregivers participated. The participants were an ethnically homogeneous group, originating from Western European or Australian backgrounds. METHOD Data were analysed inductively, using the framework method. The results are reported according to the Standards for Reporting Qualitative Research guidelines for reporting qualitative research. RESULTS In order to manage diagnostic uncertainty using safety-netting, clinicians and patients emphasised the need to understand the preconditions for the consultation (ie, the healthcare setting, the patient's capacity and existing power imbalance). Furthermore, participants raised the importance of establishing a mutual understanding regarding the patient's perspective and the severity of the situation before engaging in safety-netting advice. CONCLUSION The establishment of a shared mental model between clinician and patient of the preconditions for the clinical encounter is a vital factor affecting how safety-netting advice is communicated and received and its ability to support patients in problem detection and planning after the visit. We suggest that successful safety-netting can be viewed as a team activity, where the clinician and patient collaborate in monitoring how the patient's condition progresses after the care visit. Furthermore, our findings suggest that to be successfully implemented, safety-netting advice needs to be tailored to the clinical context in general and to the patient-clinician encounter in particular.
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Affiliation(s)
- Rita Fernholm
- Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
| | - Carolina Wannheden
- Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Stockholm, Sweden
| | - Sofia Trygg Lycke
- Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
| | - Sara Riggare
- Department of Women's and Children's Health, Participatory eHealth and Health Data, Uppsala University, Uppsala, Sweden
| | - Karin Pukk Harenstam
- Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Stockholm, Sweden
- Department of Women's and Children's Health, Karolinska Universitetssjukhuset, Stockholm, Sweden
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Black GB, Machen S, Parker-Deeks S, Cronin A, Chung D. Using an electronic safety netting tool designed to improve safety with respect to cancer referral in primary care: a qualitative service evaluation using rapid appraisal methods. BMJ Open Qual 2023; 12:e002354. [PMID: 37491106 PMCID: PMC10373707 DOI: 10.1136/bmjoq-2023-002354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 07/12/2023] [Indexed: 07/27/2023] Open
Abstract
BACKGROUND This evaluation assesses the impact of an electronic safety netting software (E-SN) package, C the Signs, in primary care services across five boroughs in North East London (NEL). AIM This study evaluates the use of E-SN software in primary care, examining its benefits and barriers, safety implications, and overall impact on individual and practice usage. DESIGN AND SETTING The study is based on semi-structured interviews with 21 clinical and non-clinical members of staff from all primary care services using the software in NEL. METHOD Semi-structured interviews were conducted to gather data on individual use of the software, safety implications and practice use of features such as the monitoring dashboard. Data were analysed using a rapid qualitative methodology. RESULTS Two approaches to E-SN software adoption were reported: whole practice adoption and self-directed use. Practices benefitted from shared responsibility for safety netting and using software to track patients' progress in secondary care. Adoption was affected by information technology and administrative resources. Decision-support tools were used infrequently due to a lack of appreciation for their benefits. Selective adoption of different E-SN functions restricted its potential impact on early diagnosis. CONCLUSION The use of E-SN software in primary care services in NEL varied among participants. While some found it to be beneficial, others were sceptical of its impact on clinical decision-making. Nonetheless, the software was found to be effective in managing referral processes and tracking patients' progress in other points of care.
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Affiliation(s)
- Georgia B Black
- Wolfson Institute of Population Health, Queen Mary University of London, London, UK
- Department of Applied Health Research, University College London, London, UK
| | - Samantha Machen
- Department of Applied Health Research, University College London, London, UK
| | - Saira Parker-Deeks
- Cancer Commissioning, NHS North East London Clinical Commissioning Group, London, UK
| | - Andrea Cronin
- Cancer Commissioning, NHS North East London Clinical Commissioning Group, London, UK
| | - Donna Chung
- Centre for Cancer Outcomes, University College London Hospitals NHS Foundation Trust, London, UK
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McDonnell T, Nicholson E, Bury G, Collins C, Conlon C, De Brún A, Doherty E, McAuliffe E. The role of contextual factors in decision-making by General Practitioners on paediatric referral to the Emergency Department: A Discrete Choice Experiment. Health Policy 2023; 132:104813. [PMID: 37037150 DOI: 10.1016/j.healthpol.2023.104813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 03/22/2023] [Accepted: 04/03/2023] [Indexed: 04/08/2023]
Abstract
A General Practitioner's (GP) decision to refer a patient to the emergency department (ED) requires consideration of a multitude of factors, and significant variation in GP referral patterns to secondary care has been recorded. This study examines the contextual factors that influence GPs when referring a paediatric patient with potentially self-limiting clinical symptoms to the ED. Utilizing a discrete choice experiment, survey data was collected from GPs in Ireland (n = 142) to elicit factors influencing this decision across five attributes: time/day of visit, repeat presentation, parents' capacity to cope, parent requesting a referral, and access to a paediatric outpatient clinic/day unit. Using mixed logit models, all attributes were statistically significant, with repeat presentation and parents lacking the capacity to cope identified as the strongest contextual factors leading to the decision to refer to the ED. There has been limited exploration of this decision-making process and this study uses a robust design to identify and rank contextual attributes. Enhanced awareness of contextual factors on referral decision-making is crucial to understanding patterns of paediatric unscheduled healthcare and to planning services that respond to parent's and children's needs, whilst allowing GPs to make decisions in the best interest of the child.
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14
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McIsaac WJ, Kukan S. Assessing the Validity of Electronic Medical Records for Identifying High Antibiotic Prescribers in Primary Care. J Prim Care Community Health 2023; 14:21501319231210616. [PMID: 37978835 PMCID: PMC10657523 DOI: 10.1177/21501319231210616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 10/06/2023] [Accepted: 10/11/2023] [Indexed: 11/19/2023] Open
Abstract
OBJECTIVES Electronic medical record (EMR) prescription data may identify high antibiotic prescribers in primary care. However, practitioners doubt that population differences between providers and delayed antibiotic prescriptions are adequately accounted for in EMR-derived prescription rates. This study assessed the validity of using EMR prescription data to produce antibiotic prescription rates, accounting for these factors. METHODS The study was a secondary analysis of antimicrobial prescriptions collected from 4 primary care clinics from 2015 to 2017. For adults with selected respiratory and urinary infections, EMR diagnostic codes, prescription data, clinical diagnoses and demographics were abstracted. Overall and delayed prescription rates were produced for EMR diagnostic codes, clinical diagnoses, by clinic, and types of infection. Direct standardization was used to adjust for case mix differences by clinic. High antibiotic prescribers, above the 75th percentile for prescriptions, were compared with low antibiotic prescribers. RESULTS Of 3108 EMR visits, there were 2577 (85.4%) eligible visits with a clinical diagnosis and prescription information. Overall antibiotic prescription rates were similar utilizing EMR records (31.6%) or clinical diagnoses (32.6%, P = .40). When delayed prescriptions were removed, prescribing rates were lower (22.4%, P < .01). EMR data overestimated prescribing rates for conditions where antibiotics are usually not indicated (17.7% EMR vs 7.6% clinical diagnoses, P < .001). High antibiotic prescribers saw more cases where antibiotics are usually indicated (23.4%) compared to low prescribers (16.8%; P = .001). CONCLUSIONS Electronic medical record prescribing rates are similar to those using clinical diagnoses overall, but overestimate prescribing by clinicians for conditions usually not needing antibiotics. EMR prescription rates do not account for delayed antibiotic prescriptions or differences in infection case-mix.
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Affiliation(s)
- Warren J. McIsaac
- Sinai Health, Toronto, ON, Canada
- University of Toronto, Toronto, ON, Canada
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15
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Barriers to Early Presentation amongst Rural Residents Experiencing Symptoms of Colorectal Cancer: A Qualitative Interview Study. Cancers (Basel) 2022; 15:cancers15010274. [PMID: 36612270 PMCID: PMC9818976 DOI: 10.3390/cancers15010274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 12/21/2022] [Accepted: 12/22/2022] [Indexed: 01/03/2023] Open
Abstract
Rural cancer inequalities are evident internationally, with rural cancer patients 5% less likely to survive than their urban counterparts. There is evidence to suggest that diagnostic delays prior to entry into secondary care may be contributing to these poorer rural cancer outcomes. This study explores the symptom appraisal and help-seeking decision-making of people experiencing symptoms of colorectal cancer in rural areas of England. Patients were randomly invited from 4 rural practices, serving diverse communities. Semi-structured interviews were undertaken with 40 people who had experienced symptoms of colorectal cancer in the preceding 8 weeks. Four key themes were identified as influential in participants' willingness and timeliness of consultation: a desire to rule out cancer (facilitator of help-seeking); stoicism and self-reliance (barrier to help-seeking); time scarcity (barrier to help-seeking); and GP/patient relationship (barrier or facilitator, depending on perceived strength of the relationship). Self-employed, and "native" rural residents most commonly reported experiencing time scarcity and poor GP/patient relationships as a barrier to (re-)consultation. Targeted, active safety-netting approaches, and increased continuity of care, may be particularly beneficial to expedite timely diagnoses and minimise cancer inequalities for rural populations.
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16
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Colliers A, Philips H, Bombeke K, Remmen R, Coenen S, Anthierens S. Safety netting advice for respiratory tract infections in out-of-hours primary care: A qualitative analysis of consultation videos. Eur J Gen Pract 2022; 28:87-94. [PMID: 35535690 PMCID: PMC9103350 DOI: 10.1080/13814788.2022.2064448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 03/28/2022] [Accepted: 03/28/2022] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND General practitioners (GPs) use safety netting advice to communicate with patients when and how to seek further help when their condition fails to improve or deteriorate. Although many respiratory tract infections (RTI) during out-of-hours (OOH) care are self-limiting, often antibiotics are prescribed. Providing safety netting advice could enable GPs to safely withhold an antibiotic prescription by dealing both with their uncertainty and the patients' concerns. OBJECTIVES To explore how GPs use safety netting advice during consultations on RTIs in OOH primary care and how this advice is documented in the electronic health record. METHODS We analysed video observations of 77 consultations on RTIs from 19 GPs during OOH care using qualitative framework analysis and reviewed the medical records. Videos were collected from August until November 2018 at the Antwerp city GP cooperative, Belgium. RESULTS Safety netting advice on alarm symptoms, expected duration of illness and/or how and when to seek help is often lacking or vague. Communication of safety netting elements is scattered throughout the end phase of the consultation. The advice is seldom recorded in the medical health record. GPs give more safety netting advice when prescribing an antibiotic than when they do not prescribe an antibiotic. CONCLUSION We provided a better understanding of how safety netting is currently carried out in OOH primary care for RTIs. Safety netting advice during OOH primary care is limited, unspecific and not documented in the medical record.
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Affiliation(s)
- Annelies Colliers
- Department of Family Medicine & Population Health (FAMPOP), University of Antwerp, Antwerp, Belgium
| | - Hilde Philips
- Department of Family Medicine & Population Health (FAMPOP), University of Antwerp, Antwerp, Belgium
| | | | - Roy Remmen
- Department of Family Medicine & Population Health (FAMPOP), University of Antwerp, Antwerp, Belgium
| | - Samuel Coenen
- Department of Family Medicine & Population Health (FAMPOP), University of Antwerp, Antwerp, Belgium
- Vaccine & Infectious Disease Institute (VAXINFECTIO) – Laboratory of Medical Microbiology, University of Antwerp, Antwerp, Belgium
| | - Sibyl Anthierens
- Department of Family Medicine & Population Health (FAMPOP), University of Antwerp, Antwerp, Belgium
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17
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Visscher S, van Stralen K, Toelen J, de Winter P. Parental and physician disagreement on help-seeking in paediatric case scenarios. Arch Dis Child 2022; 107:833-838. [PMID: 35351739 DOI: 10.1136/archdischild-2021-323504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 03/04/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVE Whenever a child falls ill, parents need to decide whether there is a need to contact medical professionals. Parental and physician perspectives on the severity of a child's illness differ. We aimed to determine triggers for help-seeking among parents. DESIGN AND SETTING We conducted a survey study among 200 parents. In four hypothetical case scenarios, an acutely ill child was described with a baseline symptom (abdominal pain, rhinitis, headache, limping), with deterioration over time. Parents had to answer when they would contact the general practitioner. Fifty-four physicians received the same case scenarios. MAIN OUTCOME MEASURES Parents and physicians did not differ significantly in help-seeking in the abdominal pain case. In the non-urgent rhinitis case, parents sought help earlier than physicians wished them to, while in the urgent illness cases of headache and limping parents tend to seek help later than physicians wished. Rising body temperature was more alarming to parents than physicians, while loss of appetite did not concern either group. Parents did not recognise several red flags, for example, drowsiness and refusal to stand. Low educated parents and parents with a history of more frequent healthcare use were inclined to seek help earlier. IMPLICATION OF RESULTS In urgent cases, parents do not seem to recognise red flags, while some non-urgent symptoms trigger them to seek help. This reveals a need for mutual education. Physician awareness of a perception gap could help them adjust their communication and empower parents.
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Affiliation(s)
- Sarah Visscher
- Department of Pediatrics, Spaarne Gasthuis, Haarlem and Hoofddorp, The Netherlands
| | - Karlijn van Stralen
- Department of Pediatrics, Spaarne Gasthuis, Haarlem and Hoofddorp, The Netherlands
| | - Jaan Toelen
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium.,Leuven Child and Youth Institute, KU Leuven, Leuven, Belgium.,Department of Pediatrics, University Hospitals Leuven, Leuven, Belgium
| | - Peter de Winter
- Department of Pediatrics, Spaarne Gasthuis, Haarlem and Hoofddorp, The Netherlands .,Department of Development and Regeneration, KU Leuven, Leuven, Belgium.,Leuven Child and Youth Institute, KU Leuven, Leuven, Belgium
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18
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Affiliation(s)
| | - Paul Silverston
- Anglia Ruskin University, Cambridge, and University of Suffolk, Ipswich, UK
| | | | - Damian Roland
- SAPPHIRE Group, Health Sciences, Leicester University, Leicester, UK
- Paediatric Emergency Medicine Leicester Academic (PEMLA) Group, Children's Emergency Department, Leicester Royal Infirmary, Leicester, UK
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19
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Monahan KJ, Davies MM, Abulafi M, Banerjea A, Nicholson BD, Arasaradnam R, Barker N, Benton S, Booth R, Burling D, Carten RV, D'Souza N, East JE, Kleijnen J, Machesney M, Pettman M, Pipe J, Saker L, Sharp L, Stephenson J, Steele RJ. Faecal immunochemical testing (FIT) in patients with signs or symptoms of suspected colorectal cancer (CRC): a joint guideline from the Association of Coloproctology of Great Britain and Ireland (ACPGBI) and the British Society of Gastroenterology (BSG). Gut 2022; 71:gutjnl-2022-327985. [PMID: 35820780 PMCID: PMC9484376 DOI: 10.1136/gutjnl-2022-327985] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 07/01/2022] [Indexed: 12/12/2022]
Abstract
Faecal immunochemical testing (FIT) has a high sensitivity for the detection of colorectal cancer (CRC). In a symptomatic population FIT may identify those patients who require colorectal investigation with the highest priority. FIT offers considerable advantages over the use of symptoms alone, as an objective measure of risk with a vastly superior positive predictive value for CRC, while conversely identifying a truly low risk cohort of patients. The aim of this guideline was to provide a clear strategy for the use of FIT in the diagnostic pathway of people with signs or symptoms of a suspected diagnosis of CRC. The guideline was jointly developed by the Association of Coloproctology of Great Britain and Ireland/British Society of Gastroenterology, specifically by a 21-member multidisciplinary guideline development group (GDG). A systematic review of 13 535 publications was undertaken to develop 23 evidence and expert opinion-based recommendations for the triage of people with symptoms of a suspected CRC diagnosis in primary care. In order to achieve consensus among a broad group of key stakeholders, we completed an extended Delphi of the GDG, and also 61 other individuals across the UK and Ireland, including by members of the public, charities and primary and secondary care. Seventeen research recommendations were also prioritised to inform clinical management.
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Affiliation(s)
- Kevin J Monahan
- The Wolfson Endoscopy Unit, Gastroenterology Department, St Mark's Hospital and Academic Institute, Harrow, London, UK
- Faculty of Medicine, Department of Surgery & Cancer, Imperial College, London, UK
| | - Michael M Davies
- Department of Colorectal Surgery, University Hospital of Wales, Cardiff, UK
| | - Muti Abulafi
- Colorectal Surgery, Croydon Health Services NHS Trust, Croydon, Greater London, UK
| | - Ayan Banerjea
- Nottingham Colorectal Service, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Brian D Nicholson
- Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Ramesh Arasaradnam
- University of Warwick, Clinical Sciences Research Institute, Coventry, UK
- Gastroenterology Department, University Hospital Coventry, Coventry, UK
| | | | - Sally Benton
- Hub Director, NHS Bowel Cancer Screening South of England Hub, Royal Surrey County Hospital NHS Foundation Trust, Guildford, Surrey, UK
| | - Richard Booth
- Colorectal Surgery, Croydon University Hospital, Croydon, UK
| | - David Burling
- Radiology, St Mark's Hospital and Academic Institute, Harrow, London, UK
| | | | | | - James Edward East
- Translational Gastroenterology Unit, Univerity of Oxford Nuffield Department of Medicine, Oxford, UK
- Gastroenterology, Mayo Clinic Healthcare, London, UK
| | - Jos Kleijnen
- Kleijnen Systematic Reviews Ltd, York, North Yorkshire, UK
| | - Michael Machesney
- Colorectal Surgery, Whipps Cross Hospital, Barts Health NHS Trust, London, UK
| | - Maria Pettman
- Colorectal Surgery, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | | | - Lance Saker
- General Practice, Oak Lodge Medical Centre, London, UK
| | - Linda Sharp
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | | | - Robert Jc Steele
- Surgery and Oncology Department, University of Dundee, Dundee, UK
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20
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Friedemann Smith C, Lunn H, Wong G, Nicholson BD. Optimising GPs' communication of advice to facilitate patients' self-care and prompt follow-up when the diagnosis is uncertain: a realist review of 'safety-netting' in primary care. BMJ Qual Saf 2022; 31:541-554. [PMID: 35354664 PMCID: PMC9234415 DOI: 10.1136/bmjqs-2021-014529] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 02/19/2022] [Indexed: 01/19/2023]
Abstract
BACKGROUND Safety-netting has become best practice when dealing with diagnostic uncertainty in primary care. Its use, however, is highly varied and a lack of evidence-based guidance on its communication could be harming its effectiveness and putting patient safety at risk. OBJECTIVE To use a realist review method to produce a programme theory of safety-netting, that is, advice and support provided to patients when diagnosis or prognosis is uncertain, in primary care. METHODS Five electronic databases, web searches, and grey literature were searched for studies assessing outcomes related to understanding and communicating safety-netting advice or risk communication, or the ability of patients to self-care and re-consult when appropriate. Characteristics of included documents were extracted into an Excel spreadsheet, and full texts uploaded into NVivo and coded. A random 10% sample was independently double -extracted and coded. Coded data wasere synthesised and itstheir ability to contribute an explanation for the contexts, mechanisms, or outcomes of effective safety-netting communication considered. Draft context, mechanism and outcome configurations (CMOCs) were written by the authors and reviewed by an expert panel of primary care professionals and patient representatives. RESULTS 95 documents contributed to our CMOCs and programme theory. Effective safety-netting advice should be tailored to the patient and provide practical information for self-care and reconsultation. The importance of ensuring understanding and agreement with advice was highlighted, as was consideration of factors such as previous experiences with healthcare, the patient's personal circumstances and the consultation setting. Safety-netting advice should be documented in sufficient detail to facilitate continuity of care. CONCLUSIONS We present 15 recommendations to enhance communication of safety-netting advice and map these onto established consultation models. Effective safety-netting communication relies on understanding the information needs of the patient, barriers to acceptance and explanation of the reasons why the advice is being given. Reduced continuity of care, increasing multimorbidity and remote consultations represent threats to safety-netting communication.
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Affiliation(s)
| | | | - Geoff Wong
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Brian D Nicholson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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21
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General practitioners' communication skills in Nairobi, Kenya: A descriptive observational study. BJGP Open 2022; 6:BJGPO.2021.0235. [PMID: 35545265 DOI: 10.3399/bjgpo.2021.0235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Revised: 02/18/2022] [Accepted: 03/08/2022] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND High quality primary care is associated with person-centeredness and effective communication that also supports continuity and coordination of care. In Kenya, there is little knowledge about the quality of communication in consultations by general practitioners (GPs). AIM To evaluate the quality of communication by GPs. DESIGN & SETTING Descriptive, observational study of 23 GPs consultations in 13 private sector primary care facilities in Nairobi, Kenya. METHOD One consultation with a randomly selected adult patient was recorded per GP, and 16 communication skills evaluated with the Stellenbosch University Observation Tool. A total percentage score was calculated per consultation, and compared with the GPs' demographics, consultations' complexity and duration using the Statistical Package for Social Sciences. RESULTS The GPs' median age was 30.0 years (IQR: 29-32) and median consultation time was 7.0 minutes (IQR =3-9). Median overall score was 64.3% (IQR: 48.4-75.7). They demonstrated skills in gathering information, making and explaining the diagnosis and suggesting appropriate management. They did not make an appropriate introduction, explore the context or patient's perspective, allow shared decision making or provide adequate safety netting. There was a positive correlation between the scores and duration of the consultations (r=0.680, P=0.001). The score was higher in consultations of moderate complexity (78.1; IQR =57.1-86.7) versus low complexity (52.2; IQR =45.1-66.6) (P=0.012). CONCLUSION Consultations were brief and biomedical by young and inexperienced GPs. GPs needed further training in communication skills, particularly with regard to person-centredness. Deploying family physicians to the primary care setting would also improve the overall quality of service delivery.
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22
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The Shared Safety Net Action Plan (SSNAP): a co-designed intervention to promote greater involvement of patients to support the timely diagnosis of cancer in primary care. Br J Gen Pract 2022; 72:e581-e591. [PMID: 35379601 PMCID: PMC8999718 DOI: 10.3399/bjgp.2021.0476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 11/29/2021] [Indexed: 11/21/2022] Open
Abstract
Background Safety netting in primary care may help diagnose cancer earlier, but it is unclear what the format and content of an acceptable safety-netting intervention would be. This project aimed to co-design a safety-netting intervention with and for primary care patients and staff. Aim This work sought to address how a safety-netting intervention would be implemented in practice; and, if and how a safety-netting intervention would be acceptable to all stakeholders. Design and setting Patient representatives, GPs, and nurse practitioners were invited to a series of co-design workshops. Patients who had and had not received a diagnosis of cancer and primary care practices took part in separate focus groups. Method Three workshops using creative co-design processes developed the format and content of the intervention prototype. The COM-B Framework underpinned five focus groups to establish views on capability, opportunity, and motivation to use the intervention to assist with prototype refinement. Results Workshops and focus groups suggested the intervention format and content should incorporate visual and written communication specifying clear timelines for monitoring symptoms and when to present back; be available in paper and electronic forms linked to existing computer systems; and be able to be delivered within a 10-minute consultation. Intervention use themes included ‘building confidence through partnership’, ‘using familiar and current procedures and systems’, and ‘seeing value’. Conclusion The Shared Safety Net Action Plan (SSNAP) — a safety-netting intervention to assist the timely diagnosis of cancer in primary care, was successfully co-designed with and for patients and primary care staff.
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23
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Black GB, Bhuiya A, Friedemann Smith C, Hirst Y, Nicholson BD. Harnessing the electronic health care record to optimise patient safety in primary care: a framework for evaluating “electronic safety netting” tools (Preprint). JMIR Med Inform 2021; 10:e35726. [PMID: 35916722 PMCID: PMC9379782 DOI: 10.2196/35726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 04/28/2022] [Accepted: 05/20/2022] [Indexed: 11/13/2022] Open
Abstract
The management of diagnostic uncertainty is part of every primary care physician’s role. e–Safety-netting tools help health care professionals to manage diagnostic uncertainty. Using software in addition to verbal or paper based safety-netting methods could make diagnostic delays and errors less likely. There are an increasing number of software products that have been identified as e–safety-netting tools, particularly since the start of the COVID-19 pandemic. e–Safety-netting tools can have a variety of functions, such as sending clinician alerts, facilitating administrative tasking, providing decision support, and sending reminder text messages to patients. However, these tools have not been evaluated by using robust research designs for patient safety interventions. We present an emergent framework of criteria for effective e–safety-netting tools that can be used to support the development of software. The framework is based on validated frameworks for electronic health record development and patient safety. There are currently no tools available that meet all of the criteria in the framework. We hope that the framework will stimulate clinical and public conversations about e–safety-netting tools. In the future, a validated framework would drive audits and improvements. We outline key areas for future research both in primary care and within integrated care systems.
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Affiliation(s)
- Georgia Bell Black
- Department of Applied Health Research, University College London, London, United Kingdom
| | - Afsana Bhuiya
- North Central London Cancer Alliance, London, United Kingdom
| | - Claire Friedemann Smith
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Yasemin Hirst
- Department of Applied Health Research, University College London, London, United Kingdom
| | - Brian David Nicholson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
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24
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Ries NM, Johnston B, Jansen J. Views of healthcare consumer representatives on defensive practice: 'We are your biggest advocate and supporter… not the enemy'. Health Expect 2021; 25:374-383. [PMID: 34859547 PMCID: PMC8849368 DOI: 10.1111/hex.13395] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 11/01/2021] [Accepted: 11/16/2021] [Indexed: 12/25/2022] Open
Abstract
Background The patient–clinician interaction is a site at which defensive practice could occur, when clinicians provide tests, procedures and treatments mainly to reduce perceived legal risks, rather than to advance patient care. Defensive practice is a driver of low‐value care and exposes patients to the risks of unnecessary interventions. To date, patient perspectives on defensive practice and its impacts on them are largely missing from the literature. This exploratory study conducted in Australia aimed to examine the views and experiences of healthcare consumer representatives in this under‐examined area. Methods Semi‐structured interviews were conducted with healthcare consumer representatives involved in healthcare consumer advocacy organisations in Australia. Data were transcribed and analysed thematically. Results Nine healthcare consumer representatives participated. Most had over 20 years of involvement and advocacy in healthcare, including personal experiences as a patient or carer and/or formal service roles on committees or complaint bodies for healthcare organisations. Participants uniformly viewed defensive practice as having a negative impact on the clinician–patient relationship. Themes identified the importance of fostering patient–clinician partnership, effective communication and informed decision‐making. The themes support a shift from the concept of defensive practice to preventive practice in partnership, which focuses on the shared interests of patients and clinicians in achieving safe and high‐value care. Conclusion This Australian study offers healthcare consumers' perspectives on the impacts of defensive practice on patients. The findings highlight the features of clinician–patient partnership that will help to improve communication and decision‐making, and prevent the defensive provision of low‐value care. Patient or Public Contribution Healthcare consumer representatives were involved as participants in this study.
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Affiliation(s)
- Nola M Ries
- Faculty of Law, Law Health Justice Research Centre, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Briony Johnston
- Faculty of Law, Law Health Justice Research Centre, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Jesse Jansen
- Faculty of Health, Medicine and Life Sciences, School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands
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25
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Edwards PJ, Bennett-Britton I, Ridd MJ, Booker M, Barnes RK. Factors affecting the documentation of spoken safety-netting advice in routine GP consultations: a cross-sectional study. Br J Gen Pract 2021; 71:e869-e876. [PMID: 34489251 PMCID: PMC8436774 DOI: 10.3399/bjgp.2021.0195] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 06/18/2021] [Indexed: 12/03/2022] Open
Abstract
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.
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Affiliation(s)
- Peter J Edwards
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol
| | - Ian Bennett-Britton
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol
| | - Matthew J Ridd
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol
| | - Matthew Booker
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol
| | - Rebecca K Barnes
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol; senior qualitative researcher, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford
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26
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Seesaghur A, Petruski-Ivleva N, Banks VL, Wang JR, Abbasi A, Neasham D, Ramasamy K. Clinical features and diagnosis of multiple myeloma: a population-based cohort study in primary care. BMJ Open 2021; 11:e052759. [PMID: 34615682 PMCID: PMC8496401 DOI: 10.1136/bmjopen-2021-052759] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVES Patients with multiple myeloma (MM) experience significant delays in diagnosis due to non-specific symptomatology. The aim of this study was to characterise the frequency and timing of clinical features in the primary care setting prior to MM diagnosis. DESIGN Population-based cohort study. SETTING Electronic health records data of approximately 17 million patients (2006-2016) within the UK Clinical Practice Research Datalink. PARTICIPANTS Patients aged ≥18 years with newly diagnosed MM (NDMM), no history of solid tumours and ≥2 years registration in a primary care practice prior to MM diagnosis. MAIN OUTCOME MEASURES Clinical features and symptoms including bone pain, skeletal-related events (SREs), investigation and confirmation of MM diagnostic CRAB criteria (hyperCalcaemia, Renal impairment, Anaemia, Bone lesions) during the 2 years prior to MM diagnosis; time between symptom manifestation and/or relevant investigation and diagnosis of MM. RESULTS Among 2646 patients with NDMM, 47.5% had a bone pain record during the 2-year period prior to MM diagnosis, mainly affecting the back. Regardless of baseline bone pain, investigations for serum calcium level were used in 36.4% of patients prior to MM diagnosis, followed by haemoglobin (65.6%) or renal function (74.1%). Median (Q1, Q3) time from first-recorded bone pain to MM diagnosis was 220 (80, 476) days. Median (Q1, Q3) time from first-recorded hypercalcaemia, renal impairment or anaemia to MM diagnosis was 23 (12, 46), 58 (17, 254) and 73 days (28, 232), respectively. An imaging investigation or referral for imaging was recorded for 60.0% of patients with bone pain/SRE and 32% without. CONCLUSIONS Nearly half of patients diagnosed with NDMM presented with bone pain approximately 7 months prior to MM diagnosis. Investigations to evaluate all CRAB criteria, including targeted imaging, were underused. Early recognition of myeloma clinical features and optimised use of investigations in primary care may potentially expedite MM diagnosis.
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Affiliation(s)
| | | | | | | | - Ali Abbasi
- Center for Observational Research (CfOR), Amgen Ltd, Uxbridge, UK
| | - David Neasham
- Center for Observational Research (CfOR), Amgen Ltd, Uxbridge, UK
| | - Karthik Ramasamy
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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McIsaac W, Kukan S, Huszti E, Szadkowski L, O'Neill B, Virani S, Ivers N, Lall R, Toor N, Shah M, Alvi R, Bhatt A, Nakamachi Y, Morris AM. A pragmatic randomized trial of a primary care antimicrobial stewardship intervention in Ontario, Canada. BMC FAMILY PRACTICE 2021; 22:185. [PMID: 34525972 PMCID: PMC8442308 DOI: 10.1186/s12875-021-01536-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 09/01/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND More than 90% of antibiotics are prescribed in primary care, but 50% may be unnecessary. Reducing unnecessary antibiotic overuse is needed to limit antimicrobial resistance. We conducted a pragmatic trial of a primary care provider-focused antimicrobial stewardship intervention to reduce antibiotic prescriptions in primary care. METHODS Primary care practitioners from six primary care clinics in Toronto, Ontario were assigned to intervention or control groups to evaluate the effectiveness of a multi-faceted intervention for reducing antibiotic prescriptions to adults with respiratory and urinary tract infections. The intervention included provider education, clinical decision aids, and audit and feedback of antibiotic prescribing. The primary outcome was total antibiotic prescriptions for these infections. Secondary outcomes were delayed prescriptions, prescriptions longer than 7 days, recommended antibiotic use, and outcomes for individual infections. Generalized estimating equations were used to estimate treatment effects, adjusting for clustering by clinic and baseline differences. RESULTS There were 1682 encounters involving 54 primary care providers from January until May 31, 2019. In intervention clinics, the odds of any antibiotic prescription was reduced 22% (adjusted Odds Ratio (OR) = 0.78; 95% Confidence Interval (CI) = 0.64.0.96). The odds that a delay in filling a prescription was recommended was increased (adjusted OR=2.29; 95% CI=1.37, 3.83), while prescription durations greater than 7 days were reduced (adjusted OR=0.24; 95% CI=0.13, 0.43). Recommended antibiotic use was similar in control (85.4%) and intervention clinics (91.8%, p=0.37). CONCLUSIONS A community-based, primary care provider-focused antimicrobial stewardship intervention was associated with a reduced likelihood of antibiotic prescriptions for respiratory and urinary infections, an increase in delayed prescriptions, and reduced prescription durations. TRIAL REGISTRATION clinicaltrials.gov ( NCT03517215 ).
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Affiliation(s)
- Warren McIsaac
- Department of Family and Community Medicine, University of Toronto, Toronto, Canada.
- Ray D. Wolfe Department of Family Medicine, Mount Sinai Hospital, Sinai Health, 60 Murray St, Toronto, ON, M5T 3L9, Canada.
| | - Sahana Kukan
- Ray D. Wolfe Department of Family Medicine, Mount Sinai Hospital, Sinai Health, 60 Murray St, Toronto, ON, M5T 3L9, Canada
| | - Ella Huszti
- Biostatistics Research Unit, University Health Network, Toronto, Canada
| | - Leah Szadkowski
- Biostatistics Research Unit, University Health Network, Toronto, Canada
| | - Braden O'Neill
- Department of Family and Community Medicine, University of Toronto, Toronto, Canada
- Department of Family and Community Medicine, St. Michael's Hospital, Toronto, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
| | - Sophia Virani
- Ray D. Wolfe Department of Family Medicine, Mount Sinai Hospital, Sinai Health, 60 Murray St, Toronto, ON, M5T 3L9, Canada
| | - Noah Ivers
- Department of Family and Community Medicine, University of Toronto, Toronto, Canada
- Department of Family Medicine, and Women's College Research Institute, Women's College Hospital, Toronto, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Rosemarie Lall
- Department of Family and Community Medicine, University of Toronto, Toronto, Canada
- Platinum Medical, Scarborough Health Network Teaching Unit, Toronto, Canada
| | - Navsheer Toor
- Department of Family and Community Medicine, University of Toronto, Toronto, Canada
- Southlake Academic Family Health Team, Southlake Regional Health Centre, Newmarket, Toronto, Ontario, Canada
| | - Mruna Shah
- Department of Family and Community Medicine, University of Toronto, Toronto, Canada
- West Durham Family Health Team, Pickering, Toronto, Ontario, Canada
| | - Ruby Alvi
- Department of Family and Community Medicine, University of Toronto, Toronto, Canada
- Summerville Family Health Team, Mississauga, Ontario, Canada
| | - Aashka Bhatt
- Department of Family and Community Medicine, University of Toronto, Toronto, Canada
| | - Yoshiko Nakamachi
- Antimicrobial Stewardship Program, University Health Network, Toronto, Canada
| | - Andrew M Morris
- Antimicrobial Stewardship Program, University Health Network, Toronto, Canada
- Department of Medicine, Division of Infectious Diseases, Sinai Health, University Health Network, and University of Toronto, Toronto, Canada
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Gagliardi AR, Yip CYY, Irish J, Wright FC, Rubin B, Ross H, Green R, Abbey S, McAndrews MP, Stewart DE. The psychological burden of waiting for procedures and patient-centred strategies that could support the mental health of wait-listed patients and caregivers during the COVID-19 pandemic: A scoping review. Health Expect 2021; 24:978-990. [PMID: 33769657 PMCID: PMC8235883 DOI: 10.1111/hex.13241] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 02/01/2021] [Accepted: 02/09/2021] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Waiting for procedures delayed by COVID-19 may cause anxiety and related adverse consequences. OBJECTIVE To synthesize research on the mental health impact of waiting and patient-centred mitigation strategies that could be applied in the COVID-19 context. METHODS Using a scoping review approach, we searched 9 databases for studies on waiting lists and mental health and reported study characteristics, impacts and intervention attributes and outcomes. RESULTS We included 51 studies that focussed on organ transplant (60.8%), surgery (21.6%) or cancer management (13.7%). Most patients and caregivers reported anxiety, depression and poor quality of life, which deteriorated with increasing wait time. The impact of waiting on mental health was greater among women and new immigrants, and those of younger age, lower socio-economic status, or with less-positive coping ability. Six studies evaluated educational strategies to develop coping skills: 2 reduced depression (2 did not), 1 reduced anxiety (2 did not) and 2 improved quality of life (2 did not). In contrast, patients desired acknowledgement of concerns, peer support, and periodic communication about wait-list position, prioritization criteria and anticipated procedure date. CONCLUSIONS Findings revealed patient-centred strategies to alleviate the mental health impact of waiting for procedures. Ongoing research should explore how to optimize the impact of those strategies for diverse patients and caregivers, particularly in the COVID-19 context. PATIENT OR PUBLIC CONTRIBUTION Six patients and four caregivers waiting for COVID-19-delayed procedures helped to establish eligibility criteria, plan data extraction and review a draft and final report.
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Affiliation(s)
- Anna R. Gagliardi
- Toronto General Hospital Research InstituteUniversity Health NetworkTorontoCanada
| | | | - Jonathan Irish
- Surgical Oncology Program/Access to Care‐SurgeryOntario Health‐Cancer Care OntarioTorontoCanada
| | | | - Barry Rubin
- Peter Munk Cardiac CentreUniversity Health NetworkTorontoCanada
| | - Heather Ross
- Ted Rogers Centre of Excellence in Heart FunctionUniversity Health NetworkTorontoCanada
| | - Robin Green
- Toronto Rehabilitation InstituteUniversity Health NetworkTorontoCanada
| | - Susan Abbey
- Medical Psychiatry & Psychosocial OncologyUniversity Health NetworkTorontoCanada
| | | | - Donna E. Stewart
- University Health Network Centre for Mental HealthUniversity of TorontoTorontoCanada
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Disbeschl S, Surgey A, Roberts JL, Hendry A, Lewis R, Goulden N, Hoare Z, Williams N, Anthony BF, Edwards RT, Law RJ, Hiscock J, Carson-Stevens A, Neal RD, Wilkinson C. Protocol for a feasibility study incorporating a randomised pilot trial with an embedded process evaluation and feasibility economic analysis of ThinkCancer!: a primary care intervention to expedite cancer diagnosis in Wales. Pilot Feasibility Stud 2021; 7:100. [PMID: 33883033 PMCID: PMC8059131 DOI: 10.1186/s40814-021-00834-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 04/07/2021] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Compared to the rest of Europe, the UK has relatively poor cancer outcomes, with late diagnosis and a slow referral process being major contributors. General practitioners (GPs) are often faced with patients presenting with a multitude of non-specific symptoms that could be cancer. Safety netting can be used to manage diagnostic uncertainty by ensuring patients with vague symptoms are appropriately monitored, which is now even more crucial due to the ongoing COVID-19 pandemic and its major impact on cancer referrals. The ThinkCancer! workshop is an educational behaviour change intervention aimed at the whole general practice team, designed to improve primary care approaches to ensure timely diagnosis of cancer. The workshop will consist of teaching and awareness sessions, the appointment of a Safety Netting Champion and the development of a bespoke Safety Netting Plan and has been adapted so it can be delivered remotely. This study aims to assess the feasibility of the ThinkCancer! intervention for a future definitive randomised controlled trial. METHODS The ThinkCancer! study is a randomised, multisite feasibility trial, with an embedded process evaluation and feasibility economic analysis. Twenty-three to 30 general practices will be recruited across Wales, randomised in a ratio of 2:1 of intervention versus control who will follow usual care. The workshop will be delivered by a GP educator and will be adapted iteratively throughout the trial period. Baseline practice characteristics will be collected via questionnaire. We will also collect primary care intervals (PCI), 2-week wait (2WW) referral rates, conversion rates and detection rates at baseline and 6 months post-randomisation. Participant feedback, researcher reflections and economic costings will be collected following each workshop. A process evaluation will assess implementation using an adapted Normalisation Measure Development (NoMAD) questionnaire and qualitative interviews. An economic feasibility analysis will inform a future economic evaluation. DISCUSSION This study will allow us to test and further develop a novel evidenced-based complex intervention aimed at general practice teams to expedite the diagnosis of cancer in primary care. The results from this study will inform the future design of a full-scale definitive phase III trial. TRIAL REGISTRATION ClinicalTrials.gov NCT04823559 .
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Affiliation(s)
- Stefanie Disbeschl
- North Wales Centre for Primary Care Research (NWCPCR), Bangor University, Cambrian 2, Wrexham Technology Park, Wrexham, LL13 7YP, UK.
| | - Alun Surgey
- North Wales Centre for Primary Care Research (NWCPCR), Bangor University, Cambrian 2, Wrexham Technology Park, Wrexham, LL13 7YP, UK
| | - Jessica L Roberts
- North Wales Centre for Primary Care Research (NWCPCR), Bangor University, Cambrian 2, Wrexham Technology Park, Wrexham, LL13 7YP, UK
| | - Annie Hendry
- North Wales Centre for Primary Care Research (NWCPCR), Bangor University, Cambrian 2, Wrexham Technology Park, Wrexham, LL13 7YP, UK
| | - Ruth Lewis
- North Wales Centre for Primary Care Research (NWCPCR), Bangor University, Cambrian 2, Wrexham Technology Park, Wrexham, LL13 7YP, UK
| | - Nia Goulden
- North Wales Organisation for Randomised Trials in Health (NWORTH), Bangor University, The Normal Site, Holyhead Road, Gwynedd, LL57 2PZ, UK
| | - Zoe Hoare
- North Wales Organisation for Randomised Trials in Health (NWORTH), Bangor University, The Normal Site, Holyhead Road, Gwynedd, LL57 2PZ, UK
| | - Nefyn Williams
- Department of Primary Care and Mental Health, Institute of Population Health, University of Liverpool, Liverpool, L69 3GL, UK
| | - Bethany Fern Anthony
- Centre for Health Economics and Medicines Evaluation (CHEME), Bangor University, The Normal Site, Holyhead Road, Gwynedd, LL57 2PZ, UK
| | - Rhiannon Tudor Edwards
- Centre for Health Economics and Medicines Evaluation (CHEME), Bangor University, The Normal Site, Holyhead Road, Gwynedd, LL57 2PZ, UK
| | - Rebecca-Jane Law
- North Wales Centre for Primary Care Research (NWCPCR), Bangor University, Cambrian 2, Wrexham Technology Park, Wrexham, LL13 7YP, UK
| | - Julia Hiscock
- North Wales Centre for Primary Care Research (NWCPCR), Bangor University, Cambrian 2, Wrexham Technology Park, Wrexham, LL13 7YP, UK
| | - Andrew Carson-Stevens
- Division of Population Medicine, School of Medicine, Cardiff University, UHW Main Building, Heath Park, Cardiff, CF14 4XN, UK
| | - Richard D Neal
- Academic Unit of Primary Care, Leeds Institute of Health Sciences, University of Leeds, Worsley Building, Leeds, LS2 9NL, UK
| | - Clare Wilkinson
- North Wales Centre for Primary Care Research (NWCPCR), Bangor University, Cambrian 2, Wrexham Technology Park, Wrexham, LL13 7YP, UK
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McIsaac WJ, Senthinathan A, Moineddin R, Nakamachi Y, Dresser L, McIntyre M, Singh S, De Oliveira N, Tannenbaum D, Bloom J, Lemieux C, Marr P, Levy M, Mitri M, Walji S, Kukan S, Morris AM. Development and evaluation of a primary care antimicrobial stewardship program (PC-ASP) in Toronto, Ontario, Canada. JOURNAL OF THE ASSOCIATION OF MEDICAL MICROBIOLOGY AND INFECTIOUS DISEASE CANADA = JOURNAL OFFICIEL DE L'ASSOCIATION POUR LA MICROBIOLOGIE MEDICALE ET L'INFECTIOLOGIE CANADA 2021; 6:32-48. [PMID: 36340211 PMCID: PMC9612432 DOI: 10.3138/jammi-2020-0021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 10/06/2020] [Indexed: 06/16/2023]
Abstract
BACKGROUND Effective community-based antimicrobial stewardship programs (ASPs) are needed because 90% of antimicrobials are prescribed in the community. A primary care ASP (PC-ASP) was evaluated for its effectiveness in lowering antibiotic prescriptions for six common infections. METHODS A multi-faceted educational program was assessed using a before-and-after design in four primary care clinics from 2015 through 2017. The primary outcome was the difference between control and intervention clinics in total antibiotic prescriptions for six common infections before and after the intervention. Secondary outcomes included changes in condition-specific antibiotic use, delayed antibiotic prescriptions, prescriptions exceeding 7 days duration, use of recommended antibiotics, and emergency department visits or hospitalizations within 30 days. Multi-method models adjusting for demographics, case mix, and clustering by physician were used to estimate treatment effects. RESULTS Total antibiotic prescriptions in control and intervention clinics did not differ (difference in differences = 1.7%; 95% CI -12.5% to 15.9%), nor did use of delayed prescriptions (-5.2%; 95% CI -24.2% to 13.8%). Prescriptions for longer than 7 days were significantly reduced (-21.3%; 95% CI -42.5% to -0.1%). However, only 781 of 1,777 encounters (44.0%) involved providers who completed the ASP education. Where providers completed the education, delayed prescriptions increased 17.7% (p = 0.06), and prescriptions exceeding 7 days duration declined (-27%; 95% CI -48.3% to -5.6%). Subsequent emergency department visits and hospitalizations did not increase. CONCLUSIONS PC-ASP effectiveness on antibiotic use was variable. Shorter prescription durations and increased use of delayed prescriptions were adopted by engaged primary care providers.
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Affiliation(s)
- Warren J McIsaac
- Ray D. Wolfe Department of Family Medicine, Sinai Health, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Arrani Senthinathan
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Rahim Moineddin
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Yoshiko Nakamachi
- Antimicrobial Stewardship Program, University Health Network, Toronto, Ontario, Canada
| | - Linda Dresser
- Antimicrobial Stewardship Program, University Health Network, Toronto, Ontario, Canada
- Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Mark McIntyre
- Antimicrobial Stewardship Program, University Health Network, Toronto, Ontario, Canada
- Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Suzanne Singh
- Ray D. Wolfe Department of Family Medicine, Sinai Health, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Nelia De Oliveira
- Ray D. Wolfe Department of Family Medicine, Sinai Health, Toronto, Ontario, Canada
| | - David Tannenbaum
- Ray D. Wolfe Department of Family Medicine, Sinai Health, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jeff Bloom
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Family and Community Medicine, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Camille Lemieux
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Family and Community Medicine, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Patricia Marr
- Department of Family and Community Medicine, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Michelle Levy
- Ray D. Wolfe Department of Family Medicine, Sinai Health, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Mira Mitri
- Ray D. Wolfe Department of Family Medicine, Sinai Health, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Sakina Walji
- Ray D. Wolfe Department of Family Medicine, Sinai Health, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Sahana Kukan
- Ray D. Wolfe Department of Family Medicine, Sinai Health, Toronto, Ontario, Canada
| | - Andrew M Morris
- Antimicrobial Stewardship Program, University Health Network, Toronto, Ontario, Canada
- Department of Medicine, Division of Infectious Diseases, Sinai Health, University Health Network, and University of Toronto, Toronto, Ontario, Canada
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Affiliation(s)
- Minal Bakhai
- NHS England and NHS Improvement London, Skipton House, London SE1 6LH, UK
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McDermott C, Vennik J, Philpott C, le Conte S, Thomas M, Eyles C, Little P, Blackshaw H, Schilder A, Hopkins C. Maximising recruitment to a randomised controlled trial for chronic rhinosinusitis using qualitative research methods: the MACRO conversation study. Trials 2021; 22:54. [PMID: 33436031 PMCID: PMC7805190 DOI: 10.1186/s13063-020-04993-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 12/22/2020] [Indexed: 11/10/2022] Open
Abstract
Background Randomised controlled trials (RCTs) are considered the ‘gold standard’ of medical evidence; however, recruitment can be challenging. The MACRO trial is a NIHR-funded RCT for chronic rhinosinusitis (CRS) addressing the challenge of comparing surgery, antibiotics and placebo. The embedded MACRO conversation study (MCS) used qualitative research techniques pioneered by the University of Bristol QuinteT team to explore recruitment issues during the pilot phase, to maximise recruitment in the main trial. Methods Setting: Five outpatient Ear Nose and Throat (ENT) departments recruiting for the pilot phase of the MACRO trial (ISRCTN Number: 36962030, prospectively registered 17 October 2018). We conducted a thematic analysis of telephone interviews with 18 recruiters and 19 patients and 61 audio-recordings of recruitment conversations. We reviewed screening and recruitment data and mapped patient pathways at participating sites. We presented preliminary findings to individual site teams. Group discussions enabled further exploration of issues, evolving strategies and potential solutions. Findings were reported back to the funder and used together with recruitment data to justify progression to the main trial. Results Recruitment in the MACRO pilot trial began slowly but accelerated in time to progress successfully to the main trial. Research nurse involvement was pivotal to successful recruitment. Engaging the wider network of clinical colleagues emerged as an important factor, ensuring the patient pathway through primary and secondary care did not inadvertently affect trial eligibility. The most common reason for patients declining participation was treatment preference. Good patient-clinician relationships engendered trust and supported patient decision-making. Overall, trial involvement appeared clearly presented by recruiters, possibly influenced by pre-trial training. The weakest area of understanding for patients appeared to be trial medications. A clear presentation of medical and surgical treatment options, together with checking patient understanding, had the potential to allay patient concerns. Conclusion The MACRO conversation study contributed to the learning process of optimising recruitment by helping to identify and address recruitment issues. Although some issues were trial-specific, others have applicability to many clinical trial situations. Using qualitative research techniques to identify/explore barriers and facilitators to recruitment may be valuable during the pilot phase of many RCTs including those with complex designs.
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Affiliation(s)
- Clare McDermott
- Primary Care and Populations Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Jane Vennik
- Primary Care and Populations Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.
| | - Carl Philpott
- Norwich Medical School, University of East Anglia, Norwich, UK.,James Paget University Hospital NHS Foundation Trust, Great Yarmouth, UK
| | - Steffi le Conte
- Surgical Interventional Trials Unit, University of Oxford, Oxford, UK
| | - Mike Thomas
- Primary Care and Populations Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Caroline Eyles
- Primary Care and Populations Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Paul Little
- Primary Care and Populations Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Helen Blackshaw
- evidENT, Ear Institute, University College London, London, UK
| | - Anne Schilder
- evidENT, Ear Institute, University College London, London, UK
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Rysst Gustafsson S, Eriksson I. Quality indicators in telephone nursing - An integrative review. Nurs Open 2020; 8:1301-1313. [PMID: 33369230 PMCID: PMC8046143 DOI: 10.1002/nop2.747] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 09/30/2020] [Accepted: 11/16/2020] [Indexed: 11/25/2022] Open
Abstract
Aim The aim of this study was to identify factors that indicate quality in telephone nursing. Design An integrative literature review. Method A literature search was performed in October 2018, in the PubMed, CINAHL, Cochrane Library, Academic Search, PsycINFO, Scopus and Web of Science databases. A total of 30 included were included and data that corresponded to the study's aim were extracted and categorized along the three areas of quality as described by Donabedian (Milbank Quarterly, 83, 691), namely structure, process and outcome. Results The analysis revealed ten factors indicating quality in telephone nursing (TN): availability and simplicity of the service, sustainable working conditions, specialist education and TN experience, healthcare resources and organization, good communication, person‐centredness, competence, correct and safe care, efficiency and satisfaction. TN services need to target all ten factors to ensure that the care given is of high quality and able to meet today's requirements for the service.
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Affiliation(s)
- Silje Rysst Gustafsson
- Division of nursing and medical technology, Department of Health Science, Luleå University of Technology, Luleå, Sweden
| | - Irene Eriksson
- School of Health Sciences, University of Skövde, Skövde, Sweden
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Drake C, Hicks N, Atkin L. Developing patient information and clinician education resources for venous thromboembolism in a physiotherapy department in response to the COVID-19 pandemic. INTERNATIONAL JOURNAL OF THERAPY AND REHABILITATION 2020. [DOI: 10.12968/ijtr.2020.0081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Venous thromboembolism is a major contributor to global disease burden and is associated with significant morbidity and mortality. Physiotherapists often encounter people who are at elevated risk of venous thromboembolism, and as such are a vital part of an interdisciplinary approach to the prevention and management venous thromboembolism. In response to the COVID-19 pandemic, appropriate and accessible patient and clinician information resources regarding venous thromboembolism are of paramount importance, to facilitate safety netting and optimise health outcomes with minimal face-to-face contact. This article describes an interdisciplinary approach to the development of patient and clinician information resources within an acute hospital physiotherapy department in the UK. This was conducted with the intention of providing appropriate safety netting for patients at risk of lower extremity venous thromboembolism and to actively facilitate prevention, detection and early intervention.
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Affiliation(s)
- Chris Drake
- Mid-Yorkshire Hospitals NHS Trust, Wakefield, UK
| | - Nicola Hicks
- Mid-Yorkshire Hospitals NHS Trust, Wakefield, UK
| | - Leanne Atkin
- Mid-Yorkshire Hospitals NHS Trust, Wakefield, UK
- School of Human and Health Sciences, University of Huddersfield, Huddersfield, UK
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Greenhalgh S, Finucane LM, Mercer C, Selfe J. Safety netting; best practice in the face of uncertainty. Musculoskelet Sci Pract 2020; 48:102179. [PMID: 32560875 PMCID: PMC7214294 DOI: 10.1016/j.msksp.2020.102179] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 05/06/2020] [Indexed: 11/30/2022]
Abstract
Safety netting is a recognised General Practitioner (GP) diagnostic strategy often used in the face of uncertainty to help ensure that a patient with unresolved or worsening symptoms knows when and how to access further advice. It is an important way of reducing clinical risk. In the context of the COVID-19 pandemic and the rapid move to mainly remote consultations within the musculoskeletal field, safety netting is an important strategy to embed within all consultations. Only those presenting with potentially serious conditions are offered face to face consultations. Screening for Red Flags and any indication of a serious cause of symptoms is always first line in any consultation, however, clinical presentations are not always black and white with patients falling into a clear diagnostic category. With patients minds more focussed on COVID-19 symptoms this can be problematic. With the additional ramifications of public health social restrictions, onward management can be a conundrum. Many people with risk factors of serious pathology are also as a consequence, vulnerable to contracting COVID-19. In situations of uncertain clinical presentations, to avoid unnecessary social contact, safety netting can help to monitor symptoms over time until the clinical context becomes more certain. Embedding safety netting within physiotherapy best practice could be a silver lining in this pandemic black cloud.
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Affiliation(s)
- Sue Greenhalgh
- Clinical Fellow Department of Health Professions, Manchester Metropolitan University, UK; Bolton NHS FT, UK.
| | | | | | - James Selfe
- Department of Health Professions, Manchester Metropolitan University, UK,Physiotherapy Department, Satakunta University of Applied Sciences, Pori, Finland
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Understanding General Practitioners' Antibiotic Prescribing Decisions in Out-of-Hours Primary Care: A Video-Elicitation Interview Study. Antibiotics (Basel) 2020; 9:antibiotics9030115. [PMID: 32156082 PMCID: PMC7148451 DOI: 10.3390/antibiotics9030115] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 03/02/2020] [Accepted: 03/04/2020] [Indexed: 11/16/2022] Open
Abstract
Infections are the most common reason why patients consult out-of-hours (OOH) primary care. Too often there is an overprescribing of antibiotics for self-limiting infections and general practitioners (GPs) do not always choose the guideline recommended antibiotics. To improve antibiotic prescribing quality, a better understanding is needed of the (non) antibiotic prescribing decisions of GPs. This study sets out to unravel GPs’ (non) antibiotic prescribing decisions in OOH primary care. We video-recorded 160 consultations on infections during OOH primary care by 21 GPs and performed video-elicitation interviews with each GP. GPs reflected on their decision-making process and communication while watching their consultation. A qualitative thematic analysis was used. GPs found that their (non) antibiotic prescribing decision-making was not only based on objective arguments, but also subconsciously influenced by their own interpretation of information. Often GPs made assumptions (about for example the patients’ reason for encounter or expectations for antibiotics) without objectifying or verifying this with the patient. From the beginning of the consultation GPs follow a dichotomous thinking process: urgent versus not urgent, viral versus bacterial, antibiotics versus no antibiotics. Safety-netting is an important but difficult tool in the OOH care context, with no long-term follow-up or relationship with the patient. GPs talk about strategies they use to talk about diagnostic uncertainty, what patients can expect or should do when things do not improve and the difficulties they encounter while doing this. This video- elicitation interview study provides actionable insights in GPs’ (non) antibiotic prescribing decisions during OOH consultations on infections.
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Swann R, Lyratzopoulos G, Rubin G, Pickworth E, McPhail S. The frequency, nature and impact of GP-assessed avoidable delays in a population-based cohort of cancer patients. Cancer Epidemiol 2020; 64:101617. [PMID: 31810885 DOI: 10.1016/j.canep.2019.101617] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 09/17/2019] [Accepted: 09/21/2019] [Indexed: 01/03/2023]
Abstract
BACKGROUND There is a growing emphasis on the speed of diagnosis as an aspect of cancer prognosis. While epidemiological data in the last decade have quantified diagnostic timeliness and its variation, whether and how often prolonged diagnostic intervals can be considered avoidable is unknown. METHODS We used data from the English National Cancer Diagnosis Audit (NCDA) on 17,042 patients diagnosed with cancer in 2014. Participating primary care physicians were asked to identify delays in diagnosis that they deemed avoidable, together with the 'setting' of the avoidable delay and key attributable factors. We used descriptive analysis and regression frameworks to assess validity and examine variation in the frequency and nature of avoidable delays. RESULTS Among 14,259 patients, 24% were deemed to have had an avoidable delay to their diagnosis. Patients with a reported avoidable delay had a longer median diagnostic interval (92 days) than those without (30 days). Of all avoidable delays, 13% were deemed to have occurred pre-consultation, 49% within primary care, and 38% within secondary care. Avoidable delays were mostly attributed to the test request/performance phase (25%). Multimorbidity was associated with greater odds of avoidable delay (OR for 3+ vs no comorbidity: 1.43 (95% CI 1.25-1.63)), with heterogeneous associations with cancer site. CONCLUSION We have shown that GP-identified instances of avoidable delay have construct validity. Whilst the causes of avoidable diagnostic delays are multi-factorial and occur in different settings and phases of the diagnostic process, their analysis can guide improvement initiatives and enable the examination of any prognostic implications.
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Affiliation(s)
- Ruth Swann
- Cancer Research UK, 2 Redman Place, London, E20 1JQ, United Kingdom; National Cancer Registration and Analysis Service, Public Health England, Wellington House, 133-155 Waterloo Road, London, SE1 8UG, United Kingdom.
| | - Georgios Lyratzopoulos
- National Cancer Registration and Analysis Service, Public Health England, Wellington House, 133-155 Waterloo Road, London, SE1 8UG, United Kingdom; Epidemiology of Cancer Healthcare and Outcomes (ECHO) Group, University College London, 1-19 Torrington Place, London, WC1E 6BT, United Kingdom
| | - Greg Rubin
- Institute of Health and Society, Newcastle University, Sir James Spence Institute, Royal Victoria Infirmary, Newcastle upon Tyne, NE1 4LP, United Kingdom
| | - Elizabeth Pickworth
- National Cancer Registration and Analysis Service, Public Health England, Wellington House, 133-155 Waterloo Road, London, SE1 8UG, United Kingdom
| | - Sean McPhail
- National Cancer Registration and Analysis Service, Public Health England, Wellington House, 133-155 Waterloo Road, London, SE1 8UG, United Kingdom
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Tompson A, Nicholson BD, Ziebland S, Evans J, Bankhead C. Quality improvements of safety-netting guidelines for cancer in UK primary care: insights from a qualitative interview study of GPs. Br J Gen Pract 2019; 69:e819-e826. [PMID: 31685542 PMCID: PMC6833915 DOI: 10.3399/bjgp19x706565] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 06/07/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Safety netting is a diagnostic strategy that involves monitoring patients with symptoms possibly indicative of serious illness, such as cancer, until they are resolved. Optimising safety-netting practice in primary care has been proposed to improve quality of care and clinical outcomes. Introducing guidelines is a potential means to achieve this. AIM To seek the insight of frontline GPs regarding proposed safety-netting guidelines for suspected cancer in UK primary care. DESIGN AND SETTING A qualitative interview study with 25 GPs practising in Oxfordshire, UK. METHOD Transcripts from semi-structured interviews were analysed thematically by a multidisciplinary research team using a mind-mapping approach. RESULTS GPs were supportive of initiatives to optimise safety netting. Guidelines on establishing who has responsibility for follow-up, keeping patient details up to date, and ensuring test result review is conducted by someone with knowledge of cancer guidelines were already being followed. Sharing diagnostic uncertainty and ensuring an up-to-date understanding of guidelines were only partially implemented. Neither informing patients of all (including negative) test results nor ensuring recurrent unexplained symptoms are always flagged and referred were considered feasible. The lack of detail, for example, the expected duration of symptoms, caused some concern. Overall, doubts were expressed about the feasibility of the guidelines given the time, recruitment, and resource challenges faced in UK primary care. CONCLUSION GPs expressed general support for safety netting, yet were unconvinced that key elements of the guidelines were feasible, especially in the context of pressures on general practice staffing and time.
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Affiliation(s)
- Alice Tompson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford
| | - Brian D Nicholson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford
| | - Sue Ziebland
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford
| | - Julie Evans
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford
| | - Clare Bankhead
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford
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Safety netting in routine primary care consultations: an observational study using video-recorded UK consultations. Br J Gen Pract 2019; 69:e878-e886. [PMID: 31740458 PMCID: PMC6863676 DOI: 10.3399/bjgp19x706601] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 07/02/2019] [Indexed: 12/13/2022] Open
Abstract
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.
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Development of a tool for coding safety-netting behaviours in primary care: a mixed-methods study using existing UK consultation recordings. Br J Gen Pract 2019; 69:e869-e877. [PMID: 31740456 PMCID: PMC6863675 DOI: 10.3399/bjgp19x706589] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 07/02/2019] [Indexed: 11/27/2022] Open
Abstract
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.
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Evans J, Macartney JI, Bankhead C, Albury C, Jones D, Ziebland S, Nicholson BD. How do GPs and patients share the responsibility for cancer safety netting follow-up actions? A qualitative interview study of GPs and patients in Oxfordshire, UK. BMJ Open 2019; 9:e029316. [PMID: 31515421 PMCID: PMC6747661 DOI: 10.1136/bmjopen-2019-029316] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 07/22/2019] [Accepted: 09/04/2019] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE To explore patients' and General Practitioners' (GPs) accounts of how responsibility for follow-up was perceived and shared in their experiences of cancer safety netting occurring within the past 6 months. DESIGN In-depth interviews were recorded and transcribed verbatim. Data were analysed through an abductive process, exploring anticipated and emergent themes. Conceptualisations of 'responsibility' were explored by drawing on a transactional to interdependent continuum drawing from the shared decision-making literature. SETTINGS AND PARTICIPANTS A purposive sample of 25 qualified GPs and 23 adult patients in Oxfordshire, UK. RESULTS The transactional sharing approach involves responsibility being passed from GP to patient. Patients expected and were willing to accept responsibility in this way as long as they received clear guidance from their GP and had capacity. In interdependent sharing, GPs principally aimed to reach consensus and share responsibility with the patient by explaining their rationale, uncertainty or by stressing the potential seriousness of the situation. Patients sharing this responsibility could be put at risk if no follow-up or timeframe was suggested, they had inadequate information, were falsely reassured or their concerns were not addressed at re-consultation. CONCLUSION GPs and patients exchange and share responsibility using a combination of transactional and interdependent styles, tailoring information based on patient characteristics and each party's level of concern. Clear action plans (written where necessary) at the end of every consultation would help patients decide when to re-consult. Further research should investigate how responsibility is shared within and outside the consultation, within primary care teams and with specialist services.
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Affiliation(s)
- Julie Evans
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - John I Macartney
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Clare Bankhead
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Charlotte Albury
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Daniel Jones
- Supportive care, early diagnosis and advanced disease research group, Hull York Medical School, Hull, UK
| | - Sue Ziebland
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Brian D Nicholson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Clarke AL, Roscoe J, Appleton R, Parashar D, Muthuswamy R, Khan O, Dale J, Nanton V. Promoting integrated care in prostate cancer through online prostate cancer-specific holistic needs assessment: a feasibility study in primary care. Support Care Cancer 2019; 28:1817-1827. [PMID: 31338642 PMCID: PMC7036062 DOI: 10.1007/s00520-019-04967-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 06/26/2019] [Indexed: 12/04/2022]
Abstract
Purpose This study assessed the feasibility of implementing a novel model of integrated prostate cancer care involving an online prostate cancer-specific holistic needs assessment (sHNA) and shared digital communication between patients and their healthcare professionals (HCPs). The sHNA produces a semi-automated care plan that is finalised in consultation between the patient and their practice nurse. Methods Men living with and beyond prostate cancer were invited to participate in a 9-month non-randomised cluster controlled feasibility study. The intervention group was asked to complete the sHNA on three occasions. Data were collected using Patient Reported Outcome Measures (PROMs) at baseline, 10 and 24 weeks, and 9 months. Outcomes included recruitment, retention, acceptability, and engagement with the sHNA and PROMs. Results Fourteen general practices (8 intervention and 6 control), and 41 men (29 intervention and 12 control) participated. Initial patient engagement with the sHNA was high, with all but one receiving practice nurse-led follow-up and an individualised care plan. The sHNA proved useful in identifying ‘red flag’ symptoms, and helping practice nurses decide when to seek further medical care for the patients. There was a high level of acceptability for patients and HCPs. However, integration of care did not occur as intended because of problems linking hospital and general practice IT systems. Conclusion While the study demonstrated the feasibility of implementing the sHNA, it did not meet the a priori progression criteria; as such, undertaking a definitive randomised controlled trial is not appropriate until the identified methodological and technical issues have been addressed.
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Affiliation(s)
| | | | | | - Deepak Parashar
- Statistics and Epidemiology Unit, Warwick Medical School, University of Warwick, Coventry, UK.,The Alan Turing Institute, London, UK.,Warwick Cancer Research Centre, University of Warwick, Coventry, UK
| | - Radha Muthuswamy
- Prostate Cancer UK Information Technology Consultant, London, UK
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