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Warwick-Giles L, Hutchinson J, Checkland K, Hammond J, Bramwell D, Bailey S, Sutton M. Exploring whether primary care networks can contribute to the national goal of reducing health inequalities: a mixed-methods study. Br J Gen Pract 2024; 74:e290-e299. [PMID: 38164529 PMCID: PMC11060797 DOI: 10.3399/bjgp.2023.0258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 11/01/2023] [Indexed: 01/03/2024] Open
Abstract
BACKGROUND Significant health inequalities exist in England. Primary care networks (PCNs), comprised of GP practices, were introduced in England in 2019 with funding linked to membership. PCNs have been tasked with tackling health inequalities. AIM To consider how the design and introduction of PCNs might influence their ability to tackle health inequalities. DESIGN AND SETTING A sequential mixed-methods study of PCNs in England. METHOD Linear regression of annual PCN-allocated funding per workload-weighted patient on income deprivation score from 2019-2023 was used. Qualitative interviews and observations of PCNs and PCN staff were undertaken across seven PCN sites in England (July 2020-March 2022). RESULTS Across 1243 networks in 2019-2020, a 10% higher level of income deprivation resulted in £0.31 (95% confidence interval [CI] = £0.25 to £0.37), 4.50%, less funding per weighted patient. In 2022-2023, the same difference in deprivation resulted in £0.16 (95% CI = £0.11 to £0.21), 0.60%, more funding. Qualitative interviews highlighted that, although there were requirements for PCNs to tackle health inequalities, the policy design, and PCN internal relationships and maturity, shaped and sometimes restricted how PCNs approached this task locally. CONCLUSION Allocated PCN funding has become more pro-poor over time, suggesting that the need to account for deprivation within funding models is understood by policymakers. The following additional approaches have been highlighted that could support PCNs to tackle inequalities: better management support; encouragement and support to redistribute funding internally to support practices serving more deprived populations; and greater specificity in service requirements.
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Affiliation(s)
- Lynsey Warwick-Giles
- Centre for Primary Care and Health Services Research, University of Manchester, Manchester
| | - Joseph Hutchinson
- Centre for Primary Care and Health Services Research, University of Manchester, Manchester
| | - Kath Checkland
- Centre for Primary Care and Health Services Research, University of Manchester, Manchester
| | - Jonathan Hammond
- Centre for Primary Care and Health Services Research, University of Manchester, Manchester
| | - Donna Bramwell
- Centre for Primary Care and Health Services Research, University of Manchester, Manchester
| | - Simon Bailey
- Centre for Health Services Studies, University of Kent, Canterbury
| | - Matt Sutton
- Centre for Primary Care and Health Services Research, University of Manchester, Manchester
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Bramwell D, Hammond J, Warwick-Giles L, Bailey S, Checkland K. Implementing the Additional Roles Reimbursement Scheme in seven English Primary Care Networks: a qualitative study. Br J Gen Pract 2024; 74:e323-e329. [PMID: 38164533 PMCID: PMC11044018 DOI: 10.3399/bjgp.2023.0216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 11/01/2023] [Indexed: 01/03/2024] Open
Abstract
BACKGROUND The Additional Roles Reimbursement Scheme (ARRS) provides funding to Primary Care Networks (PCNs) in England to recruit additional staff into specified roles. The intention was to support general practice by recruiting an extra 26 000 staff by 2024, increasing access and easing workload pressures. AIM To explore the establishment of the ARRS as part of PCNs' development to understand their role in supporting general practice. DESIGN AND SETTING A longitudinal, qualitative case study involving seven geographically dispersed PCNs across England. METHOD Data were collected from July 2020 to March 2022, including 91 semi-structured interviews and 87 h of meeting observations. Transcripts were analysed using the framework approach. RESULTS Implementation of the ARRS was variable across the study sites, but most shared similar experiences and concerns. The COVID-19 pandemic had a significant impact on the introduction of the new roles, and significant variability was found in modes of employment. Cross-cutting issues included: the need for additional space to accommodate new staff; the inflexibility of aspects of the scheme, including reinvestment of unspent funds; and the need for support and oversight of employed staff. Perceived benefits of the ARRS include improved patient care and the potential to save GP time. CONCLUSION The findings suggest the ARRS has potential to fulfil its objective of supporting and improving access to general practice. However, attention to operational requirements including appropriate funding, estates, and management of staff is important if this is to be realised, as is clarity for the scheme post-contract end in 2024.
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Affiliation(s)
- Donna Bramwell
- Centre for Primary Care and Health Services Research, University of Manchester, Manchester
| | - Jonathan Hammond
- Centre for Primary Care and Health Services Research, University of Manchester, Manchester
| | - Lynsey Warwick-Giles
- Centre for Primary Care and Health Services Research, University of Manchester, Manchester
| | - Simon Bailey
- Centre for Health Services Studies, University of Kent, Canterbury, Kent
| | - Kath Checkland
- Centre for Primary Care and Health Services Research, University of Manchester, Manchester
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Potter LC, Stone T, Swede J, Connell F, Cramer H, McGeown H, Carvalho M, Horwood J, Feder G, Farr M, Gaps B. Improving access to general practice for and with people with severe and multiple disadvantage: a qualitative study. Br J Gen Pract 2024; 74:e330-e338. [PMID: 38575183 PMCID: PMC11005924 DOI: 10.3399/bjgp.2023.0244] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 11/01/2023] [Indexed: 04/06/2024] Open
Abstract
BACKGROUND People with severe and multiple disadvantage (SMD) who experience combinations of homelessness, substance misuse, violence, abuse, and poor mental health have high health needs and poor access to primary care. AIM To improve access to general practice for people with SMD by facilitating collaborative service improvement meetings between healthcare staff, people with lived experience of SMD, and those who support them; participants were then interviewed about this work. DESIGN AND SETTING The Bridging Gaps group is a collaboration between healthcare staff, researchers, women with lived experience of SMD, and a charity that supports them in a UK city. A project was co-produced by the Bridging Gaps group to improve access to general practice for people with SMD, which was further developed with three inner-city general practices. METHOD Nine service improvement meetings were facilitated at three general practices, and six of these were formally observed. Nine practice staff and four women with lived experience of SMD were interviewed. Three women with lived experience of SMD and one staff member who supports them participated in a focus group. Data were analysed inductively and deductively using thematic analysis. RESULTS By providing time and funding opportunities to motivated general practice staff and involving participants with lived experience of SMD, service changes were made in an effort to improve access for people with SMD. These included prioritising patients on an inclusion patient list with more flexible access, providing continuity for patients via a care coordinator and micro-team of clinicians, and developing an information-sharing document. The process and outcomes improved connections within and between general practices, support organisations, and people with SMD. CONCLUSION The co-designed strategies described in this study could be adapted locally and evaluated in other areas. Investing in this focused way of working may improve accessibility to health care, health equity, and staff wellbeing.
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Affiliation(s)
- Lucy C Potter
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol
| | - Tracey Stone
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol; National Institute for Health and Care Research Applied Research Collaboration West, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol
| | | | | | - Helen Cramer
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol
| | - Helen McGeown
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol
| | | | - Jeremy Horwood
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol; National Institute for Health and Care Research Applied Research Collaboration West, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol
| | - Gene Feder
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol
| | - Michelle Farr
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol; National Institute for Health and Care Research Applied Research Collaboration West, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol
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Bharmal A, Parekh R, Maini A, Pinder R, Majeed A. The NHS Long Term Workforce Plan: what does this mean for general practices? Br J Gen Pract 2024; 74:198-199. [PMID: 38664054 PMCID: PMC11060822 DOI: 10.3399/bjgp24x737073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2024] Open
Affiliation(s)
- Aamena Bharmal
- Department of Primary Care and Public Health, Imperial College London, London
| | - Ravi Parekh
- External Examiner, various universities; Director of the Medical Education Innovation and Research Centre, Department of Primary Care and Public Health, Imperial College London, London
| | - Arti Maini
- Department of Primary Care and Public Health, Imperial College London, London
| | - Richard Pinder
- Department of Primary Care and Public Health, Imperial College London, London
| | - Azeem Majeed
- Department of Primary Care and Public Health, Imperial College London, London
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O'Malley R, O'Connor P, Lydon S. Strategies that facilitate the delivery of exceptionally good patient care in general practice: a qualitative study with patients and primary care professionals. BMC Prim Care 2024; 25:141. [PMID: 38678200 PMCID: PMC11055247 DOI: 10.1186/s12875-024-02352-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 03/27/2024] [Indexed: 04/29/2024]
Abstract
BACKGROUND In recent years, proactive strengths-based approaches to improving quality of care have been advocated. The positive deviance approach seeks to identify and learn from those who perform exceptionally well. Central to this approach is the identification of the specific strategies, behaviours, tools and contextual strategies used by those positive deviants to perform exceptionally well. This study aimed to: identify and collate the specific strategies, behaviours, processes and tools used to support the delivery of exceptionally good care in general practice; and to abstract the identified strategies into an existing framework pertaining to excellence in general practice; the Identifying and Disseminating the Exceptional to Achieve Learning (IDEAL) framework. METHODS This study comprised a secondary analysis of data collected during semi-structured interviews with 33 purposively sampled patients, general practitioners, practice nurses, and practice managers. Discussions explored the key factors and strategies that support the delivery of exceptional care across five levels of the primary care system; the patient, provider, team, practice, and external environment. For analysis, a summative content analysis approach was undertaken whereby data were inductively analysed and summated to identify the key strategies used to achieve the delivery of exceptionally good general practice care, which were subsequently abstracted as a new level of the IDEAL framework. RESULTS In total, 222 individual factors contributing to exceptional care delivery were collated and abstracted into the framework. These included specific behaviours (e.g., patients providing useful feedback and personal history to the provider), structures (e.g., using technology effectively to support care delivery (e.g., electronic referrals & prescriptions)), processes (e.g., being proactive in managing patient flow and investigating consistently delayed wait times), and contextual factors (e.g., valuing and respecting contributions of every team member). CONCLUSION The addition of concrete and contextual strategies to the IDEAL framework has enhanced its practicality and usefulness for supporting improvement in general practices. Now, a multi-level systems approach is needed to embed these strategies and create an environment where excellence is supported. The refined framework should be developed into a learning tool to support teams in general practice to measure, reflect and improve care within their practice.
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Affiliation(s)
- Roisin O'Malley
- Discipline of General Practice, University of Galway, Newcastle, 1 Distillery Road, Galway, H91TK33, Ireland.
| | - Paul O'Connor
- Discipline of General Practice, University of Galway, Newcastle, 1 Distillery Road, Galway, H91TK33, Ireland
| | - Sinéad Lydon
- Discipline of General Practice, University of Galway, Newcastle, 1 Distillery Road, Galway, H91TK33, Ireland
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Hazen ACM, Sloeserwij VM, de Groot E, de Gier JJ, de Wit NJ, de Bont AA, Zwart DLM. Non-dispensing pharmacists integrated into general practices as a new interprofessional model: a qualitative evaluation of general practitioners' experiences and views. BMC Health Serv Res 2024; 24:502. [PMID: 38654340 DOI: 10.1186/s12913-024-10703-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Accepted: 02/09/2024] [Indexed: 04/25/2024] Open
Abstract
BACKGROUND A new interprofessional model incorporating non-dispensing pharmacists in general practice teams can improve the quality of pharmaceutical care. However, results of the model are dependent on the context. Understanding when, why and how the model works may increase chances of successful broader implementation in other general practices. Earlier theories suggested that the results of the model are achieved by bringing pharmacotherapeutic knowledge into general practices. This mechanism may not be enough for successful implementation of the model. We wanted to understand better how establishing new interprofessional models in existing healthcare organisations takes place. METHODS An interview study, with a realist informed evaluation was conducted. This qualitative study was part of the Pharmacotherapy Optimisation through Integration of a Non-dispensing pharmacist in primary care Teams (POINT) project. We invited the general practitioners of the 9 general practices who (had) worked closely with a non-dispensing pharmacist for an interview. Interview data were analysed through discussions about the coding with the research team where themes were developed over time. RESULTS We interviewed 2 general practitioners in each general practice (18 interviews in total). In a context where general practitioners acknowledge the need for improvement and are willing to work with a non-dispensing pharmacist as a new team member, the following mechanisms are triggered. Non-dispensing pharmacists add new knowledge to current general practice. Through everyday talk (discursive actions) both general practitioners and non-dispensing pharmacists evolve in what they consider appropriate, legitimate and imaginable in their work situations. They align their professional identities. CONCLUSIONS Not only the addition of new knowledge of non-dispensing pharmacist to the general practice team is crucial for the success of this interprofessional healthcare model, but also alignment of the general practitioners' and non-dispensing pharmacists' professional identities. This is essentially different from traditional pharmaceutical care models, in which pharmacists and GPs work in separate organisations. To induce the process of identity alignment, general practitioners need to acknowledge the need to improve the quality of pharmaceutical care interprofessionally. By acknowledging the aspect of interprofessionality, both general practitioners and non-dispensing pharmacists will explore and reflect on what they consider appropriate, legitimate and imaginable in carrying out their professional roles. TRIAL REGISTRATION The POINT project was pre-registered in The Netherlands National Trial Register, with Trial registration number NTR-4389.
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Affiliation(s)
- A C M Hazen
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht (UMCU), Utrecht University, Universiteitsweg 100 3584 CG Utrecht. Postal address STR 6.131, P.O. Box 85500, 3508 GA, Utrecht, The Netherlands.
| | - V M Sloeserwij
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht (UMCU), Utrecht University, Universiteitsweg 100 3584 CG Utrecht. Postal address STR 6.131, P.O. Box 85500, 3508 GA, Utrecht, The Netherlands
| | - E de Groot
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht (UMCU), Utrecht University, Universiteitsweg 100 3584 CG Utrecht. Postal address STR 6.131, P.O. Box 85500, 3508 GA, Utrecht, The Netherlands
| | - J J de Gier
- Department of Pharmacotherapy, - Epidemiology and - Economics, University of Groningen, Antonius Deusinglaan 1, Building 3214, 9713 AV, Groningen, The Netherlands
| | - N J de Wit
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht (UMCU), Utrecht University, Universiteitsweg 100 3584 CG Utrecht. Postal address STR 6.131, P.O. Box 85500, 3508 GA, Utrecht, The Netherlands
| | - A A de Bont
- Tilburg School of Social and Behavioral Sciences, Warandelaan 2, 5037 AB, Tilburg, The Netherlands
| | - D L M Zwart
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht (UMCU), Utrecht University, Universiteitsweg 100 3584 CG Utrecht. Postal address STR 6.131, P.O. Box 85500, 3508 GA, Utrecht, The Netherlands
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Wright M, Haysom G. Managing patient complaints to improve your practice. Aust J Gen Pract 2023; 52:848-851. [PMID: 38049130 DOI: 10.31128/ajgp-07-23-6901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/06/2023]
Abstract
BACKGROUND Increasing numbers of patient complaints to regulators suggest practices need effective systems to manage and address patient concerns. Many patient complaints can often be dealt with at a practice level, but patients can have difficulty reporting negative experiences directly. OBJECTIVE This article explores the benefits of having a system to accept and deal with patient feedback within a practice and identifies barriers preventing patients from raising their concerns directly. DISCUSSION Managing patient complaints well at a practice level can prevent them escalating, as well as offering insights to reduce risk and improve patient care. Understanding factors that inhibit patients from raising concerns, or prevent staff from being able to accept and deal with complaints, allows an opportunity for practices to implement strategies to address these barriers and support patients and staff. Effective strategies include process improvements, as well as cultural changes and support for those managing a complaint process.
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Affiliation(s)
- Michael Wright
- MBBS, MSC, PhD, FRACGP, Chief Medical Officer, Avant Mutual Group Limited, Sydney, NSW; Research Fellow, Centre for Health Economics Research and Evaluation, University of Technology Sydney, Sydney, NSW; AJGP Editorial Advisory Committee member, RACGP, Melbourne, Vic
| | - Georgie Haysom
- BSc, LLB (Hons), LLM (Bioethics), GAICD, Head of Research, Education and Advocacy, Avant, NSW
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Patzer KH. Nachhaltige Praxis - für die meisten Ärzte ein wichtiges Thema. MMW Fortschr Med 2023; 165:24. [PMID: 37973736 DOI: 10.1007/s15006-023-3141-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
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Affiliation(s)
- Azeem Majeed
- Department of Primary Care and Public Health, Imperial College London
| | - Simon Hodes
- Bridgewater Surgeries, Watford
- Cleveland Clinic London
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Cooney K. Has covid-19 precipitated the end of the family doctor? BMJ 2022; 376:o320. [PMID: 35121614 DOI: 10.1136/bmj.o320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Rae M, Marshall M. General practice and public health: fostering collaboration for better health for populations. BMJ 2021; 375:n2916. [PMID: 34824087 DOI: 10.1136/bmj.n2916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Ashworth AJ. Scotland is (over)ripe for corporate takeover of general practice. BMJ 2021; 374:n2043. [PMID: 34408001 DOI: 10.1136/bmj.n2043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Denton S, de Lusignan S. Correcting flaws in GP funding: avoid missing pockets of deprivation and don't penalise areas with reduced life expectancy. BMJ 2021; 374:n1674. [PMID: 34215572 DOI: 10.1136/bmj.n1674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Susan Denton
- Guildowns Group Practice, Guildford, UK
- Guildford Renaissance in Primary Care, North Guildford PCN, UK
| | - Simon de Lusignan
- Woodbridge Hill Surgery, Guildford, UK
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Abstract
BACKGROUND Outside the cities, the medical services in the municipality are often centred around one GP practice. The local medical service is key to the municipality's healthcare preparedness. We wished to investigate how the healthcare personnel perceived the restructuring at their GP practice during the COVID-19 outbreak in March 2020, and the factors that facilitated and impeded the process. MATERIAL AND METHOD The article is based on a focus group interview that was conducted with eight nurses and medical secretaries at Otta GP practice in June 2020. The interview was transcribed and analysed using systematic text condensation. RESULTS The informants described a chaotic and demanding situation, in which they had to deal with their own as well as the patients' fears. They found crisis management to be difficult in a situation where the leadership in the municipality were unaware of the challenges of the GP practice. Lack of guidelines from the authorities at the start of the outbreak gave rise to considerable uncertainty. Through collaboration and flexibility, the practice arrived at new ways of working in order to safeguard its running. This gave a strong feeling of coping and fellowship, and a greater awareness of the informants' own importance in the front line of crisis management. INTERPRETATION The study elucidates the role of support staff in the face of a crisis for the GP practice. Competent employees with the latitude and tools to tackle the challenges quickly guided the practice from chaos to a new type of working day. The municipality could have supported the process by ensuring the necessary resources and general guidelines for prioritisation of tasks.
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Saint-Lary O, Gautier S, Le Breton J, Gilberg S, Frappé P, Schuers M, Bourgueil Y, Renard V. How GPs adapted their practices and organisations at the beginning of COVID-19 outbreak: a French national observational survey. BMJ Open 2020; 10:e042119. [PMID: 33268433 PMCID: PMC7712933 DOI: 10.1136/bmjopen-2020-042119] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES To describe how general practitioners (GPs) adapted their practices to secure and maintain access to care in the epidemic phase. A secondary objective was to explore if GPs' individual characteristics and type of practice determined their adaptation. DESIGN Observational study using an online questionnaire. Organisational changes were measured by a main question and detailed in two specific outcomes. To identify which GPs' characteristics impacted organisational changes, successive multivariate logistic modelling was performed. First, we identified the GPs' characteristics related to organisational changes with a univariate analysis. Then, we tested the adjusted associations between this variable and the following GPs' characteristics: age, gender and type of practice. SETTING The questionnaire was administered online between 14 March and 21 March 2020. Practitioners were recruited by email using the contact lists of different French scientific GP societies. PARTICIPANTS The target population was GPs currently practising in France (n=46 056). We obtained a total of 7481 responses. PRIMARY AND SECONDARY OUTCOME MEASURES Primary outcome: Proportion of GPs who adapted their practice. Secondary outcome: GPs' characteristics related to organisational changes. RESULTS Among the 7481 responses, 5425 were complete and were analysed. 3849 GPs (70.9%) changed their activity, 3605 GPs (66.5%) increased remote consultations and 2315 GPs (42.7%) created a specific pathway for probable patients with COVID-19. Among the 3849 GPs (70.9%) who changed their practice, 3306 (91.7%) gave more answers by phone, 996 (27.6%) by email and 1105 (30.7%) increased the use of video consultations. GPs working in multi-professional group practices were more likely to have changed their activity since the beginning of the epidemic wave than GPs working in mono-professional group or single medical practices (adjusted OR: 1.32, 95% CI 1.12 to 1.56, p=0.001). CONCLUSIONS French GPs adapted their practices regarding access to care for patients in the context of the COVID-19 epidemic. This adaptation was higher in multi-professional group practices.
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Affiliation(s)
- Olivier Saint-Lary
- Université Paris-Saclay, UVSQ, Univ. Paris-Sud, Inserm, Primary Care and Prevention, CESP, Villejuif, France
- Department of Family Medicine, UVSQ, Faculty of Health Sciences Simone Veil, Montigny Le Bretonneux, France
- Conseil Scientifique du Collège National des Généralistes Enseignants (CNGE), Paris, France
| | - Sylvain Gautier
- Université Paris-Saclay, UVSQ, Univ. Paris-Sud, Inserm, Primary Care and Prevention, CESP, Villejuif, France
- Mission RESPIRE, EHESP-CNAMTS-IRDES - EA MOS 7348, 93210 la Plaine Saint Denis, Saint-Denis, France
| | - Julien Le Breton
- Department of family medicine, UPEC, Faculty of Health, Créteil, France
- Société Française de Médecine Générale (SFMG), Issy-les-Moulineaux, France
- Inserm U955, Université Paris Est Créteil, Institut Mondor de Recherche Biomédicale, équipe CEpiA (Clinical Epidemiology and Ageing), Créteil, France
- Institut Jean-François REY (IJFR), Paris, France
| | - Serge Gilberg
- Conseil Scientifique du Collège National des Généralistes Enseignants (CNGE), Paris, France
- Départment of family medicine, Université de Paris, Paris, France
| | - Paul Frappé
- Départment of family medicine, Université de Saint Etienne, Saint-Étienne, France
| | - Matthieu Schuers
- Départment of family medicine, Université de Rouen, Rouen, France
| | - Yann Bourgueil
- Mission RESPIRE, EHESP-CNAMTS-IRDES - EA MOS 7348, 93210 la Plaine Saint Denis, Saint-Denis, France
| | - Vincent Renard
- Conseil Scientifique du Collège National des Généralistes Enseignants (CNGE), Paris, France
- Department of family medicine, UPEC, Faculty of Health, Créteil, France
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Pratt R. General practice public relations storm: shaped in broadcast, fixed in narrowcast. BMJ 2020; 371:m4653. [PMID: 33257344 DOI: 10.1136/bmj.m4653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Richard Pratt
- Three Spires Medical Practice, Truro Health Park, Truro TR1 2JA, UK
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Johnson CE, Senior H, McVey P, Team V, Ives A, Mitchell G. End-of-life care in rural and regional Australia: Patients', carers' and general practitioners' expectations of the role of general practice, and the degree to which they were met. Health Soc Care Community 2020; 28:2160-2171. [PMID: 32488974 DOI: 10.1111/hsc.13027] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 02/16/2020] [Accepted: 04/23/2020] [Indexed: 06/11/2023]
Abstract
The study objective was to explore the characteristics of rural general practice which exemplify optimal end-of-life (EOL) care from the perspective of people diagnosed with cancer, their informal carers and general practitioners (GPs); and the extent to which consumers perceived that actual EOL care addressed these characteristics. Semi-structured telephone interviews were conducted with six people diagnosed with cancer, three informal carers and four GPs in rural and regional Australia. Using a social constructionist approach, thematic analysis was undertaken. Seven characteristics were perceived to be essential for optimal EOL care: (1) commitment and availability, (2) building of therapeutic relationships, (3) effective communication, (4) psychosocial support, (5) proficient symptom management, (6) care coordination and (7) recognition of the needs of carers. Most GPs consistently addressed these characteristics. Comprehensive EOL care that meets the needs of people dying with cancer is not beyond the resources of rural and regional GPs and communities.
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Affiliation(s)
- Claire E Johnson
- Monash Nursing and Midwifery, Monash University, Melbourne, Victoria, Australia
- Medical School, The University of Western Australia, Perth, Western Australia, Australia
- Supportive and Palliative Care, Easter Health, Melbourne, Victoria, Australia
| | - Hugh Senior
- Primary Care Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
- College of Health, Massey University, Auckland, New Zealand
| | - Peta McVey
- Susan Wakil School of Nursing, University of Sydney, Sydney, New South Wales, Australia
| | - Victoria Team
- Monash Nursing and Midwifery, Monash University, Melbourne, Victoria, Australia
| | - Angela Ives
- Medical School, The University of Western Australia, Perth, Western Australia, Australia
| | - Geoffrey Mitchell
- Primary Care Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
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Coughlan B, Duschinsky R, O'Connor ME, Woolgar M. Identifying and managing care for children with autism spectrum disorders in general practice: A systematic review and narrative synthesis. Health Soc Care Community 2020; 28:1928-1941. [PMID: 32667097 DOI: 10.1111/hsc.13098] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 06/17/2020] [Accepted: 06/19/2020] [Indexed: 06/11/2023]
Abstract
Many healthcare systems are organised such that General Practitioners (GPs) often have a key role in identifying autism spectrum disorders (hereafter collectively referred to as autism) in children. In this review, we explored what GPs know about autism and the factors that influence their ability to identify and manage care for their patients with autism in practice. We conducted a systematic narrative review using eight electronic databases. These included Embase and MEDLINE via Ovid, Web of Knowledge, PsycINFO via Ebscohost, PubMed, Scopus, ProQuest Dissertations and Thesis, and Applied Social Sciences Index and Abstracts (ASSIA) via ProQuest. Our search yielded 2,743 citations. Primary research studies were included, and we did not impose any geographical, language or date restrictions. We identified 17 studies that met our inclusion criteria. Studies included in the review were conducted between 2003 and 2019. We thematically synthesised the material and identified the following themes: the prototypical image of a child with autism; experience, sources of information, and managing care; barriers to identification; strategies to aid in identification; and characteristics that facilitate expertise. Together, the findings from this review present a mixed picture of GP knowledge and experiences in identifying autism and managing care for children with the condition. At one end of the continuum, there were GPs who had not heard of autism or endorsed outmoded aetiological theories. Others, however, demonstrated a sound knowledge of the conditions but had limited confidence in their ability to identify the condition. Many GPs and researchers alike called for more training and this might be effective. However, framing the problem as one of a lack of training risks silences the array of organisational factors that impact on a GP's ability to provide care for these patients.
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Affiliation(s)
- Barry Coughlan
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Robbie Duschinsky
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | | | - Matt Woolgar
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
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Gomà-I-Freixanet M, Calvo-Rojas V, Portell M. Psychosocial characteristics and affective symptomatology associated with patient self-initiated consultations in Spanish general practice. Health Soc Care Community 2020; 28:2312-2319. [PMID: 32511850 DOI: 10.1111/hsc.13052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 04/08/2020] [Accepted: 05/13/2020] [Indexed: 06/11/2023]
Abstract
We aimed to determine the sociodemographic and psychosocial profile, and the associated subclinical affective symptomatology of users above the 95th percentile in the distribution of patient self-initiated, face-to-face consultations. Additionally, we sought to determine the contribution of subclinical symptomatology in differentiating between the groups above or below this cut-off point. A total of 16,803 users who self-initiated at least one face-to-face consultation with a GP at any of 13 PHC practices over 1 year, were eligible. After discarding those fulfilling exclusion criteria, 129 cases and 109 controls, matched by gender and age, answered the Family APGAR, the Duke-UNC and the Goldberg Anxiety-Depression scale. Both groups did not differ significantly on any of the sociodemographic and psychosocial variables recorded showing a similar percentage distribution. However, users with high self-initiated consultation rates obtained lower scores on the affective social support subscale from the Duke-UNC. Regarding Goldberg scale, the two groups differed significantly on the likelihood of displaying depression and/or anxiety symptoms. Users with a high probability of suffering from depression and/or anxiety were more prevalent among users on the top 5% in the distribution. Altogether, results indicate that these users report a lack of affective social support and have a higher probability of suffering from subclinical depression and/or anxiety. Early detection and treatment of affective symptomatology would temperate this excess in consultation. General practitioners, social workers and psychologists could act as gatekeepers, preventing this overuse of medical services and in turn lowering economical costs, professional burnout and patients' suffering and discontent.
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Affiliation(s)
- Montserrat Gomà-I-Freixanet
- Department of Clinical and Health Psychology, Universitat Autònoma de Barcelona, Barcelona, Catalonia, Spain
| | - Valentín Calvo-Rojas
- Centre d'Atenció Primària Montnegre, Institut Català de la Salut, Barcelona, Catalonia, Spain
| | - Mariona Portell
- Department of Psychobiology and Methodology of Health Sciences, Universitat Autònoma de Barcelona, Barcelona, Catalonia, Spain
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Atmore C, Stokes T. Turning on a dime-pre- and post-COVID-19 consultation patterns in an urban general practice. N Z Med J 2020; 133:65-75. [PMID: 33032304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
AIMS To investigate changes in general practice consultation patterns in response to reduced face-to-face patient contact during the COVID-19 pandemic. METHODS A retrospective before and after case notes review study of one urban general practice to investigate patient contact in the first two weeks of New Zealand general practices' COVID-19 response in 2020, compared to the same period in 2019. RESULTS Twenty percent of patients had contact with the practice in both samples, with similar proportions by age, gender, ethnicity, deprivation and presence of multimorbidity or mental health diagnoses. Similar numbers of acute illness, accident-related and prevention patient contacts occurred in both samples, with more long-term condition-related contact in 2020. While 70% of patient contacts were face-to-face in 2019, 21% were face-to-face in 2020. Most acute illness, accident-related and long-term condition-related contacts were able to be provided through virtual means, but most prevention-related contacts were face-to-face. CONCLUSIONS This single practice study showed total patient contact was similar over both sample periods, but most contact in 2020 was virtual. Further longitudinal multi-practice studies to confirm these findings and describe future consultation patterns are needed to inform general practice service delivery post-COVID-19.
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Affiliation(s)
- Carol Atmore
- General Practitioner, Senior Lecturer, Department of General Practice and Rural Health, Otago Medical School, University of Otago, Dunedin
| | - Tim Stokes
- General Practitioner, Elaine Gurr Professor of General Practice, Department of General Practice and Rural Health, Otago Medical School, University of Otago, Dunedin
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Trankle SA, Usherwood T, Abbott P, Roberts M, Crampton M, Girgis CM, Riskallah J, Chang Y, Saini J, Reath J. Key stakeholder experiences of an integrated healthcare pilot in Australia: a thematic analysis. BMC Health Serv Res 2020; 20:925. [PMID: 33028299 PMCID: PMC7542969 DOI: 10.1186/s12913-020-05794-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Accepted: 10/01/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In Australia and other developed countries, chronic illness prevalence is increasing, as are costs of healthcare, particularly hospital-based care. Integrating healthcare and supporting illness management in the community can be a means of preventing illness, improving outcomes and reducing unnecessary hospitalisation. Western Sydney has high rates of diabetes, heart and respiratory diseases and the NSW State Ministry of Health funded a range of key strategies through the Western Sydney Integrated Care Program (WSICP) to integrate care across hospital and community settings for patients with these illnesses. Complementing our previously reported analysis related to specific WSICP strategies, this research provided information concerning overall experiences and perspectives of WSICP implementation and integrated care generally. METHODS We administered 125 in-depth interviews in two rounds over 12 months with 83 participants including patients and their carers, care facilitators, hospital specialists and nurses, allied health professionals, general practitioners and primary care nurses, and program managers. Half of the participants (n = 42) were interviewed twice. We conducted an inductive, thematic analysis on the interview transcripts. RESULTS Key themes related to the set-up and operationalising of WSICP; challenges encountered; and the added value of the program. Implementing WSICP was a large and time consuming undertaking but challenges including those with staffing and information technology were being addressed. The WSICP was considered valuable in reducing hospital admissions due to improved patient self-management and a focus on prevention, greater communication and collaboration between healthcare providers across health sectors and an increased capacity to manage chronic illness in the primary care setting. CONCLUSIONS Patients, carers and health providers experienced the WSICP as an innovative integrated care model and valued its patient-centred approach which was perceived to improve access to care, increase patient self-management and illness prevention, and reduce hospital admissions. Long-term sustainability of the WSICP will depend on retaining key staff, more effectively sharing information including across health sectors to support enhanced collaboration, and expanding the suite of activities into other illness areas and locations. Enhanced support for general practices to manage chronic illness in the community, in collaboration with hospital specialists is critical. Timely evaluation informs ongoing program implementation.
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Affiliation(s)
- Steven A Trankle
- Department General Practice, School of Medicine, Western Sydney University, Building 30.3.18 Campbelltown Campus, Locked Bag 1797, Penrith, NSW, 2751, Australia.
| | - Tim Usherwood
- Westmead Clinical School, Sydney Medical School, The University of Sydney, Sydney, Australia
- Western Sydney Local Health District (Westmead Hospital), Sydney, Australia
- George Institute for Global Health, Sydney, Australia
| | - Penelope Abbott
- Department General Practice, School of Medicine, Western Sydney University, Building 30.3.18 Campbelltown Campus, Locked Bag 1797, Penrith, NSW, 2751, Australia
| | - Mary Roberts
- Westmead Clinical School, Sydney Medical School, The University of Sydney, Sydney, Australia
- Western Sydney Local Health District (Westmead Hospital), Sydney, Australia
| | | | - Christian M Girgis
- Westmead Clinical School, Sydney Medical School, The University of Sydney, Sydney, Australia
- Western Sydney Local Health District (Westmead Hospital), Sydney, Australia
- Royal North Shore Hospital, Sydney, Australia
| | - John Riskallah
- Western Sydney Local Health District (Blacktown Hospital), Sydney, Australia
| | - Yashu Chang
- Department General Practice, School of Medicine, Western Sydney University, Building 30.3.18 Campbelltown Campus, Locked Bag 1797, Penrith, NSW, 2751, Australia
- Western Sydney Local Health District (Blacktown Hospital), Sydney, Australia
| | - Jaspreet Saini
- Western Sydney Primary Health Network, Sydney, Australia
| | - Jennifer Reath
- Department General Practice, School of Medicine, Western Sydney University, Building 30.3.18 Campbelltown Campus, Locked Bag 1797, Penrith, NSW, 2751, Australia
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Affiliation(s)
| | - George Freeman
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | | | - Martin Roland
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
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25
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Affiliation(s)
- Nathaniel J T Aspray
- Northumbria GP Training Programme, Manor House, Coach Lane Campus, Newcastle upon Tyne NE7 7XA, UK
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26
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Stigter RW, de Graaf AP. [The role of the general practitioner in the treatment of suicidal patients: the problems they encounter in practice]. Ned Tijdschr Geneeskd 2020; 164:D5163. [PMID: 33030327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
In this commentary, the current directives and supporting methods to assess suicidal behaviour are briefly introduced and their shortcoming in predicting the risk of suicide is acknowledged. The treatment of a patient with suicidal behaviour by a general practitioner (GP), based on an already existing relationship between the two, is questioned. Instead, a close collaboration between GP and emergency mental healthcare providers is recommended. This working relationship should be maintained by both parties. Suicide after an intervention can have a major impact on the professionals involved. Therefore, these cases deserve specialised attention to ensure sustainable commitment of healthcare professionals confronted with complex mental health cases.
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Morreel S, Philips H, Verhoeven V. Organisation and characteristics of out-of-hours primary care during a COVID-19 outbreak: A real-time observational study. PLoS One 2020; 15:e0237629. [PMID: 32790804 PMCID: PMC7425859 DOI: 10.1371/journal.pone.0237629] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 07/30/2020] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND During the COVID-19 pandemic, general practitioners worldwide re-organise care in very different ways because of the lack of evidence-based protocols. OBJECTIVE This paper describes the organisation and the characteristics of consultations in Belgian out-of-hours primary care during five weekends at the peak of a COVID-19 outbreak and compares it to a similar period in 2019. METHODS Real-time observational study using pseudonymised routine clinical data extracted out of reports from home visits, telephone- and physical consultations (iCAREdata). Nine general practice cooperatives (GPCs) participated covering a population of 1 513 523. RESULTS All GPCs rapidly re-organised care in order to handle the outbreak and provide a safe working environment. The average consultation rate was 222 per 100 000 citizens per weekend. These consultations were handled by telephone alone in 40% (N = 6293). A diagnosis at risk of COVID-19 was registered in 6692 (43%) consultations,. Out of 5311 physical consultations, 1460 were at risk of COVID-19 of which 443 (30%) did not receive prior telephone consultation to estimate this risk. Compared to 2019, the workload initially increased due to telephone consultations but afterwards declined drastically. The physical consultation rate declined by 45% with a marked decline in diagnoses unrelated to COVID-19. CONCLUSIONS General practitioners can rapidly re-organise out-of-hours care to handle patient flows during a COVID-19 outbreak. Forty percent of the out-of-hours primary care contacts are handled by telephone consultations alone. We recommend to give a telephone consultation to all patients and not to rely on call takers to differentiate between infectious and regular care. The demand for physical consultations declined drastically provoking questions about patient's safety for care unrelated to COVID-19.
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Affiliation(s)
- Stefan Morreel
- Department of ELIZA (Primary and Interdisciplinary Care), University of Antwerp, Antwerpen, Belgium
| | - Hilde Philips
- Department of ELIZA (Primary and Interdisciplinary Care), University of Antwerp, Antwerpen, Belgium
| | - Veronique Verhoeven
- Department of ELIZA (Primary and Interdisciplinary Care), University of Antwerp, Antwerpen, Belgium
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28
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Wayne AN. Covid-19 - an example of induced change in general practice. Med Leg J 2020; 88:55. [PMID: 32779990 DOI: 10.1177/0025817220938005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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29
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de Lusignan S, Jones N, Dorward J, Byford R, Liyanage H, Briggs J, Ferreira F, Akinyemi O, Amirthalingam G, Bates C, Lopez Bernal J, Dabrera G, Eavis A, Elliot AJ, Feher M, Krajenbrink E, Hoang U, Howsam G, Leach J, Okusi C, Nicholson B, Nieri P, Sherlock J, Smith G, Thomas M, Thomas N, Tripathy M, Victor W, Williams J, Wood I, Zambon M, Parry J, O'Hanlon S, Joy M, Butler C, Marshall M, Hobbs FDR. The Oxford Royal College of General Practitioners Clinical Informatics Digital Hub: Protocol to Develop Extended COVID-19 Surveillance and Trial Platforms. JMIR Public Health Surveill 2020; 6:e19773. [PMID: 32484782 PMCID: PMC7333793 DOI: 10.2196/19773] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 05/29/2020] [Accepted: 06/01/2020] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Routinely recorded primary care data have been used for many years by sentinel networks for surveillance. More recently, real world data have been used for a wider range of research projects to support rapid, inexpensive clinical trials. Because the partial national lockdown in the United Kingdom due to the coronavirus disease (COVID-19) pandemic has resulted in decreasing community disease incidence, much larger numbers of general practices are needed to deliver effective COVID-19 surveillance and contribute to in-pandemic clinical trials. OBJECTIVE The aim of this protocol is to describe the rapid design and development of the Oxford Royal College of General Practitioners Clinical Informatics Digital Hub (ORCHID) and its first two platforms. The Surveillance Platform will provide extended primary care surveillance, while the Trials Platform is a streamlined clinical trials platform that will be integrated into routine primary care practice. METHODS We will apply the FAIR (Findable, Accessible, Interoperable, and Reusable) metadata principles to a new, integrated digital health hub that will extract routinely collected general practice electronic health data for use in clinical trials and provide enhanced communicable disease surveillance. The hub will be findable through membership in Health Data Research UK and European metadata repositories. Accessibility through an online application system will provide access to study-ready data sets or developed custom data sets. Interoperability will be facilitated by fixed linkage to other key sources such as Hospital Episodes Statistics and the Office of National Statistics using pseudonymized data. All semantic descriptors (ie, ontologies) and code used for analysis will be made available to accelerate analyses. We will also make data available using common data models, starting with the US Food and Drug Administration Sentinel and Observational Medical Outcomes Partnership approaches, to facilitate international studies. The Surveillance Platform will provide access to data for health protection and promotion work as authorized through agreements between Oxford, the Royal College of General Practitioners, and Public Health England. All studies using the Trials Platform will go through appropriate ethical and other regulatory approval processes. RESULTS The hub will be a bottom-up, professionally led network that will provide benefits for member practices, our health service, and the population served. Data will only be used for SQUIRE (surveillance, quality improvement, research, and education) purposes. We have already received positive responses from practices, and the number of practices in the network has doubled to over 1150 since February 2020. COVID-19 surveillance has resulted in tripling of the number of virology sites to 293 (target 300), which has aided the collection of the largest ever weekly total of surveillance swabs in the United Kingdom as well as over 3000 severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) serology samples. Practices are recruiting to the PRINCIPLE (Platform Randomised trial of INterventions against COVID-19 In older PeopLE) trial, and these participants will be followed up through ORCHID. These initial outputs demonstrate the feasibility of ORCHID to provide an extended national digital health hub. CONCLUSIONS ORCHID will provide equitable and innovative use of big data through a professionally led national primary care network and the application of FAIR principles. The secure data hub will host routinely collected general practice data linked to other key health care repositories for clinical trials and support enhanced in situ surveillance without always requiring large volume data extracts. ORCHID will support rapid data extraction, analysis, and dissemination with the aim of improving future research and development in general practice to positively impact patient care. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/19773.
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Affiliation(s)
- Simon de Lusignan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
- Royal College of General Practitioners, London, United Kingdom
| | - Nicholas Jones
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Jienchi Dorward
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Rachel Byford
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Harshana Liyanage
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - John Briggs
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Filipa Ferreira
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Oluwafunmi Akinyemi
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | | | | | | | | | | | - Alex J Elliot
- Real-time Syndromic Surveillance Team, Field Service, Public Health England, Birmingham, United Kingdom
| | - Michael Feher
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | | | - Uy Hoang
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Gary Howsam
- Royal College of General Practitioners, London, United Kingdom
| | - Jonathan Leach
- Royal College of General Practitioners, London, United Kingdom
| | - Cecilia Okusi
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Brian Nicholson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Philip Nieri
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Julian Sherlock
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Gillian Smith
- Real-time Syndromic Surveillance Team, Field Service, Public Health England, Birmingham, United Kingdom
| | - Mark Thomas
- Royal College of General Practitioners, London, United Kingdom
| | - Nicholas Thomas
- Royal College of General Practitioners, London, United Kingdom
| | - Manasa Tripathy
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - William Victor
- Royal College of General Practitioners, London, United Kingdom
| | - John Williams
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Ian Wood
- Royal College of General Practitioners, London, United Kingdom
- EMIS Group, Leeds, United Kingdom
| | | | | | | | - Mark Joy
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Chris Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Martin Marshall
- Royal College of General Practitioners, London, United Kingdom
| | - F D Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
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Sturman N, Matheson D. 'Genuine doctor care': Perspectives on general practice and community-based care of Australian men experiencing homelessness. Health Soc Care Community 2020; 28:1301-1309. [PMID: 32096349 DOI: 10.1111/hsc.12963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 01/06/2020] [Accepted: 02/07/2020] [Indexed: 06/10/2023]
Abstract
People with complex health and social needs, including tri-morbidity and homelessness, are challenging for modern healthcare systems. These clients have poor health and social outcomes. They tend to use available health resources inefficiently, with fragmented, uncoordinated use of multiple health and social care services. Increasing access for these clients to well-supported general practice care may be an effective response to these challenges. The aim of this study was to explore client experiences of, and attitudes to, community-based healthcare, and general practice in particular, to identify opportunities to improve healthcare provision. Five focus groups with a total of 20 men currently experiencing homelessness were facilitated by the corresponding author in an inner-city homeless hostel. Discussions were transcribed, coded and analysed thematically. The analysis was informed by earlier focus group discussions with community-based homeless healthcare providers. Participants reported reluctance to engage with healthcare providers outside times of perceived crisis, and experiences of stigma and dismissive care. Some participants were sceptical of the motivations of health and social care providers, including general practitioners. Presentations with physical and psychological pain featured prominently in participant accounts. Three key themes identified important aspects of client experiences of community-based healthcare which indicate potential areas for improvement. These themes were as follows: the relative invisibility and low salience of general practice compared to hospital-based emergency and inpatient services; discontinuity within community-based healthcare and across transitions between community-based and other healthcare; and inconsistent and unsatisfactory general practitioner responses to physical and psychological pain. These responses included apparent over-prescribing, under-prescribing and short-term 'band-aid' responses. Generalist medical expertise was valued in general practitioners, but not consistently experienced. A number of challenges and opportunities exist, at both individual and system levels, for general practice to realise its potential to deliver effective, compassionate and efficient care to clients experiencing homelessness.
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Affiliation(s)
- Nancy Sturman
- Primary Care Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane, Qld, Australia
| | - Don Matheson
- Health Alliance, North PHN and Metro North Hospital and Health Service, Brisbane, Qld, Australia
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Cardwell K, Smith SM, Clyne B, McCullagh L, Wallace E, Kirke C, Fahey T, Moriarty F. Evaluation of the General Practice Pharmacist (GPP) intervention to optimise prescribing in Irish primary care: a non-randomised pilot study. BMJ Open 2020; 10:e035087. [PMID: 32595137 PMCID: PMC7322285 DOI: 10.1136/bmjopen-2019-035087] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
OBJECTIVE Limited evidence suggests integration of pharmacists into the general practice team could improve medicines management for patients, particularly those with multimorbidity and polypharmacy. This study aimed to develop and assess the feasibility of an intervention involving pharmacists, working within general practices, to optimise prescribing in Ireland. DESIGN Non-randomised pilot study. SETTING Primary care in Ireland. PARTICIPANTS Four general practices, purposively sampled and recruited to reflect a range of practice sizes and demographic profiles. INTERVENTION A pharmacist joined the practice team for 6 months (10 hours/week) and undertook medication reviews (face to face or chart based) for adult patients, provided prescribing advice, supported clinical audits and facilitated practice-based education. OUTCOME MEASURES Anonymised practice-level medication (eg, medication changes) and cost data were collected. Patient-reported outcome measure (PROM) data were collected on a subset of older adults (aged ≥65 years) with polypharmacy using patient questionnaires, before and 6 weeks after medication review by the pharmacist. RESULTS Across four practices, 786 patients were identified as having 1521 prescribing issues by the pharmacists. Issues relating to deprescribing medications were addressed most often by the prescriber (59.8%), compared with cost-related issues (5.8%). Medication changes made during the study equated to approximately €57 000 in cost savings assuming they persisted for 12 months. Ninety-six patients aged ≥65 years with polypharmacy were recruited from the four practices for PROM data collection and 64 (66.7%) were followed up. There were no changes in patients' treatment burden or attitudes to deprescribing following medication review, and there were conflicting changes in patients' self-reported quality of life. CONCLUSIONS This non-randomised pilot study demonstrated that an intervention involving pharmacists, working within general practices is feasible to implement and has potential to improve prescribing quality. This study provides rationale to conduct a randomised controlled trial to evaluate the clinical and cost-effectiveness of this intervention.
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Affiliation(s)
- Karen Cardwell
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Susan M Smith
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Barbara Clyne
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, Dublin, Ireland
- HRB Collaboration in Ireland for Clinical Effectiveness Reviews (HRB-CICER), Health Information and Quality Authority, Dublin, Ireland
| | - Laura McCullagh
- National Centre for Pharmacoeconomics, St James's University Teaching Hospital, Dublin, Ireland
- Department of Pharmacology and Therapeutics, Trinity Centre for Health Sciences, Trinity College Dublin, Dublin, Ireland
| | - Emma Wallace
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Ciara Kirke
- National Quality Improvement Team, Health Service Executive, Dublin, Ireland
| | - Tom Fahey
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Frank Moriarty
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, Dublin, Ireland
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Verhoeven V, Tsakitzidis G, Philips H, Van Royen P. Impact of the COVID-19 pandemic on the core functions of primary care: will the cure be worse than the disease? A qualitative interview study in Flemish GPs. BMJ Open 2020; 10:e039674. [PMID: 32554730 PMCID: PMC7306272 DOI: 10.1136/bmjopen-2020-039674] [Citation(s) in RCA: 183] [Impact Index Per Article: 45.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 06/08/2020] [Accepted: 06/09/2020] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVES The current COVID-19 pandemic, as well as the measures taken to control it, have a profound impact on healthcare. This study was set up to gain insights into the consequences of the COVID-19 outbreak on the core competencies of general practice, as they are experienced by general practitioners (GPs) on the frontline. DESIGN, SETTING, PARTICIPANTS We performed a descriptive study using semistructured interviews with 132 GPs in Flanders, using a topic list based on the WONCA definition of core competencies in general practice. Data were analysed qualitatively using framework analysis. RESULTS Changes in practice management and in consultation strategies were quickly adopted. There was a major switch towards telephone triage and consults, for covid-related as well as for non-covid related problems. Patient-centred care is still a major objective. Clinical decision-making is largely focused on respiratory assessment and triage, and GPs feel that acute care is compromised, both by their own changed focus and by the fact that patients consult less frequently for non-covid problems. Chronic care is mostly postponed, and this will have consequences that will extend and become visible after the corona crisis. Through the holistic eyes of primary care, the current outbreak-as well as the measures taken to control it-will have a profound impact on psychological and socioeconomic well-being. This impact is already visible in vulnerable people and will continue to become clear in the medium and long terms. GPs think that they are at high risk of getting infected. Dropping out and being unable to contribute their part or becoming virus transmitters are reported to be greater concerns than getting ill themselves. CONCLUSIONS The current times have a profound impact on the core competences of primary care. Although the vast increase in patients soliciting medical help and the necessary separate covid and non-covid flows have been dealt with, GPs are worried about the continuity of regular care and the consequences of the anticovid measures. These may become a threat for the general health of the population and for the provision of primary healthcare in the near and distant future.
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Affiliation(s)
- Veronique Verhoeven
- Department of Primary and Interdisciplinary Care, University of Antwerp, Antwerpen, Belgium
| | - Giannoula Tsakitzidis
- Department of Primary and Interdisciplinary Care, University of Antwerp, Antwerpen, Belgium
| | - Hilde Philips
- Department of Primary and Interdisciplinary Care, University of Antwerp, Antwerpen, Belgium
| | - Paul Van Royen
- Department of Primary and Interdisciplinary Care, University of Antwerp, Antwerpen, Belgium
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Abstract
OBJECTIVE To identify the extent to which administrative tasks carried out by primary care staff in general practice could be automated. DESIGN A mixed-method design including ethnographic case studies, focus groups, interviews and an online survey of automation experts. SETTING Three urban and three rural general practice health centres in England selected for differences in list size and organisational characteristics. PARTICIPANTS Observation and interviews with 65 primary care staff in the following job roles: administrator, manager, general practitioner, healthcare assistant, nurse practitioner, pharmacy technician, phlebotomist, practice nurse, pharmacist, prescription clerk, receptionist, scanning clerk, secretary and medical summariser; together with a survey of 156 experts in automation technologies. METHODS 330 hours of ethnographic observation and documentation of administrative tasks carried out by staff in each of the above job roles, followed by coding and classification; semistructured interviews with 10 general practitioners and 6 staff focus groups. The online survey of machine learning, artificial intelligence and robotics experts was analysed using an ordinal Gaussian process prediction model to estimate the automatability of the observed tasks. RESULTS The model predicted that roughly 44% of administrative tasks carried out by staff in general practice are 'mostly' or 'completely' automatable using currently available technology. Discussions with practice staff underlined the need for a cautious approach to implementation. CONCLUSIONS There is considerable potential to extend the use of automation in primary care, but this will require careful implementation and ongoing evaluation.
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Affiliation(s)
- Matthew Willis
- Oxford Internet Institute, University of Oxford, Oxford, UK
- School of Information, University of Michigan, Ann Arbor, Michigan, USA
| | - Paul Duckworth
- Department of Engineering Science, University of Oxford, Oxford, UK
| | - Angela Coulter
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Eric T Meyer
- Oxford Internet Institute, University of Oxford, Oxford, UK
- School of Information, University of Texas at Austin, Austin, Texas, USA
| | - Michael Osborne
- Department of Engineering Science, University of Oxford, Oxford, UK
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Czerny E, Lepaux V. [General medicine theses supervised by GPS: New methods for new research topics]. Sante Publique 2020; 31:703-710. [PMID: 32372608 DOI: 10.3917/spub.195.0703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
INTRODUCTION This paper examines whether the development of general medicine as a specialty in France since the mid-2000s has had an impact on medical theses. It analyses the changes resulting from the discipline's autonomatization process, involving an investment in some human and social science methods.Purpose of research: In a diachronic approach, all dissertations defended in a general medicine department in 1999, 2007 and 2015 were analyzed (N = 291). We performed systematic coding of the types of methods used, the areas of research investigated, as well as the supervisors' areas of specialization. We used this coded data to develop a typology of research topics (using a hierarchic classification method based on the coordinates of a principal component analysis). RESULTS Over the period under study, we observed a complexification of medical theses, which increasingly addressed multi-dimensional research topics. We also noted the emergence of new types of subjects, dealing with the exercise of the specialty and close to social science concerns (on the practices and dispositions of healthcare actors). Qualitative methods have been used more and more often, as a result of the increase in the number of theses supervised by GPs. CONCLUSIONS The reform of general medicine has impacted the subjects treated and methods used in theses, and sheds light on the dynamics of the emergence of a new health research field.
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Sewell B, Jones M, Gray H, Wilkes H, Lloyd-Bennett C, Beddow K, Bevan M, Fitzsimmons D. Rapid cancer diagnosis for patients with vague symptoms: a cost-effectiveness study. Br J Gen Pract 2020; 70:e186-e192. [PMID: 31932296 PMCID: PMC6960004 DOI: 10.3399/bjgp20x708077] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 09/22/2019] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND A pilot rapid diagnosis centre (RDC) allows GPs within targeted clusters to refer adults with vague and/or non-specific symptoms suspicious of cancer, who do not meet criteria for referral under an urgent suspected cancer (USC) pathway, to a multidisciplinary RDC clinic where they are seen within 1 week. AIM To explore the cost-effectiveness of the RDC compared with standard clinical practice. DESIGN AND SETTING Cost-effectiveness modelling using routine data from Neath Port Talbot Hospital, Wales. METHOD Discrete-event simulation modelled a cohort of 1000 patients from referral to radiological diagnosis based on routine RDC and hospital data. Control patients were those referred to a USC pathway but then downgraded. Published sources provided estimates of patient quality of life (QoL) and pre-diagnosis anxiety. The model calculates time to diagnosis, costs, and quality-adjusted life years (QALYs), and estimates the probability of the RDC being a cost-effective strategy. RESULTS The RDC reduces mean time to diagnosis from 84.2 days in usual care to 5.9 days if a diagnosis is made at clinic, or 40.8 days if further investigations are booked during RDC. RDC provision is the superior strategy (that is, less costly and more effective) compared with standard clinical practice when run near or at full capacity. However, it is not cost-effective if capacity utilisation drops below 80%. CONCLUSION An RDC for patients presenting with vague or non-specific symptoms suspicious of cancer in primary care reduces time to diagnosis and provides excellent value for money if run at ≥80% capacity.
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Affiliation(s)
- Bernadette Sewell
- Swansea Centre for Health Economics, Swansea University, Swansea, Wales
| | - Mari Jones
- Swansea Centre for Health Economics, Swansea University, Swansea, Wales
| | | | - Heather Wilkes
- Dr Wilkes & Partners, Briton Ferry Health Centre, Swansea Bay University Health Board, Neath, Wales
| | | | - Kim Beddow
- Neath Port Talbot Hospital, Swansea Bay University Health Board, Neath, Port Talbot, Wales
| | - Martin Bevan
- Neath Port Talbot Hospital, Swansea Bay University Health Board, Neath, Port Talbot, Wales
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Heald A, Stedman M, Lunt M, Livingston M, Cortes G, Gadsby R. General practice (GP) level analysis shows that patients' own perceptions of support within primary care as reported in the GP patient survey (GPPS) are as important as medication and services in improving glycaemic control. Prim Care Diabetes 2020; 14:29-32. [PMID: 31133530 DOI: 10.1016/j.pcd.2019.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 04/25/2019] [Accepted: 04/26/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND The way that GP practices organize their services impacts as much on glycaemia in type 2 diabetes as does prescribing. AIM Our aim was to evaluate the link between patients' own perception of support within primary care and the % patients at each GP practice at target glycaemic control (TGC) and at high glycaemic risk (HGR). DESIGN AND SETTING Utilisation of National Diabetes Audit (NDA) available data combined with the General practitioner patient survey (GPPS). METHOD The NDA 2016_17 published data on numbers of type 2 patients, levels of local diabetes services and the target glycaemic control (TGC) % and high glycaemic risk (HGR) % achieved. The GPPS 2017 published % "No" responses from long term condition (LTC) patients to the question "In the last 6 months, had you enough support from local services or organisations to help manage LTCs?". Multivariate regression was used on the set of indicators capturing patients' demographics and services provided. RESULTS 6498 practices were included (with more than 2.5 million T2DM patients) and median values with band limits that included 95% practices for % "No" response to the question above was 12% (2%-30%), for TGC 67% (54%-78%) and for HGR 6% (2%-13%). The model accounted for 25% TGC variance and 26% HGR variance. The standardised β values shown as (TGC/HGR) (+=more people; -=less people) for older age (+0.24/-0.25), sulphonylurea use (-0.21/+0.14), greater social disadvantage (-0.09/+0.21), GPPS Support %No (-0.08/+0.12), %Completion 8 checks (+0.09/-0.12) and metformin use (+0.11/-0.05). CONCLUSION The relation between the person with diabetes and clinician in primary care is shown to be quantitatively potentially as important in influencing glycaemic outcome as the services provided and medication prescribed. We suggest that all of us in who work in the health care system can bear this in mind in our everyday work.
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Affiliation(s)
- Adrian Heald
- The School of Medicine and Manchester Academic Health Sciences Centre, University of Manchester, Manchester, United Kingdom; Department of Diabetes and Endocrinology, Salford Royal Hospital, Salford, United Kingdom.
| | - Mike Stedman
- Res Consortium, Andover, Hampshire, United Kingdom
| | - Mark Lunt
- The School of Medicine and Manchester Academic Health Sciences Centre, University of Manchester, Manchester, United Kingdom
| | - Mark Livingston
- Department of Blood Sciences, Walsall Manor Hospital, Walsall, United Kingdom
| | - Gabriela Cortes
- High Speciality Regional Hospital of Ixtapaluca, Mexico City, Mexico
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Armitage LC, Mahdi A, Lawson BK, Roman C, Fanshawe T, Tarassenko L, Farmer AJ, Watkinson PJ. Screening for Hypertension in the INpatient Environment(SHINE): a protocol for a prospective study of diagnostic accuracy among adult hospital patients. BMJ Open 2019; 9:e033792. [PMID: 31806616 PMCID: PMC6924759 DOI: 10.1136/bmjopen-2019-033792] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION A significant percentage of patients admitted to hospital have undiagnosed hypertension. However, present hypertension guidelines in the UK, Europe and USA do not define a blood pressure threshold at which hospital inpatients should be considered at risk of hypertension, outside of the emergency setting. The objective of this study is to identify the optimal in-hospital mean blood pressure threshold, above which patients should receive postdischarge blood pressure assessment in the community. METHODS AND ANALYSIS Screening for Hypertension in the INpatient Environment is a prospective diagnostic accuracy study. Patients admitted to hospital whose mean average daytime blood pressure after 24 hours or longer meets the study eligibility threshold for mean daytime blood pressure (≥120/70 mm Hg) and who have no prior diagnosis of, or medication for hypertension will be eligible. At 8 weeks postdischarge, recruited participants will wear an ambulatory blood pressure monitor for 24 hours. Mean daytime ambulatory blood pressure will be calculated to assess for the presence or absence of hypertension. Diagnostic performance of in-hospital blood pressure will be assessed by constructing receiver operator characteristic curves from participants' in-hospital mean systolic and mean diastolic blood pressure (index test) versus diagnosis of hypertension determined by mean daytime ambulatory blood pressure (reference test). ETHICS AND DISSEMINATION Ethical approval has been provided by the National Health Service Health Research Authority South Central-Oxford B Research Ethics Committee (19/SC/0026). Findings will be disseminated through national and international conferences, peer-reviewed journals and social media.
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Affiliation(s)
- Laura C Armitage
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Adam Mahdi
- Institute of Biomedical Engineering, Department of Engineering Science, University of Oxford, Oxford, Oxfordshire, UK
| | - Beth K Lawson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Cristian Roman
- Institute of Biomedical Engineering, Department of Engineering Science, University of Oxford, Oxford, Oxfordshire, UK
| | - Thomas Fanshawe
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Lionel Tarassenko
- Institute of Biomedical Engineering, Department of Engineering Science, University of Oxford, Oxford, Oxfordshire, UK
| | - Andrew J Farmer
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Peter J Watkinson
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
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Abstract
The use of telemedicine (TM) to deliver health care has been growing throughout the United States and internationally through asynchronous and synchronous technology. It has proven to be an effective way of delivering health care at a distance. There are multiple ways that a practice can offer these services, from direct-to-consumer to consultations in ambulatory or inpatient services. TM can be used to deliver care in homes, schools, and virtually anywhere that a patient and provider can access technology. For rural communities, emergency departments and inpatient specialty consults that were not available previously are now routine. TM also has been proven to be effective in decreasing costs to patients and increasing access in pediatrics while providing high degrees of satisfaction among patients and providers. [Pediatr Ann. 2019;48(12):e479-e484.].
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Forstner J, Kunz A, Straßner C, Uhlmann L, Kuemmel S, Szecsenyi J, Wensing M. Improving continuity of patient care across sectors: study protocol of the process evaluation of a quasi-experimental multi-centre study regarding an admission and discharge model in Germany (VESPEERA). BMJ Open 2019; 9:e031245. [PMID: 31722944 PMCID: PMC6858220 DOI: 10.1136/bmjopen-2019-031245] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Hospital stays are critical events as they often disrupt continuity of care. This process evaluation aims to describe and explore the implementation of the VESPEERA programme (Improving continuity of patient care across sectors: An admission and discharge model in general practices and hospitals, Versorgungskontinuitaet sichern: Patientenorientiertes Einweisungs- und Entlassmanagement in Hausarztpraxen und Krankenhauesern). The evaluation concerns the intervention fidelity, reach in targeted populations, perceived effects, working mechanisms, feasibility, determinants for implementation, including contextual factors, and associations with the outcomes evaluation. The aim of the VESPEERA programme is the development, implementation and evaluation of a structured admission and discharge programme in general practices and hospitals. METHODS AND ANALYSIS The process evaluation is linked to the VESPEERA outcomes evaluation, which has a quasi-experimental multi-centre design with four study arms and is conducted in hospitals and general practices in Germany. The VESPEERA programme comprises several components: an assessment before admission, an admission letter, a telephonic discharge conversation between hospital and general practice before discharge, discharge information for patients, structured planning of follow-up care after discharge in the general practice and a telephone monitoring for patients with a risk of rehospitalisation. The process evaluation has a mixed-methods design, incorporating interviews (patients, both care providers who do and do not participate in the VESPEERA programme, total n=75), questionnaires (patients and care providers who participate in the VESPEERA programme, total n=475), implementation plans of hospitals, data documented in general practices, claims-based data and hospital process data. Data analysis is descriptive and explorative. Qualitative data will be transcribed and analysed using framework analysis based on the Consolidated Framework for Implementation Research. Associations between the outcomes of the program and measures in the process evaluation will be explored in regression models. ETHICS AND DISSEMINATION Ethics approval has been obtained by the ethics committee of the Medical Faculty Heidelberg prior to the start of the study (S-352/2018). Results will be disseminated through a final report to the funding agency, articles in peer-reviewed journals and conferences. TRIAL REGISTRATION NUMBER http://www.drks.de/DRKS00015183. TRIAL STATUS The study protocol on hand is the protocol V.1.1 from 18 June 2018. Recruitment for interviews started on 3 September 2018 and will approximately be completed by the end of May 2019.
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Affiliation(s)
- Johanna Forstner
- Department of General Practice and Health Services Research, Heidelberg University, Heidelberg, Germany
| | - Aline Kunz
- Department of General Practice and Health Services Research, Heidelberg University, Heidelberg, Germany
| | - Cornelia Straßner
- Department of General Practice and Health Services Research, Heidelberg University, Heidelberg, Germany
| | - Lorenz Uhlmann
- Institute of Medical Biometry and Informatics, Heidelberg University, Heidelberg, Germany
| | | | - Joachim Szecsenyi
- Department of General Practice and Health Services Research, Heidelberg University, Heidelberg, Germany
| | - Michel Wensing
- Department of General Practice and Health Services Research, Heidelberg University, Heidelberg, Germany
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Roberts S, Eaton S, Finch T, Lewis-Barned N, Lhussier M, Oliver L, Rapley T, Temple-Scott D. The Year of Care approach: developing a model and delivery programme for care and support planning in long term conditions within general practice. BMC Fam Pract 2019; 20:153. [PMID: 31703620 PMCID: PMC6839214 DOI: 10.1186/s12875-019-1042-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 10/24/2019] [Indexed: 11/10/2022]
Abstract
BACKGROUND People with long term conditions (LTCs) make most of the daily decisions and carry out the activities which affect their health and quality of life. Only a fraction of each contact with a health care professional (HCP) is spent supporting this. This paper describes how care and support planning (CSP) and an implementation framework to redesign services, were developed to address this in UK general practice. Focussed on what is important to each individual, CSP brings together traditional clinical issues and the person's lived experience in a solution focussed, forward looking conversation with an emphasis on 'people not diseases'. METHODS The components of CSP were developed in three health communities using diabetes as an exemplar. This model was extended and refined for other single conditions and multimorbidity across 40 sites and two nations, over 15 years. Working with local teams and communities the authors used theoretical models of care, implementation and spread, developing and tailoring training, support and resources to embed CSP as usual care, sharing learning across a community of practice. RESULTS The purpose, content, process, developmental hurdles and impact of this CSP model are described, alongside an implementation strategy. There is now a robust, reproducible five step model; preparation, conversation, recording, actions and review. Uniquely, preparation, involving information sharing with time for reflection, enables an uncluttered conversation with a professional focussed on what is important to each person. The components of the Year of Care House act as a checklist for implementation, a metaphor for their interdependence and a flexible framework. Spreading CSP involved developing exemplar practices and building capacity across local health communities. These reported improved patient experience, practitioner job satisfaction, health behaviours and outcomes, teamwork, practice organisation, resource use, and links with wider community activities. CONCLUSIONS Tested in multiple settings, CSP is a reproducible and practical model of planned care applicable to all LTCs, with the capacity to be transformative for people with LTCs and health care professionals. It recaptures relational dimensions of care with transactional elements in the background. Options for applying this model and implementation framework at scale now need to be explored.
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Affiliation(s)
- Sue Roberts
- Year of Care Partnerships, Northumbria Healthcare NHS Foundation Trust, Wansbeck Hospital, Ashington, Northumberland, NE63 9JJ, England.
| | - Simon Eaton
- Year of Care Partnerships, Northumbria Healthcare NHS Foundation Trust, Wansbeck Hospital, Ashington, Northumberland, NE63 9JJ, England
| | - Tracy Finch
- Northumbria University, Coach Lane Campus, Benton, Newcastle upon Tyne, NE7 7XA, England
| | - Nick Lewis-Barned
- Year of Care Partnerships, Northumbria Healthcare NHS Foundation Trust, Wansbeck Hospital, Ashington, Northumberland, NE63 9JJ, England
| | - Monique Lhussier
- Northumbria University, Coach Lane Campus, Benton, Newcastle upon Tyne, NE7 7XA, England
| | - Lindsay Oliver
- Year of Care Partnerships, Northumbria Healthcare NHS Foundation Trust, Wansbeck Hospital, Ashington, Northumberland, NE63 9JJ, England
| | - Tim Rapley
- Northumbria University, Coach Lane Campus, Benton, Newcastle upon Tyne, NE7 7XA, England
| | - Dawn Temple-Scott
- Year of Care Partnerships, Northumbria Healthcare NHS Foundation Trust, Wansbeck Hospital, Ashington, Northumberland, NE63 9JJ, England
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Walker AJ, Pretis F, Powell-Smith A, Goldacre B. Variation in responsiveness to warranted behaviour change among NHS clinicians: novel implementation of change detection methods in longitudinal prescribing data. BMJ 2019; 367:l5205. [PMID: 31578187 PMCID: PMC6771379 DOI: 10.1136/bmj.l5205] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES To determine how clinicians vary in their response to new guidance on existing or new interventions, by measuring the timing and magnitude of change at healthcare institutions. DESIGN Automated change detection in longitudinal prescribing data. SETTING Prescribing data in English primary care. PARTICIPANTS English general practices. MAIN OUTCOME MEASURES In each practice the following were measured: the timing of the largest changes, steepness of the change slope (change in proportion per month), and magnitude of the change for two example time series (expiry of the Cerazette patent in 2012, leading to cheaper generic desogestrel alternatives becoming available; and a change in antibiotic prescribing guidelines after 2014, favouring nitrofurantoin over trimethoprim for uncomplicated urinary tract infection (UTI)). RESULTS Substantial heterogeneity was found between institutions in both timing and steepness of change. The range of time delay before a change was implemented was large (interquartile range 2-14 months (median 8) for Cerazette, and 5-29 months (18) for UTI). Substantial heterogeneity was also seen in slope following a detected change (interquartile range 2-28% absolute reduction per month (median 9%) for Cerazette, and 1-8% (2%) for UTI). When changes were implemented, the magnitude of change showed substantially less heterogeneity (interquartile range 44-85% (median 66%) for Cerazette and 28-47% (38%) for UTI). CONCLUSIONS Substantial variation was observed in the speed with which individual NHS general practices responded to warranted changes in clinical practice. Changes in prescribing behaviour were detected automatically and robustly. Detection of structural breaks using indicator saturation methods opens up new opportunities to improve patient care through audit and feedback by moving away from cross sectional analyses, and automatically identifying institutions that respond rapidly, or slowly, to warranted changes in clinical practice.
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Affiliation(s)
- Alex J Walker
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Oxford OX2 6GG, UK
| | - Felix Pretis
- Department of Economics, University of Victoria, Victoria, BC, Canada
- Institute for New Economic Thinking, Oxford Martin School, University of Oxford, Oxford, UK
| | - Anna Powell-Smith
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Oxford OX2 6GG, UK
| | - Ben Goldacre
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Oxford OX2 6GG, UK
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Forbes LJ, Forbes H, Sutton M, Checkland K, Peckham S. How widespread is working at scale in English general practice? An observational study. Br J Gen Pract 2019; 69:e682-e688. [PMID: 31501167 PMCID: PMC6733587 DOI: 10.3399/bjgp19x705533] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Accepted: 04/16/2019] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Over the last 5 years, national policy has encouraged general practices to serve populations of >30 000 people (called 'working at scale') by collaborating with other practices. AIM To describe the number of English general practices working at scale, and their patient populations. DESIGN AND SETTING Observational study of general practices in England. METHOD Data published by the NHS on practices' self-reports of working in groups were supplemented with data from reports by various organisations and practice group websites. Practices were categorised by the extent to which they were working at scale; within these categories, the age distribution of the practice population, level of socioeconomic deprivation, rurality, and prevalence of longstanding illness were then examined. RESULTS Approximately 55% of English practices (serving 33.5 million patients) were working at scale, individually or collectively serving populations of >30 000 people. Organisational models representing close collaboration for the purposes of core general practice services were identifiable for approximately 5% of practices; these comprised large practices, superpartnerships, and multisite organisations. Approximately 50% of practices were working in looser forms of collaboration, focusing on services beyond core general practice; for example, primary care in the evenings and at weekends. Data on organisational models and the purpose of the collaboration were very limited for this group. CONCLUSION In early 2018, approximately 5% of general practices were working closely at scale; approximately half of practices were working more loosely at scale. However, data were incomplete. Better records of what is happening at practice level should be collected so that the effect of working at scale on patient care can be evaluated.
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Affiliation(s)
- Lindsay Jl Forbes
- Centre for Health Services Studies, University of Kent at Canterbury, Canterbury
| | - Hannah Forbes
- Division of Population Health, Health Services Research & Primary Care, University of Manchester, Manchester
| | - Matt Sutton
- Division of Population Health, Health Services Research & Primary Care, University of Manchester, Manchester
| | - Katherine Checkland
- Division of Population Health, Health Services Research & Primary Care, University of Manchester, Manchester
| | - Stephen Peckham
- Centre for Health Services Studies, University of Kent at Canterbury, Canterbury
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Kamstrup-Larsen N, Dalton SO, Grønbæk M, Broholm-Jørgensen M, Thomsen JL, Larsen LB, Johansen C, Tolstrup J. The effectiveness of general practice-based health checks on health behaviour and incidence on non-communicable diseases in individuals with low socioeconomic position: a randomised controlled trial in Denmark. BMJ Open 2019; 9:e029180. [PMID: 31537563 PMCID: PMC6756442 DOI: 10.1136/bmjopen-2019-029180] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The effectiveness of health checks aimed at the general population is disputable. However, it is not clear whether health checks aimed at certain groups at high risk may reduce adverse health behaviour and identify persons with metabolic risk factors and non-communicable diseases (NCDs). OBJECTIVES To assess the effect of general practice-based health checks on health behaviour and incidence on NCDs in individuals with low socioeconomic position. METHODS Individuals with no formal education beyond lower secondary school and aged 45-64 years were randomly assigned to the intervention group of a preventive health check or to control group of usual care in a 1:1 allocation. Randomisation was stratified by gender and 5-year age group. Due to the real-life setting, blinding of participants was only possible in the control group. Effects were analysed as intention to treat (ITT) and per protocol. The trial was undertaken in 32 general practice units in Copenhagen, Denmark. INTERVENTION Invitation to a prescheduled preventive health check from the general practitioner (GP) followed by a health consultation and an offer of follow-up with health risk behaviour change or preventive medical treatment, if necessary. PRIMARY OUTCOME MEASURES Smoking status at 12-month follow-up. Secondary outcomes included status in other health behaviours such as alcohol consumption, physical activity and body mass index (measured by self-administered questionnaire), as well as incidence of metabolic risk factors and NCDs such as hypertension, hypercholesterolaemia, chronic obstructive pulmonary disease, diabetes mellitus, hypothyroidism, hyperthyroidism and depression (drawn from national healthcare registries). RESULTS 1104 participants were included in the study. For the primary outcome, 710 participants were included in the per protocol analysis, excluding individuals who did not attend the health check, and 1104 participants were included in the ITT analysis. At 12-month follow-up, 37% were daily smokers in the intervention group and 37% in the control group (ORs=0.99, 95% CI: 0.76 to 1.30). No difference in health behaviour nor in the incidence of metabolic risk factors and NCDs between the intervention and control group were found. Side effects were comparable across the two groups. CONCLUSION The lack of effectiveness may be due to low intensity of intervention, a high prevalence of metabolic risk factors and NCDs among the participants at baseline as well as a high number of contacts with the GPs in general or to the fact that general practices are not an effective setting for prevention. TRIAL REGISTRATION NUMBER NCT01979107.
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Affiliation(s)
- Nina Kamstrup-Larsen
- National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
| | - Susanne Oksbjerg Dalton
- Survivorship Research Unit, Danish Cancer Society, Copenhagen, Denmark
- Department of Clinical Oncology and Palliative Care, Zealand University Hospital, Naestved, Denmark
| | - Morten Grønbæk
- National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
| | | | - Janus Laust Thomsen
- Research Unit for General Practice in Aalborg, Department of Clinical Medicine, Aalborg University Hospital, Aalborg, Denmark
| | - Lars Bruun Larsen
- Research Unit of General Practice in Odense, University of Southern Denmark, Odense, Denmark
| | - Christoffer Johansen
- Survivorship Research Unit, Danish Cancer Society, Copenhagen, Denmark
- Late Effect Research Unit CASTLE, Finsen Center, Rigshospitalet, Copenhagen, Denmark
| | - Janne Tolstrup
- National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
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Heald A, Davies M, Stedman M, Livingston M, Lunt M, Fryer A, Gadsby R. Analysis of English general practice level data linking medication levels, service activity and demography to levels of glycaemic control being achieved in type 2 diabetes to improve clinical practice and patient outcomes. BMJ Open 2019; 9:e028278. [PMID: 31494602 PMCID: PMC6731821 DOI: 10.1136/bmjopen-2018-028278] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE Evaluate relative clinical effectiveness of treatment options for type 2 diabetes mellitus (T2DM) using a statistical model of real-world evidence within UK general practitioner practices (GPP), to quantify the opportunities for diabetes care performance improvement. METHOD From the National Diabetes Audit in 2015-2016 and 2016-2017, GPP target glycaemic control (TGC-%HbA1c ≤58 mmol/mol) and higher glycaemic risk (HGR -%HbA1c results >86 mmol/mol) outcomes were linked using multivariate linear regression to prescribing, demographics and practice service indicators. This was carried out both cross-sectionally (XS) (within year) and longitudinally (Lo) (across years) on 35 indicators. Standardised β coefficients were used to show relative level of impact of each factor. Improvement opportunity was calculated as impact on TGC & HGR numbers. RESULTS Values from 6525 GPP with 2.7 million T2DM individuals were included. The cross-sectional model accounted for up to 28% TGC variance and 35% HGR variance, and the longitudinal model accounted for up to 9% TGC and 17% HGR variance. Practice service indicators including % achieving routine checks/blood pressure/cholesterol control targets were positively correlated, while demographic indicators including % younger age/social deprivation/white ethnicity were negatively correlated. The β values for selected molecules are shown as (increased TGC; decreased HGR), canagliflozin (XS 0.07;0.145/Lo 0.04;0.07), metformin (XS 0.12;0.04/Lo -;-), sitagliptin (XS 0.06;0.02/Lo 0.10;0.06), empagliflozin (XS-;0.07/Lo 0.09;0.07), dapagliflozin (XS -;0.04/Lo -;0.4), sulphonylurea (XS -0.18;-0.12/Lo-;-) and insulin (XS-0.14;0.02/ Lo-0.09;-). Moving all GPP prescribing and interventions to the equivalent of the top performing decile of GPP could result in total patients in TGC increasing from 1.90 million to 2.14 million, and total HGR falling from 191 000 to 123 000. CONCLUSIONS GPP using more legacy therapies such as sulphonylurea/insulin demonstrate poorer outcomes, while those applying holistic patient management/use of newer molecules demonstrate improved glycaemic outcomes. If all GPP moved service levels/prescribing to those of the top decile, both TGC/HGR could be substantially improved.
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Affiliation(s)
- Adrian Heald
- Department of Diabetes and Endocrinology, Salford Royal NHS Foundation Trust, Salford, UK
- The School of Medicine and Manchester Academic Health Sciences Centre, The University of Manchester, Manchester, UK
| | | | | | - Mark Livingston
- Clinical Biochemistry, Walsall Healthcare NHS Trust, Walsall, UK
| | - Mark Lunt
- The School of Medicine and Manchester Academic Health Sciences Centre, The University of Manchester, Manchester, UK
| | - Anthony Fryer
- Clinical Biochemistry, University Hospitals of North Midlands, Stoke on Trent, Staffordshire, UK
| | - Roger Gadsby
- Warwick Medical School, University of Warwick, Coventry, UK
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Tönnies J, Hartmann M, Wensing M, Szecsenyi J, Icks A, Friederich HC, Haun MW. Mental health specialist video consultations for patients with depression or anxiety disorders in primary care: protocol for a randomised controlled feasibility trial. BMJ Open 2019; 9:e030003. [PMID: 31488484 PMCID: PMC6731787 DOI: 10.1136/bmjopen-2019-030003] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION Most people suffering from depression and anxiety disorders are entirely treated in primary care. Due to growing challenges in ageing societies, for example, patients' immobility and multimorbidity, the transition to specialised care becomes increasingly difficult. Although the co-location of general practitioners and mental health specialists improves the access to psychosocial care, integrated in-person approaches are not practical for rural and single-doctor practices with limited personnel and financial resources. Treating primary care patients via internet-based video consultations by remotely located mental health specialists bears the potential to overcome structural barriers and provide low-threshold care. The aim of this randomised controlled feasibility trial is to investigate the feasibility of implementing of mental health specialist video consultations in primary care practices. METHODS AND ANALYSIS Fifty primary care patients with significant depression and/or anxiety symptomatology will be randomised in two groups receiving either the treatment as usual as provided by their general practitioner or up to five video consultations conducted by a mental health specialist. The video consultations focus on (1) systematic diagnosis plus proactive monitoring using validated clinical rating scales, (2) the establishment of an effective working alliance and (3) a stepped-care algorithm within integrated care adjusting treatments based on clinical outcomes. We will investigate the following outcomes: effectiveness of the recruitment strategies, patient acceptance of randomisation, practicability of the technical and logistical processes related to implementing video consultations in the practices' workflows, feasibility of the data collection and clinical parameters. ETHICS AND DISSEMINATION This trial has undergone ethical scrutiny and has been approved by the Medical Faculty of the University of Heidelberg Ethics Committee (S-634/2018). The findings will be disseminated to the research community through presentations at conferences and publications in scientific journals. This feasibility trial will prepare the ground for a large-scale, fully powered randomised controlled trial. TRIAL REGISTRATION NUMBER DRKS00015812.
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Affiliation(s)
- Justus Tönnies
- Department of General Internal Medicine and Psychosomatics, Heidelberg University, Heidelberg, Germany
| | - Mechthild Hartmann
- Department of General Internal Medicine and Psychosomatics, Heidelberg University, Heidelberg, Germany
| | - Michel Wensing
- Department of General Practice and Health Services Research, Heidelberg University, Heidelberg, Germany
| | - Joachim Szecsenyi
- Department of General Practice and Health Services Research, Heidelberg University, Heidelberg, Germany
| | - Andrea Icks
- Institute of Health Services Research and Health Economics, Heinrich Heine University, Düsseldorf, Germany
- Institute for Health Services Research and Health Economics, German Diabetes Center (DDZ), Leibniz Institute for Diabetes Research at Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Hans-Christoph Friederich
- Department of General Internal Medicine and Psychosomatics, Heidelberg University, Heidelberg, Germany
| | - Markus W Haun
- Department of General Internal Medicine and Psychosomatics, Heidelberg University, Heidelberg, Germany
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Kvamme MF, Wang CEA, Waage T, Risør MB. Careful expressions of social aspects: How local professionals in high school settings, municipal services, and general practice communicate care to youth presenting persistent bodily complaints. Health Soc Care Community 2019; 27:1175-1184. [PMID: 30969453 DOI: 10.1111/hsc.12762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 02/21/2019] [Accepted: 03/13/2019] [Indexed: 06/09/2023]
Abstract
Persistent health complaints pose communicative dilemmas in care encounters, adversely affecting patient experiences and pathways. Little is known about the impact and role of professionals in encounters with young people with incipient, debilitating, and persistent symptoms. This study aims to explore communicative dilemmas and the role of language in care provided by local professionals in high school settings, municipal services, and general practice to young people presenting persistent bodily complaints. The study is based on in-depth individual interviews conducted from April to July 2016 with 12 professionals identified and selected during anthropological multi-sited fieldwork in a Norwegian community. We identify two modalities of what we have chosen to call 'careful expression', used as strategies across professions to overcome communicative dilemmas. Professionals reflexively and pragmatically negotiated with the powers of language to influence illness experience and to enact empowered young subjects. These insights may prove relevant for future studies of care encounters while also indicating a critical attitude to institutional logics that affect care responses.
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Affiliation(s)
- Maria F Kvamme
- Department of Community Medicine, General Practice Research Unit, Faculty of Health Sciences, UiT The Arctic University of Norway, Tromsø, Norway
| | - Catharina E A Wang
- Department of Psychology, Faculty of Health Sciences, UiT The Arctic University of Norway, Tromsø, Norway
| | - Trond Waage
- Department of Social Sciences, Visual Cultural Studies, UiT The Arctic University of Norway, Tromsø, Norway
| | - Mette B Risør
- Department of Community Medicine, General Practice Research Unit, Faculty of Health Sciences, UiT The Arctic University of Norway, Tromsø, Norway
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Abstract
This viewpoint outlines a brief history of primary care health reforms over the last 25 years, and how this history has influenced the business of caring. It also suggests where we should next look to improve the provision of equitable patient-centred care in the current climate of fiscal constraint, while meeting the challenges of an ageing population and increasing multimorbidity.
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Lewis NV, Dowrick A, Sohal A, Feder G, Griffiths C. Implementation of the Identification and Referral to Improve Safety programme for patients with experience of domestic violence and abuse: A theory-based mixed-method process evaluation. Health Soc Care Community 2019; 27:e298-e312. [PMID: 30868711 PMCID: PMC6617800 DOI: 10.1111/hsc.12733] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 01/14/2019] [Accepted: 02/11/2019] [Indexed: 06/09/2023]
Abstract
Identification and Referral to Improve Safety (IRIS) is a training and support programme to improve the response to domestic violence and abuse (DVA) in general practice. Following a pragmatic cluster-randomised trial, IRIS has been implemented in over 30 administrative localities in the UK. The trial and local evaluations of the IRIS implementation showed an increase in referrals from general practice to third sector DVA services with a variation in the referral rates within and across practices. Using Normalisation Process Theory (NPT), we aimed to understand the reasons for such variability by identifying factors that influenced the implementation of IRIS in the National Health Service (NHS). We conducted a mixed-method process evaluation which included: (a) a case study (100 hr of participant observation, 19 interviews); (b) a survey (n = 118); (c) qualitative analysis of free-text comments from the survey; (d) qualitative interviews (n = 8); (e) document review (n = 44). Data were collected from NHS and third sector staff across five London boroughs from August 2015 to December 2017, analysed descriptively and thematically and triangulated using the NPT constructs coherence, cognitive participation, collection action and reflexive monitoring. The survey showed wide variation in the extent to which practice staff saw IRIS as a normal part of their daily work. Qualitative data and documents illuminated drivers of DVA work, implementation barriers and suggested solutions. The drivers were related to individual professional's characteristics and relationships. The barriers were linked to the differing sense-making and legitimisation of DVA work and differing contexts between the NHS and third sector. Solutions were adaptations to IRIS relative to these contextual differences. The suggested solutions can be used to update IRIS commissioning guidance, training for trainers and training for general practice. The updates should reflect the importance of ongoing support of IRIS from practice leads and commissioners, extended funding periods for IRIS and continuity of the IRIS team.
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Affiliation(s)
- Natalia V. Lewis
- Centre for Primary Care and Public HealthQueen Mary University of LondonLondonUK
- Centre for Academic Primary Care, Bristol Medical School, University of BristolBristolUK
| | - Anna Dowrick
- Centre for Primary Care and Public HealthQueen Mary University of LondonLondonUK
| | - Alex Sohal
- Centre for Primary Care and Public HealthQueen Mary University of LondonLondonUK
| | - Gene Feder
- Centre for Academic Primary Care, Bristol Medical School, University of BristolBristolUK
| | - Chris Griffiths
- Centre for Primary Care and Public HealthQueen Mary University of LondonLondonUK
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van Braak M, Visser M, Holtrop M, Statius Muller I, Bont J, van Dijk N. What motivates general practitioners to change practice behaviour? A qualitative study of audit and feedback group sessions in Dutch general practice. BMJ Open 2019; 9:e025286. [PMID: 31154299 PMCID: PMC6549704 DOI: 10.1136/bmjopen-2018-025286] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Adopting an attributional perspective, the current article investigates how audit and feedback group sessions contribute to general practitioners' (GPs) motivation to change their practice behaviour to improve care. We focus on the contributions of the audit and feedback itself (content) and the group discussion (process). METHODS Four focus groups, comprising a total of 39 participating Dutch GPs, discussed and compared audit and feedback of their practices. The focus groups were analysed thematically. RESULTS Audit and feedback contributed to GPs' motivation to change in two ways: by raising awareness about aspects of their current care practice and by providing indications of the possible impact of change. For these contributions to play out, the audit and feedback should be reliable and valid, specific, recent and recurrent and concern GPs' own practices or practices within their own influence sphere. Care behaviour attributed to external, uncontrollable or unstable causes would not induce change. The added value of the group is twofold as well: group discussion contributed to GPs' motivation to change by providing a frame of reference and by affording insights that participants would not have been able to achieve on their own. CONCLUSIONS In audit and feedback group sessions, both audit and feedback information and group discussion can valuably contribute to GPs' motivation to change care practice behaviour. Peer interaction can positively contribute to explore alternative practices and avenues for improvement. Local or regional peer meetings would be beneficial in facilitating reflection and discussion. An important avenue for future studies is to explore the contribution of audit and feedback and small-group discussion to actual practice change.
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Affiliation(s)
- Marije van Braak
- General Practice, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Mechteld Visser
- General Practice, Amsterdam University Medical Centre, Amsterdam, The Netherlands
| | - Marije Holtrop
- General Practitioners Holtrop and Sieben, Amsterdam, The Netherlands
| | | | - Jettie Bont
- General Practice, Amsterdam University Medical Centre, Amsterdam, The Netherlands
| | - Nynke van Dijk
- General Practice, Amsterdam University Medical Centre, Amsterdam, The Netherlands
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Abstract
Digital healthcare provision in England has been driven mainly by a 'top-down' approach and a focus on digital infrastructure rather than front-line delivery. This has laid the foundation, but digital care delivery still has a long way to go. This article describes an action learning programme to create digitally ready nurses. The programme, which underpins action six of NHS England's ten-point plan for general practice nursing, shows that a 'ground-up' approach to upskill and empower front-line clinicians is central to embedding technology-enabled care services (TECS). Following completion of the action learning sets (ALSs), 24 general practice nursing digital champions across Staffordshire have used TECS to deliver a range of benefits for their practice teams. This has informed the introduction and extension of the programme, with national funding for a further 12 regional pilot ALSs across England in 2018-19. Importantly, the active learning individualised approach provides a digitally ready workforce with the ability and support to adopt TECS in areas of clinical need. This ability is central to the next stage in the digital transformation of healthcare.
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Affiliation(s)
- Paul Beaney
- Keele University, Keele, Staffordshire, England
| | - Rachel Hatfield
- NHS Stoke-on-Trent Clinical Commissioning Group, Stoke-on-Trent, England
| | - Ann Hughes
- NHS North Staffordshire Clinical Commissioning Group, Stoke-on-Trent, England
| | - Marc Schmid
- Redmoor Health, Preston, Lancashire, England
| | - Ruth Chambers
- Keele University, NHS Stoke-on-Trent Clinical Commissioning Group, Stoke-on-Trent, England
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