Development of the Brief Geriatric Assessment for the General Practitioner

OBJECTIVES

The study aimed to develop a brief geriatric assessment (BGA) tool for the general practitioner to evaluate geriatric syndromes in community-dwelling older adults.

DESIGN

A cross-sectional study.

SETTING

58 communities from four aging cities in Taiwan.

PARTICIPANTS

1,258 community-dwelling older adults aged 65 years and above.

MEASUREMENTS

The BGA targeted physical function impairment, cognitive impairment, and mood impairment. The cutoff values of physical function tests (handgrip strength and 6-meter walk test [6MWT]) were estimated by receiver operating characteristic analysis. Second, the diagnostic validity of the BGA was calculated in terms of sensitivity, specificity, and predictive values, which were compared to corresponding comprehensive geriatric assessment (CGA) items. Third, the associated risk factors of geriatric syndromes were selected using stepwise logistic regression. Finally, we combined items selected from literature and CGA and then proposed a practical BGA framework.

RESULTS

The proposed BGA comprised dominant handgrip strength, 6MWT, self-report personal birthday, address, and telephone number, question 'Do you have depressive mood for the past two weeks?', Rinne tuning-fork tests, Snellen scale, and body mass index. It evaluated multidimensional aspects of geriatrics syndromes including physical, cognitive, mood, and sensory impairment, sarcopenia, and nutrition status. Sensitivities in the Taiwan BGA items ranged from 48% for dominant handgrip strength to 97.6% for 6MWT corresponding to physical impairment; 58.3% for cognitive impairment corresponding to Short Portable Mental Status Questionnaire; 62.7% for mood impairment corresponding to Geriatric Depression Scale. The Taiwan BGA for the general practitioner takes less than 10 minutes and is suitable in the community setting.

CONCLUSION

Early management of geriatric syndromes in the community is important. The current study demonstrated a practical BGA tool for the general practitioner to comprehensively assess geriatric syndromes in community-dwelling older adults.

Diagnosis, treatment, and follow-up of heart failure patients by general practitioners: A Delphi consensus statement

Aims

Creation of an algorithm that includes the most important parameters (history, clinical parameters, and anamnesis) that can be linked to heart failure, helping general practitioners in recognizing heart failure in an early stage and in a better follow-up of the patients.

Methods and results

The algorithm was created using a consensus-based Delphi panel technique with fifteen general practitioners and seven cardiologists from Belgium. The method comprises three iterations with general statements on diagnosis, referral and treatment, and follow-up. Consensus was obtained for the majority of statements related to diagnosis, referral, and follow-up, whereas a lack of consensus was seen for treatment statements. Based on the statements with good and perfect consensus, an algorithm for general practitioners was assembled, helping them in diagnoses and follow-up of heart failure patients. The diagnosis should be based on three essential pillars, i.e. medical history, anamnesis and clinical examination. In case of suspected heart failure, blood analysis, including the measurement of NT-proBNP levels, can already be performed by the general practitioner followed by referral to the cardiologist who is then responsible for proper diagnosis and initiation of treatment. Afterwards, a multidisciplinary health care process between the cardiologist and the general practitioner is crucial with an important role for the general practitioner who has a key role in the up-titration of heart failure medication, down-titration of the dose of diuretics and to assure drug compliance.

Conclusions

Based on the consensus levels of statements in a Delphi panel setting, an algorithm is created to help general practitioners in the diagnosis and follow-up of heart failure patients.

General practitioners' knowledge of and attitudes towards prescribing psychoactive drugs in dementia care: a cross-sectional questionnaire study

Background

Despite their adverse effects, antipsychotics are frequently prescribed to manage behavioural and psychological symptoms of dementia (BPSD). At present, we do not have a good understanding of general practitioners’ (GPs) current management of BPSD.

Aims

To explore the knowledge, attitudes, and opinions of GPs regarding the prescribing of psychoactive drugs in managing BPSD.

Methods

This was a descriptive cross-sectional study. A questionnaire was adapted from a previous study and piloted with three GPs and was posted to a census sample of all GPs working in counties Cork and Kerry, Ireland. We collected and analysed both quantitative and qualitative data.

Results

Of the 456 eligible GPs who received the questionnaire, 168 GPs returned completed questionnaires (response rate 36.8%). All respondents (100%, 168/168) believed that antipsychotics did not benefit all patients with BPSD. The majority of GPs (69%, 116/168) routinely recommended non-pharmacological interventions before medication to manage BPSD. Most GPs (60.7%, 102/168) welcomed more training and experience to improve their management of BPSD. The qualitative comments provided by GPs described a pressure to prescribe from nursing home staff. GPs highlighted that the management of BPSD is difficult in daily practice and felt that antipsychotics still have a role to play.

Conclusions

This study identified several factors influencing the prescription of antipsychotics for patients with BPSD as well as the prescribing dilemmas faced by GPs in their daily practice. These findings can be used to guide future interventions aimed at reducing inappropriate prescribing in dementia care.

Electronic supplementary material

The online version of this article (10.1007/s11845-020-02356-7) contains supplementary material, which is available to authorized users.

Impact on guidelines: The general practitioner point of view

Primary care physicians are uniquely placed to offer holistic, patient-centred care to patients with T2DM. While the recent FDA-mandated cardiovascular outcome trials offer a wealth of data to inform treatment discussions, they have also contributed to increasing complexity in treatment decisions, and in the guidelines that seek to assist in making these decisions. To assist physicians in avoiding treatment inertia, Primary Care Diabetes Europe has formulated a position statement that summarises our current understanding of the available T2DM treatment options in various patient populations. New data from recent outcomes trials is contextualised and summarised for the primary care physician. This consensus paper also proposes a unique and simple tool to stratify patients into 'very high' and 'high' cardiovascular risk categories and outlines treatment recommendations for patients with atherosclerotic cardiovascular disease, heart failure and chronic kidney disease. Special consideration is given to elderly/frail patients and those with obesity. A visual patient assessment tool is provided, and a comprehensive set of prescribing tips is presented for all available classes of glucose-lowering therapies. This position statement will complement the already available, often specialist-focused, T2DM treatment guidelines and provide greater direction in how the wealth of outcome trial data can be applied to everyday practice.

Diagnosis of Cutaneous Melanoma: the Gap Between the Knowledge of General Practitioners and Dermatologists in a Brazilian Population

The early diagnosis of cutaneous melanoma provides less aggressive treatment reducing mortality. General practitioners are responsible for cancer diagnoses in the Brazilian Public Health System and therefore play a crucial role in the prevention and early detection of melanoma. To assess the melanoma knowledge of a primary healthcare physician, the general practitioner, compared to a dermatologist. General practitioners and dermatologists answered a questionnaire about melanoma and the management of suspected cases. The results of both groups were compared. The sample consisted of 80 specialists and 160 general practitioners. When asked about the "ABCDE" rule, 96.2% of the dermatologists knew about it, compared to 34.4% of the general practitioners. The percentage of dermatologists who examined the whole skin of the patient at high risk for melanoma was 90% vs. 24.5% amongst general practitioners. The most cited reasons for the absence of the examination of patients at risk for melanoma were lack of time at the consultations (17.6% specialists, 66.1% generalists) and an excessive number of patients (17.6% specialists, 61.5% generalists). General practitioner has less knowledge about melanoma compared to the dermatologists and presents deficient behaviors about patients at risk or who have suspicious lesions, indicating the need for training and continuing education.

Diagnosing and providing initial management for patients with Gestational Diabetes: What is the General Practitioner's experience?

AIM

This study explores the General Practice (GP) experience of Gestational Diabetes Mellitus (GDM). Much has been written about patient perspectives, yet little is known about the GP perspective at initial diagnosis and management. GDM is increasingly managed in the secondary and tertiary sector, the confidence of GPs and their role in ongoing care has not been examined. Given GDM's poor follow up rates, all aspects of the patient journey warrant close examination.

METHODS

Through purposive and snowball sampling, we conducted semi-structured interviews with GPs in Brisbane, Australia between April and October 2018. Data collection, until saturation, and analysis were concurrent, and the Leximancer analysis tool assisted with content analysis and suggestion of themes.

RESULTS

Dominant themes include uncertainty/urgency and feeling under-utilised. GPs have a pragmatic approach in the face of uncertainty, and adopt one of several strategies to meet patient needs. A key issue that may impact on long term follow up and high quality GP-patient relationships is concern about the patient being 'taken away' by the hospital. Communication with the hospital is generally perceived as poor.

CONCLUSIONS

The experience of GPs in the initial diagnosis and management of GDM may assist in improving GDM follow up.

Adoption and Performance of Complementary Clinical Information Technologies: Analysis of a Survey of General Practitioners

Background

The benefits from the combination of 4 clinical information systems (CISs)—electronic health records (EHRs), health information exchange (HIE), personal health records (PHRs), and telehealth—in primary care depend on the configuration of their functional capabilities available to clinicians. However, our empirical knowledge of these configurations and their associated performance implications is very limited because they have mostly been studied in isolation.

Objective

This study aims to pursue 3 objectives: (1) characterize general practitioners (GPs) by uncovering the typical profiles of combinations of 4 major CIS capabilities, (2) identify physician and practice characteristics that predict cluster membership, and (3) assess the variation in the levels of performance associated with each configuration.

Methods

We used data from a survey of GPs conducted throughout the European Union (N=5793). First, 4 factors, that is, EHRs, HIE, PHRs, and Telehealth, were created. Second, a cluster analysis helps uncover clusters of GPs based on the 4 factors. Third, we compared the clusters according to five performance outcomes using an analysis of variance (ANOVA) and a Tamhane T2 post hoc test. Fourth, univariate and multivariate multinomial logistic regressions were used to identify predictors of the clusters. Finally, with a multivariate multinomial logistic regression, among the clusters, we compared performance in terms of the number of patients treated (3 levels) over the last 2 years.

Results

We unveiled 3 clusters of GPs with different levels of CIS capability profiles: strong (1956/5793, 37.36%), medium (2764/5793, 47.71%), and weak (524/5793, 9.04%). The logistic regression analysis indicates that physicians (younger, female, and less experienced) and practice (solo) characteristics are significantly associated with a weak profile. The ANOVAs revealed a strong cluster associated with significantly high practice performance outcomes in terms of the quality of care, efficiency, productivity, and improvement of working processes, and two noncomprehensive medium and weak profiles associated with medium (equifinal) practice performance outcomes. The logistic regression analysis also revealed that physicians in the weak profile are associated with a decrease in the number of patients treated over the last 2 years.

Conclusions

Different CIS capability profiles may lead to similar equifinal performance outcomes. This underlines the importance of looking beyond the adoption of 1 CIS capability versus a cluster of capabilities when studying CISs. GPs in the strong cluster exhibit a comprehensive CIS capability profile and outperform the other two clusters with noncomprehensive profiles, leading to significantly high performance in terms of the quality of care provided to patients, efficiency of the practice, productivity of the practice, and improvement of working processes. Our findings indicate that medical practices should develop high capabilities in all 4 CISs if they have to maximize their performance outcomes because efforts to develop high capabilities selectively may only be in vain.

Minor surgery in general practice in Ireland- a report of workload and safety

BACKGROUND

The provision of minor surgical services is an established part of the task profile of general practitioners (GPs) in many countries in Europe and elsewhere. This study aimed to collect data on the clinical process and outcomes for specified minor surgical procedures undertaken in Irish general practice by GPs experienced in minor surgery in order to document the scope and safety of minor surgery being undertaken.

METHODS

Over a six-month period, 24 GPs in 20 practices recorded data on a pre-determined list of procedures undertaken in adults (aged 18 and older); procedures for ingrown toenails were also recorded for those aged 12-18 years. Clinical data were rendered fully anonymous by the participating GPs, entered onto the Excel database template and returned to the project team monthly.

RESULTS

On average, each practice undertook 212 procedures in a six-month period. The four most frequent procedures include two relatively non-invasive procedures (cryosurgical ablation of skin lesions and aspiration and/or injection of joints) and two more invasive procedures (full thickness excision of skin lesion and shave, punch or incisional biopsy). Overall, 83.8% of relevant specimens were submitted for histology. Combining benign and malignant cases, there was an overall 87% clinical and histological concordance; 85% of malignancies were suspected clinically. A complication was recorded in 0.9% after 1 month.

CONCLUSIONS

Irish GPs with experience in minor surgery can provide a range of surgical services in the community safely.

Investigation and analysis of standardized training for residents of general practitioners of Gansu Province in China

BACKGROUND

China's standardized training for residents of General Practitioners (GPs) is aimed at providing the postgraduate training for family doctors who will serve the primary health care institutions. The aim of this paper is to investigate the standardized training situation, satisfaction with standardized training, work situation, intention, satisfaction and attitude of GPs who have finished standardized training.

METHODS

This study was undertaken in 6 training hospitals in Gansu province using a questionnaire with 45 questions.

RESULTS

Approximately 275 residents of GPs were enrolled. Finally, 263 residents completed the questionnaire (95.64% response rate), including 133 females (50.57%) and 130 males (49.43%) with an average age of 28 years (standard deviation, 1.93 years; range, 25-36 years). Additionally, 56.65% were single and 43.35% were married. Of all subjects, 92.40% residents had obtained certification of standardized training for residents of GPs and only 39.54% residents were satisfied with monthly income during training. There were 171 oriented rural medical graduates, of whom, only 42.69% expressed the willing to continue working in the primary health care institutions after the serve time (6 years) expired. Around 86.31% of residents of GPs who had finished standardized training got jobs with more than half serving in the primary health care institutions. For medical institutions and sanitary bureau were clear about general medicine policies, only 29.96% subjects registered as GPs. Among the residents in general practice department, 68.42% were engaged in the diagnosis and treatment of common disease and frequently-occurring diseases as well as referral of patients. The percentage of residents who were satisfied with the job and income were 30.40 and 14.98%, respectively.

CONCLUSION

Standardized training for residents of GPs in China is gradually improving. In order to cultivate more GPs and increase their willing to serve in the primary health care institutions, it is necessary to formulate and execute better policy of GPs, publize general medicine and improve the training quality.

Evaluation of awareness about primary immunodeficiencies among physicians before and after implementation of the educational program: A longitudinal study

Increasing physicians’ awareness is one of the main ways to improve early diagnosis of rare diseases. A survey among physicians of different specialties to evaluate the knowledge about primary immunodeficiencies (PID) was conducted in 2016 and in 2019 –before and after the implementation of an educational program. We compare responses from 82 doctors who participated in the 2016 survey, and 67 doctors who have taken part in the survey in 2019: pediatricians, general practitioners / family physicians and physicians of pediatric sub specialties. The percentage of correct answers to all survey questions after the implementation of the educational program has significantly increased (79.0% in 2019 versus 58.3% in 2016, P<0.0001). This increase in the percentage of correct answers was noted among the surveyed doctors of all specialties. Particular progress was found among pediatricians, who have achieved more than 80% of correct answers. In 2019 the doctors demonstrated better knowledge on the warning signs of PID and specific features of Nijmegen breakage syndrome, DiGeorge syndrome and ataxia-telangiectasia syndrome. Thus, the implementation of an educational program improved physicians’ awareness of PIDs, and will contribute to early detection of PIDs and their medical care.

Validation of the Dutch version of the primary care resources and support for self-management tool: A tool to assess the quality of self-management support

Introduction

Enhancing the self-management activities of patients improves the quality of care and is an integrated element of current healthcare provision. However, self-management support (SMS) is not yet common in healthcare. The Primary Care Resources and Support for Self-Management (PCRS) is a tool for healthcare professionals to assess the quality of SMS. In this study, we assessed the validity and reliability of the Dutch version of the PCRS.

Method

The validation of the PCRS was performed in Dutch healthcare centres. Correlations between the PCRS scores and the Assessment of Chronic Illness Care (ACIC) and Clinician Support for Patient Activation Measure (CS-PAM) scores were calculated to assess the convergent and discriminant validity. A confirmatory factor analysis (CFA) was performed to test the factor structure. Lastly, the internal consistency and face validity were assessed.

Results

The convergent and discriminant validity were good, with respective correlations of 0.730 (p < 0.001) and 0.030 (p > 0.050) between the PCRS and the ACIC SMS subscale and the PCRS and the CS-PAM. Although 49% of the variance of the PCRS was explained by one factor, the CFA could not confirm a fit between a one-factor model and the data. The reliability was excellent (Cronbach’s α = 0.921).

Conclusion

The PCRS showed good validity and excellent internal consistency. However, the evidence for its validity was inconclusive. We therefore suggest rephrasing specific items.

Troubling the non-specialist prescription of HIV pre-exposure prophylaxis (PrEP): the views of Australian HIV experts

The broadening of access to HIV pre-exposure prophylaxis (PrEP) in Australia has rekindled debates about which types of clinicians are best suited to deliver HIV prevention innovations: specialist HIV services or primary care physicians and general practitioners (GPs). We conducted 21 semi-structured qualitative interviews in 2017 with Australian HIV sector experts working across policy, advocacy, clinical service provision, research, and health promotion. These interviews took place before a national policy commitment to subsidising access to PrEP was achieved. We explored how participants conceptualised PrEP, patients and GPs at this key turning point in the history of HIV prevention. Participants expressed varied views regarding GPs' anticipated ability to successfully navigate the potential complexities associated with PrEP roll-out. While participants were supportive of greater patient access to PrEP, they expressed concerns about non-specialist GPs' cultural competence and expertise regarding sexuality and clinical practice, and the potential for patients to experience discrimination and homophobia from non-expert GPs. This study has broad implications for thinking about experts and expertise, the implementation of previously specialised medicine into mainstream settings, and the anticipated challenges of LGBTIQ+ inclusive healthcare.

Awareness of ADHD in primary care: stakeholder perspectives

BACKGROUND

Attention Deficit Hyperactivity Disorder (ADHD) is underdiagnosed in many European countries and the process of accessing care and diagnosis is complex and variable. In many countries, general practitioners (GPs) refer on to secondary care where individuals receive an assessment and, if appropriate, a diagnosis and access to care. It is therefore essential that GPs have a clear understanding of the disorder and its care pathways. While previous studies have highlighted potential barriers in GPs' ADHD awareness, this qualitative study aims to further explore individual stakeholders' experiences.

METHODS

Semi-structured interviews explored the views of multiple stakeholders- GPs (n = 5), healthcare specialists (n = 5), patients (adults with ADHD n = 5) and parents (n = 5) with experience of the presentation and management of ADHD in primary care. These interviews were analysed using thematic analyses and following principles of grounded theory.

RESULTS

Stakeholders described ADHD assessment, diagnosis and treatment as an intricate process. Many factors affected this process such as complex pathways, lack of services, limited GP recognition and knowledge, and communicative difficulties between and within multiple stakeholders.

CONCLUSION

This analysis underlines the significant impact that receiving (or not) a diagnosis can have, and further explores muddled ADHD care pathways, highlighting key issues around GP identification and the shortage of adult services. Implications for practice and future research are discussed, suggesting a strong need for more commissioned pathways and GP specific educational programs.

Uptake of best practice recommendations in the management of patients with diabetes and periodontitis: a cross-sectional survey of healthcare professionals in primary care

OBJECTIVES

To investigate the practices of healthcare professionals in relation to best practice recommendations for the multidisciplinary management of people with diabetes and periodontitis, focusing on two clinical behaviours: informing patients about the links between diabetes and periodontitis, and suggesting patients with poorly controlled diabetes go for a dental check-up.

DESIGN

Cross-sectional design utilising online questionnaires to assess self-reported performance and constructs from Social Cognitive Theory (SCT) and Normalisation Process Theory.

SETTING

Primary care medical practices (n=37) in North East, North Cumbria and South West of England Clinical Research Networks.

PARTICIPANTS

96 general practitioners (GPs), 48 nurses and 21 healthcare assistants (HCAs).

RESULTS

Participants reported little to no informing patients about the links between diabetes and periodontitis or suggesting that they go for a dental check-up. Regarding future intent, both GPs (7.60±3.38) and nurses (7.94±3.69) scored significantly higher than HCAs (4.29±5.07) for SCT proximal goals (intention) in relation to informing patients about the links (p<0.01); and nurses (8.56±3.12) scored significantly higher than HCAs (5.14±5.04) for suggesting patients go for a dental check-up (p<0.001). All professional groups agreed on the potential value of both behaviours, and nurses scored significantly higher than GPs for legitimation (conforms to perception of job role) in relation to informing (nurses 4.16±0.71; GPs 3.77±0.76) and suggesting (nurses 4.13±0.66; GPs 3.75±0.83) (both p<0.01). The covariate background information (OR=2.81; p=0.03) was statistically significant for informing patients about the links.

CONCLUSIONS

Despite evidence-informed best practice recommendations, healthcare professionals currently report low levels of informing patients with diabetes about the links between diabetes and periodontitis and suggesting patients go for a dental check-up. However, healthcare professionals, particularly nurses, value these behaviours and consider them appropriate to their role. While knowledge of the evidence is important, future guidelines should consider different strategies to enable implementation of the delivery of healthcare interventions.

Training and standardization of general practitioners in the use of lung ultrasound for the diagnosis of pediatric pneumonia

BACKGROUND

Pneumonia is a leading cause of death in children of low-resource settings. Barriers to care include an early and accurate diagnosis. Lung ultrasound is a novel tool for the identification of pediatric pneumonia; however, there is currently no standardized approach to train in image acquisition and interpretation of findings in epidemiological studies. We developed a training program for physicians with limited ultrasound experience on how to use ultrasound for the diagnosis of pediatric pneumonia and how to standardize image interpretation using a panel of readers.

METHODS

Twenty-five physicians participating in the training program conducted lung ultrasounds in all children with suspected pneumonia, aged 3 to 35 months, presenting to three subdistrict hospitals in Sylhet, Bangladesh, between June 2015 and September 2017.

RESULTS

A total of 9051 pediatric lung ultrasound assessments were conducted through 27 months of data collection. Study physicians underwent training and all were successfully standardized, achieving 91% agreement and maintained a sensitivity and specificity of 88% and 92%, respectively, when their diagnosis was compared with experts. Overall kappa between two readers was high (0.86, 95% confidence interval [CI], 0.84-0.87), and remained high when a third expert reader was included (0.80, 95% CI, 0.79-0.81). Agreement and kappa statistics were similarly high when stratified by age, sex, presence of danger signs, or hypoxemia.

CONCLUSIONS

Lung ultrasound is a novel tool for the diagnosis of pediatric pneumonia with evidence supporting its validity and feasibility of implementation. Here we introduced a training program that resulted in a high level of inter-sonographer agreement.

General practitioners' use of ICPC diagnoses and their correspondence with patient record notes

BACKGROUND

The quality of the general practitioners' setting of diagnoses using codes from the International Classification for Primary Care (ICPC) is important, because these codes are used for purposes of quality development, research and public health statistics. It is uncertain, however, to what extent these diagnoses present a correct picture of the content of and reasons for the consultations and the prevalence of illness in the population. The objective of this study was to identify the extent to which the general practitioners' use of diagnostic codes correlates with the content of the patient record notes.

MATERIAL AND METHOD

A total of 23 general practitioners from five different medical centres in Agder county participated in the study. The patient record notes from all patient contacts over two working days in 2013 were reviewed by two experienced general practitioners who assessed the degree of correspondence between the content of the patient record notes and the concomitant ICPC diagnostic codes.

RESULTS

A total of 1 819 patient contact were assessed, and for 1 591 of these (87.5 %) it was possible to assess the correspondence between the patient record notes and the diagnosis. We found good correspondence for 693 (85.3 %) consultations and 321 (69.9 %) simple contacts with issuance of a prescription. For simple contacts with no issuance of a prescription there was good correspondence for 213 (83.9 %), although 144 of a total of 398 (36.2 %) could not be assessed because the patient record notes were absent, too brief or imprecise.

INTERPRETATION

The diagnoses made during consultations corresponded well with the patient record notes examined in this study. The results may indicate that caution should be exercised in including simple contacts in the data on diagnoses in public statistics. The findings should be followed up in larger-scale and more representative national studies.

The impact of general practitioners' gender on process indicators in Hungarian primary healthcare: a nation-wide cross-sectional study

OBJECTIVES

The objectives of our study were (1) to investigate the association between gender of the general practitioner (GP) and the quality of primary care in Hungary with respect to process indicators for GP performance and (2) to assess the size of the gender impact.

STUDY DESIGN

A nation-wide cross-sectional study was performed in 2016.

SETTING AND PARTICIPANTS

The study covered all general medical practices in Hungary (n=4575) responsible for the provision of primary healthcare (PHC) for adults. All GPs in their private practices are solo practitioners.

MAIN OUTCOME MEASURES

Multilevel logistic regression models were used to analyse the association between GP gender and process indicators of PHC, and attributable proportion (AP) was calculated.

RESULTS

48% of the GPs (n=2213) were women in the study. The crude rates of care provided by female GPs were significantly higher for seven out of eight evaluated indicators than those provided by male GPs. Adjusted for practice, physician and patient factors, GP gender was associated with the haemoglobin A1c (HbA1c) measurement: OR=1.18, 95% CI (1.14 to 1.23); serum creatinine measurement: OR=1.14, 95% CI (1.12 to 1.17); lipid measurement: OR=1.14, 95% CI (1.11 to 1.16); eye examination: OR=1.06, 95% CI (1.03 to 1.08); mammography screening: OR=1.05, 95% CI (1.03 to 1.08); management of patients with chronic obstructive pulmonary disease: OR=1.05, 95% CI (1.01 to 1.09) and the composite indicator: OR=1.08, 95% CI (1.07 to 1.1), which summarises the number of care events and size of target populations of each indicator. The AP at the specific indicators varied from 0.97% (95% CI 0.49% to 1.44%) of influenza immunisation to 8.04% (95% CI 7.4% to 8.67%) of eye examinations.

CONCLUSION

Female GP gender was an independent predictor of receiving higher quality of care. The actual size of the gender effect on the quality of services seemed to be notable. Factors behind the gender effect should receive more attention in quality improvement particularly in countries where the primary care is organised around solo practices.

'Optimising PharmacoTherapy In the multimorbid elderly in primary CAre' (OPTICA) to improve medication appropriateness: study protocol of a cluster randomised controlled trial

INTRODUCTION

Multimorbidity and polypharmacy are major risk factors for potentially inappropriate prescribing (eg, overprescribing and underprescribing), and systematic medication reviews are complex and time consuming. In this trial, the investigators aim to determine if a systematic software-based medication review improves medication appropriateness more than standard care in older, multimorbid patients with polypharmacy.

METHODS AND ANALYSIS

Optimising PharmacoTherapy In the multimorbid elderly in primary CAre is a cluster randomised controlled trial that will include outpatients from the Swiss primary care setting, aged ≥65 years with ≥three chronic medical conditions and concurrent use of ≥five chronic medications. Patients treated by the same general practitioner (GP) constitute a cluster, and clusters are randomised 1:1 to either a standard care sham intervention, in which the GP discusses with the patient if the medication list is complete, or a systematic medication review intervention based on the use of the 'Systematic Tool to Reduce Inappropriate Prescribing'-Assistant (STRIPA). STRIPA is a web-based clinical decision support system that helps customise medication reviews. It is based on the validated 'Screening Tool of Older Person's Prescriptions' (STOPP) and 'Screening Tool to Alert doctors to Right Treatment' (START) criteria to detect potentially inappropriate prescribing. The trial's follow-up period is 12 months. Outcomes will be assessed at baseline, 6 and 12 months. The primary endpoint is medication appropriateness, as measured jointly by the change in the Medication Appropriateness Index (MAI) and Assessment of Underutilisation (AOU). Secondary endpoints include the degree of polypharmacy, overprescribing and underprescribing, the number of falls and fractures, quality of life, the amount of formal and informal care received by patients, survival, patients' quality adjusted life years, patients' medical costs, cost-effectiveness of the intervention, percentage of recommendations accepted by GPs, percentage of recommendation rejected by GPs and patients' willingness to have medications deprescribed.

ETHICS AND DISSEMINATION

The ethics committee of the canton of Bern in Switzerland approved the trial protocol. The results of this trial will be published in a peer-reviewed journal.

MAIN FUNDING

Swiss National Science Foundation, National Research Programme (NRP 74) 'Smarter Healthcare'.

TRIAL REGISTRATION NUMBERS

Clinicaltrials.gov (NCT03724539), KOFAM (Swiss national portal) (SNCTP000003060), Universal Trial Number (U1111-1226-8013).

Factors influencing Urate Lowering Therapies prescription for asymptomatic hyperuricemia by general practitioners: a qualitative study

BACKGROUND

Urate Lowering Therapies (ULTs), mainly Xanthine Oxydase Inhibitors, are widely used by general practitioners (GPs) in asymptomatic hyperuricemia, although no guideline currently recommends to do so. The use of ULTs in asymptomatic hyperuricemia has been associated with an increased risk of ULTs-related adverse drug reactions.

AIM

Our study aimed at exploring GPs' views and practices in relation to the prescription or non-prescription of ULT in asymptomatic hyperuricemia.

METHODS

We conducted a qualitative study using individual semi-structured interviews with 14 French GPs. We built a purposeful sample searching for maximum variation on 8 GPs' personal and professional criteria such as age, years of installation, location of their practice. We conducted a thematic analysis of the transcripts, following Miles and Huberman three steps model: data reduction, data presentation, conclusion drawing and verifications.

RESULTS

We identified two behaviors leading to inappropriate prescription of ULTs among interviewed GPs. Primary prescribers frequently used uric acid serum levels and had a positive representation of ULTs. Other GPs behaved in an ambivalent way: they did not initiate ULTs, but systematically renewed preexisting prescriptions. They had a negative perception of ULTs but considered them unimportant during drug reassessment. De-prescribing occurred mainly because of external input such as the need to lighten the prescription or the participation in an audit in general practice.

CONCLUSIONS

Our results support several strategies of ULTs de-prescribing in asymptomatic hyperuricemia: the promotion of de-prescribing of serum acid uric lab test in daily practice (a), supporting the clinical reasoning in the case of asymptomatic hyperuricemia detection (b) but also during ULTs renewals (c) leading to a prioritization of the safest prescriptions (d) through shared medical decision (e). Additional studies are necessary to further develop and evaluate these de-prescribing strategies.

[Outpatient follow-up of liver transplant recipients: the essential role of the general practitioner]

The population of liver transplant recipients has increased in Switzerland over the last few years. Morbidity and mortality after liver transplantation are due, in the early post-transplant period, to surgical and infectious complications as well as to rejection, whereas cardiovascular, metabolic, renal and oncologic complications are the most frequent complications in the late post-transplant period. The role of the general practitioner in the long-term follow-up of liver transplant recipients is of the highest importance and can represent the first-line care of these patients as soon as 6 to 12 months post-transplantation, while maintaining a close and regular collaboration with the transplant center. Multidisciplinary and structured follow-up, along with some specific screening tests, is warranted in order to refine patient management in a timely manner and to optimize outcomes.

General practitioner and pharmacist collaboration: does this improve risk factors for cardiovascular disease and diabetes? A systematic review protocol

INTRODUCTION

Cardiovascular disease (CVD) remains a major cause of morbidity and premature mortality globally. Despite the availability of low-cost evidence based medicines, there is a significant treatment gap in those with established or at high risk of CVD in the primary care setting. Pharmacist-based interventions have shown to improve patient outcomes for many chronic diseases including CVD. However, there is little synthesised evidence that has examined the effects of collaborative care between general practitioners (GPs) and pharmacists on patients' cardiovascular risk outcomes. This protocol aims to outline the methods employed in a systematic review of current literature to assess whether interprofessional collaboration between GPs and pharmacists has an impact on improving cardiovascular risk outcomes among patients in the primary care setting.

METHODS AND ANALYSIS

Randomised controlled trials (RCTs) will be identified through database searches, scanning reference lists of relevant studies, hand searching of key journals and citation searching of key papers. Two independent reviewers will screen studies against eligibility criteria and extract data using standardised forms. Databases including MEDLINE, EMBASE, Cochrane, CINAHL and International Pharmaceutical Abstracts, will be searched from the beginning of each database until October 2018. Primary outcome includes improvement in cardiovascular risk factors, such as hypertension, due to GP and pharmacist cooperation. Secondary outcome is to describe the different types of GP and pharmacist collaborative models of care. A narrative synthesis of findings will be presented. A meta-analysis will be performed if the data are homogenous.

ETHICS AND DISSEMINATION

This study does not require ethics approval. The results of the systematic review described within this protocol will be disseminated through presentations at relevant conferences and publication in a peer-reviewed journal. The methods will be used to inform future reviews.

PROSPERO REGISTRATION NUMBER

CRD42017055259.

General practitioners' views on the diagnostic innovations in DSM-5 somatic symptom disorder - A focus group study

BACKGROUND

The innovations concerning the new diagnosis somatic symptom disorder (SSD) in the DSM-5 include the introduction of psychological diagnostic criteria and the elimination of the need to exclude all potential somatic causes of the symptoms. Thus far, it is unknown how general practitioners (GPs) evaluate the innovations conceptually and regarding their applicability in primary care.

METHOD

We performed six focus groups with GPs. A semi-structured interview-guideline included a presentation of the innovations of SSD and questions about the innovations and their potential (dis-)advantages from the GPs' points of view. The material was analyzed using structuring qualitative content analysis.

RESULTS

A total of 41 GPs participated (mean (sd) age = 51 (8.5) years, female = 17, male = 24). The GPs assessed that the diagnostic innovations could help them to focus on symptom-related concerns and anxiety as core aspects of the patients' complaints. However, the meaning of the term excessive in the psychological diagnostic criteria (i.e., excessive worries, anxiety, time and energy) was ambiguous for the GPs. The GPs appreciated that a mental disorder can be assigned in addition to a severe physical disease. The GPs found it unlikely that diagnostic workup of somatic symptoms would be cut short if the diagnostic criteria of SSD were fulfilled in a given patient.

CONCLUSION

Altogether, for the GPs, the advantages of the new diagnostic criteria for SSD outweighed the disadvantages. In particular, the newly included psychological criteria were seen as an important advancement in comparison to the previous need of merely excluding a physical disease.

Awareness, knowledge, and practice patterns of general practitioner residents and specialists toward hidradenitis suppurativa: a survey study

INTRODUCTION

Hidradenitis suppurativa (HS) is an unrecognized chronic inflammatory and debilitating disease with severe consequences for patients' quality of life.

METHODS

A survey was performed among general practitioner (GP) residents and consultants in order to determine awareness, knowledge, and attitudes about HS.

RESULTS

Among 372 respondents, 74% were GP residents in the first 2 years, 22% GP residents in the 3rd and 4th year, and 4% consultants. For a patient with boils and/or recurrent abscesses in folds, 90% considered a diagnosis of HS with no significant difference according to years of experience. These patients were referred to dermatology by 273 residents (80%) and eight consultants (53%), and this difference is statistically significant (p < 0.05). Regarding acute treatment, 84% prescribed topical antibiotics and 76% oral antibiotics. Respecting therapeutic approach, we observed that treatment with non-steroidal anti-inflammatory drugs is higher among older residents (51%) compared to younger ones (36%, p < 0.02) and the prescription of oral clindamycin is higher among consultants (31%) compared to residents (12%, p < 0.04).

CONCLUSIONS

Our survey demonstrates that knowledge of HS is lacking among primary care physicians. Communication channels between GPs and dermatologists are often hampered, and so we recommend incorporating medical education into GP residency programs on how to treat mild HS, when to refer, and how to approach HS.

Factors affecting the changing role of GP clinicians in community hospitals: a qualitative interview study in England

BACKGROUND

GPs were a key driving force for the development of a network of community hospitals across England, and have provided medical cover for most of them. However, during the past decade there has been a significant shift, with the dominant trend appearing to be one of declining GP involvement.

AIM

To explore how and why the role of GPs within community hospitals in England is changing.

DESIGN AND SETTING

Qualitative study in a sample of nine diverse community hospitals in England.

METHOD

Qualitative interviews with community hospital clinical staff.

RESULTS

In all, 20 interviews were conducted and two models of medical care observed: GPs employed by a practice and trust-employed doctors. Interviewees confirmed the trend towards declining GP involvement, with the factors driving change identified as being GP workload and recruitment challenges, a change from 'step-up' admissions from the community to 'step-down' admissions from acute hospitals, fewer local patients being admitted, increased medical acuity of patients admitted, increased burden of medical support required, and inadequate remuneration. The majority of doctors viewed community hospital work in a positive light, welcoming the opportunities for personal development and to acquire new clinical skills. GPs viewed community hospital work as an extension of primary care, adding to job satisfaction.

CONCLUSION

Multiple factors have driven changes in the role of GP community hospital clinicians. The NHS needs to develop a focused strategy if GPs are to remain engaged with community hospital work.

Career orientation and its impact factors of general practitioners in Shanghai, China: a cross-sectional study

OBJECTIVES

To understand the career orientation and impact factors of general practitioners (GPs) in Shanghai.

DESIGN

A cross-sectional study was carried out from August 2014 to December 2015 using the Career Orientations Inventory (short form).

SETTING AND PARTICIPANTS

We conducted a cross-sectional study of 1159 GPs, of which 1067 (92.06%) completed the assessment tools, from 223 community healthcare centres in Shanghai RESULTS: The top career orientation was organisational job security (71.60%), followed by technical competence (12.18%). Compared with female GPs, male GPs scored higher in managerial competence (p<0.001), creativity and entrepreneurship (p<0.001), and lower in organisational job security (p=0.034). Compared with GPs younger than 40, those aged 40 years and older scored higher in sense of service (p=0.003) and lower in autonomy (p=0.022) and lifestyle integration (p=0.039). Compared with GPs with lower education levels, those with at least a bachelor's degree scored higher in managerial competence (p=0.001 and autonomy (p=0.025). In addition, those with fewer than 10 years of work experience scored higher in managerial competence (p=0.008) and scored lower in geographical security (p=0.032) compared with GPs with longer durations of work experience. GPs with senior professional positions scored higher in technical competence (p=0.012) compared with those with lower professional positions.

CONCLUSIONS

The search for job stability and the lack of career prospect planning are two factors that impact community GP growth. Individualised skills training and career development planning should be provided to GPs of specific genders, educational background and vocational competence, in order to enhance their job satisfaction and service quality, thereby achieving retention of this staff group.

Efficiency versus thoroughness in medication review: a qualitative interview study in UK primary care

BACKGROUND

Medication reviews may improve the safety of prescribing and the National Institute for Health and Care Excellence (NICE) highlights the importance of involving patients in this process.

AIM

To explore GP and pharmacist perspectives on how medication reviews were conducted in general practice in the UK.

DESIGN AND SETTING

Analysis of semi-structured interviews with GPs and pharmacists working in the South West of England, Northern England, and Scotland, sampled for heterogeneity. Interviews took place between January and October 2017.

METHOD

Interviews focused on experience of medication review. Data saturation was achieved when no new insights arose from later interviews. Interviews were analysed thematically.

RESULTS

In total, 13 GPs and 10 pharmacists were interviewed. GPs and pharmacists perceived medication review as an opportunity to improve prescribing safety. Although interviewees thought patients should be involved in decisions about their medicines, high workload pressures meant that most medication reviews were conducted with limited or no patient input. For some GPs, a medication review was done 'in the quickest way possible to say that it was done'. Pharmacists were perceived by both professions as being more thorough but less time efficient than GPs, and few pharmacists were routinely involved in medication reviews even in practices employing a pharmacist. Interviewees argued that it was easier to continue medicines than it was to stop them, particularly because stopping medicines required involving the patient and this generated extra work.

CONCLUSION

Practices tended to prioritise being efficient (getting the work done) rather than being thorough (doing it well), so that most medication reviews were carried out with little or no patient involvement, and medicines were rarely stopped or reduced. Time and resource constraints are an important barrier to implementing NICE guidance.

High-risk basal cell carcinoma excision in primary care: a retrospective observational study of compliance with NICE guidance

OBJECTIVES

To assess compliance with 2010 National Institute for Health and Care Excellence (NICE) guidance on cancer services relating to the management of basal cell carcinomas (BCC) in the community, where except in specific circumstances it is recommended that only low-risk BCCs should be excised routinely.

DESIGN AND SETTING

A retrospective observational study of the histopathology reports of BCC excisions received from primary care in two district general hospitals in the South of England. One hundred consecutive BCC excisions were analysed from each hospital.

OUTCOME MEASURES

The numbers of high-risk BCCs excised in primary care according to histological subtype, anatomical site and age and if these excisions were compliant with NICE 2010 guidance. Completeness of excision and mention of BCC on histology request were secondary outcomes.

RESULTS

Histologically high-risk subtypes were present in 32% (64/200) of BCCs excised in the community. Only 17/64 were excised by general practitioners (GPs) who were accredited to do so. Non-compliance regarding anatomical site occurred in 16% of samples; only one was non-compliant regarding patient age. There was a high overall rate of complete excision (94.5%) with variation in presence of the term BCC on histology request forms.

CONCLUSIONS

NICE 2010 guidance relating to BCC excision in primary care was not followed in a considerable number of cases. Compliance with NICE 2010 guidance depends on the ability to recognise high-risk BCCs clinically and manage appropriately. It also shows that despite close supervision by secondary care, there are still failures of compliance.GP training in identification of subtypes of BCC might be improved, as well as an increase in numbers of GPs accredited to carry out high-risk BCC excisions. Difficulty in diagnosing high-risk histological subtypes of BCC preoperatively should be considered in any future revision of NICE guidance.

Validity of the scan of postgraduate educational environment domains (SPEED) questionnaire in a rural general practice training setting

BACKGROUND

The educational environment is critical to learning and is determined by social interactions. Trainee satisfaction translates to career commitment, retention and a positive professional attitude as well as being an important factor in assessing the impact of the training program. This study aimed to validate the Scan of Postgraduate Educational Environment Domain (SPEED) tool and assess its appropriateness in evaluating the quality of General Practice (GP) rural postgraduate educational environment.

METHODS

A questionnaire containing the 15-item SPEED tool was administered to GP registrars to examine their perceptions of the educational environment. Principal component analysis (PCA) and exploratory factor analysis (EFA) were used to gather evidences of the validity of the instrument based on its internal structure. Additional validity evidence and reliability estimates were obtained using many-facet Rasch model analysis (MFRM).

RESULTS

The survey was completed by 351 registrars with a response rate of 60%. Parallel analysis performed using principal component analysis and exploratory factor analysis suggests that the SPEED tool is unidimensional. The MFRM analysis demonstrated an excellent degree of infit and outfit for items and training sites, but not for persons. The MFRM analysis also estimated high reliability levels for items (0.98), training sites (0.95) and persons within training sites (ranging from 0.87 to 0.93 in each training sites). Overall, the registrars agreed that the educational environment had high quality, with most (13 out of 15) of the items rated above 4 out of 5.

CONCLUSIONS

This study demonstrated a high degree of validity and reliability of the SPEED tool for the measurement of the quality of the educational environment in a rural postgraduate GP training context. However, when applied in a new setting, the tool may not function as a multidimensional tool consistent with its theoretical grounding.

European Practical and Patient-Centred Guidelines for Adult Obesity Management in Primary Care

The first contact for patients with obesity for any medical treatment or other issues is generally with General Practitioners (GPs). Therefore, given the complexity of the disease, continuing GPs' education on obesity management is essential. This article aims to provide obesity management guidelines specifically tailored to GPs, favouring a practical patient-centred approach. The focus is on GP communication and motivational interviewing as well as on therapeutic patient education. The new guidelines highlight the importance of avoiding stigmatization, something frequently seen in different health care settings. In addition, managing the psychological aspects of the disease, such as improving self-esteem, body image and quality of life must not be neglected. Finally, the report considers that achieving maximum weight loss in the shortest possible time is not the key to successful treatment. It suggests that 5-10% weight loss is sufficient to obtain substantial health benefits from decreasing comorbidities. Reducing waist circumference should be considered even more important than weight loss per se, as it is linked to a decrease in visceral fat and associated cardiometabolic risks. Finally, preventing weight regain is the cornerstone of lifelong treatment, for any weight loss techniques used (behavioural or pharmaceutical treatments or bariatric surgery).

[Appropriateness, self-audit and extractors in general medicine.]

The author presents the results of a personal audit proposed to the GPs by the ASL 6 Euganea of the Veneto Region. The results obtained show significant differences between the data provided by the pharmaceutical sector and those obtained by consulting the individual database. The therapeutic adherence of antihypertensive drugs appears to be particularly discordant. The audit also suggests inappropriate use of PPIs, improper use of corticosteroids for aerosols after modification of the prescribability and reduced adherence to statin therapy.

The value of an embedded qualitative study in a trial of a second antidepressant for people who had not responded to one antidepressant: understanding the perspectives of patients and general practitioners

BACKGROUND

Depression is the leading cause of disability worldwide, and is a major contributor to the overall global burden of disease. The number of prescriptions for antidepressants has risen dramatically in recent years yet up to 50% of patients who are treated for depression with antidepressants do not report feeling better as a result of treatment, and do not show the desired improvement on depression measures. We report a qualitative study embedded in a trial of second antidepressant for people who had not responded to one antidepressant, exploring the acceptability of a combination of antidepressants from the perspectives of both patients and practitioners, together with experiences of participating in a clinical trial.

METHODS

A qualitative study embedded in a randomized controlled trial investigating the effectiveness and cost-effectiveness of combining mirtazapine with Serotonin-Noradrenaline Reuptake Inhibitor (SNRI) or Selective Serotonin Reuptake Inhibitor (SSRI) antidepressants versus SNRI or SSRI therapy alone (the MIR trial). 59 interviews were conducted with people who declined to participate in the trial, people who completed the study and people who withdrew from the intervention, and 16 general practitioners.

RESULTS

Across the data-sets, four main themes were identified: the hard work of managing depression, uncertainties over the value of a second antidepressant, help-seeking at a point of crisis, and attainment and maintenance of a hard-won equilibrium.

CONCLUSIONS

Exploring reasons for declining to participate in a trial of a second antidepressant in people who had not responded to one antidepressant suggests that people who are already taking one antidepressant may be reluctant to take a second, being wary of possible side-effects, but also being unconvinced of the logic behind such a combination. In addition, people describe being in a state of equilibrium and reluctant to make a change, reflecting that this equilibrium is 'hard-won' and they are unwilling to risk disturbing this. This makes some people reluctant to enrol in a clinical trial. Understanding a patient's view on medication is important for GPs when discussing antidepressants.

TRIAL REGISTRATION

MIR Trial Registration: ISRCTN 06653773 .

General practitioners' use of sickness certification guidelines in Sweden at introduction and four years later: a survey study

Objective

National sickness certification guidelines were introduced in Sweden in 2007, comprising both overarching and diagnoses-specific recommendations. This study aimed to investigate how general practitioners (GP) used and perceived the usefulness of these guidelines in the sickness certification process close after introduction and 4 years later.

Design

Two nationwide cross-sectional surveys in 2008 and 2012.

Setting

Swedish healthcare.

Participants

Physicians working in primary healthcare and having sickness certification consultations at least a few times per year (n = 4214 in 2008, and n = 4067 in 2012).

Main Outcome Measures

Frequency of use and perceived usefulness of the sickness certification guidelines.

Results

Most GPs used the guidelines at least a few times per year (in 2008 74.6%; in 2012 85.2%). In 2008, 44.1% reported a need to develop competence in using the guidelines, compared with 23.3% in 2012. Of those using the guidelines, 36.7% in 2008 and 44.6% in 2012 reported it problematic to write sickness certificates in accordance with the guidelines. Most GPs (89.2% in 2008 and 88.8% in 2012) valued the guidelines beneficial to ensure quality in sickness certification consultations. A larger proportion in 2012 compared with 2008 reported that the guidelines facilitated contacts with patients (61.2%, respectively, 55.6%), as well as with other stakeholders.

Conclusions

The guidelines were perceived as useful and beneficial to ensure high quality in sickness certification consultations, and facilitated contacts with patients as well as other stakeholders. In 2012, still one-fourth reported a need to develop more competence in using the sickness certification guidelines.

Development and pilot testing of a tool to assess evidence-based practice skills among French general practitioners

BACKGROUND

There is currently an absence of valid and relevant instruments to evaluate how Evidence-based Practice (EBP) training improves, beyond knowledge, physicians' skills. Our aim was to develop and test a tool to assess physicians' EBP skills.

METHODS

The tool we developed includes four parts to assess the necessary skills for applying EBP steps: clinical question formulation; literature search; critical appraisal of literature; synthesis and decision making. We evaluated content and face validity, then tested applicability of the tool and whether external observers could reliably use it to assess acquired skills. We estimated Kappa coefficients to measure concordance between raters.

RESULTS

Twelve general practice (GP) residents and eleven GP teachers from the University of Bordeaux, France, were asked to: formulate four clinical questions (diagnostic, prognosis, treatment, and aetiology) from a proposed clinical vignette, find articles or guidelines to answer four relevant provided questions, analyse an original article answering one of these questions, synthesize knowledge from provided synopses, and decide about the four clinical questions. Concordance between two external raters was excellent for their assessment of participants' appraisal of the significance of article results (K = 0.83), and good for assessment of the formulation of a diagnostic question (K = 0.76), PubMed/Medline (K = 0.71) or guideline (K = 0.67) search, and of appraisal of methodological validity of articles (K = 0.68).

CONCLUSIONS

Our tool allows an in-depth analysis of EBP skills, thus could supplement existing instruments focused on knowledge or specific EBP step. The actual usefulness of such tools to improve care and population health remains to be evaluated.

Uncertainty about the effort-performance relationship in threshold-based payment schemes

Incentive schemes often feature a threshold beyond which providers receive no additional payment for performance. We investigate whether providers' uncertainty about the relationship between effort and measured performance leads to financially unrewarded performance in such schemes. Using data from the British Quality and Outcomes Framework, we proxy general practitioners' uncertainty about the effort-performance relationship by their experience with the scheme and their span of control. We find evidence that providers respond to uncertainty by exerting financially unrewarded performance, suggesting that uncertainty may be a mechanism by which payers can extract unrewarded performance.

Role of the general practitioner in the care of BRCA1 and BRCA2 mutation carriers: General practitioner and patient perspectives

BACKGROUND

General practitioners (GPs) have an increasing role in referring patients with putative mutation in BRCA1/2 genes for genetics consultation and for long-term follow-up of mutation carriers.

METHODS

We compared the expectations of the GPs' role according to BRCA1/2 mutation carriers and to GPs themselves.

RESULTS

Overall, 38% (58/152) of eligible GPs and 70% (176/252) of eligible patients were surveyed. Although 81% of GPs collected the family history, only 24% considered that they know criteria indicating genetics consultation and 39% sufficient knowledge of BRCA1/2 guidelines to answer patients' questions. Twelve% of GPs were aware of the French national guidelines. Among unsatisfied patients, 40% felt that their GP was able to answer (moderately, sufficiently, or completely) specific questions about BRCA1/2 care as compared with 81% in satisfied patients. Only 33% of GPs reported being informed directly by the geneticist about the patients' results. GPs' main expectations for their role in BRCA1/2 carrier care were psychological support and informing relatives about screening (72% and 71%, respectively), which contrasts with the perceptions of patients, who mainly requested medical advice for BRCA1/2-related care (51%).

CONCLUSION

There is an important need for GP training and enhancing interactions between GPs and geneticists to improve the GP's role in BRCA1/2 screening and management.

Partners at Care Transitions: exploring healthcare professionals' perspectives of excellence at care transitions for older people

INTRODUCTION

Hospital admissions are shorter than they were 10 years ago. Notwithstanding the benefits of this, patients often leave hospital requiring ongoing care. The transition period can therefore be risky, particularly for older people with complex health and social care needs. Previous research has predominantly focused on the errors and harms that occur during transitions of care. In contrast, this study adopts an asset-based approach to learn from factors that facilitate safe outcomes. It seeks to explore how staff within high-performing ('positively deviant') teams successfully support transitions from hospital to home for older people.

METHODS AND ANALYSIS

Six high-performing general practices and six hospital specialties that demonstrate exceptionally low or reducing 30-day emergency hospital readmission rates will be invited to participate in the study. Healthcare staff from these clinical teams will be recruited to take part in focus groups, individual interviews and/or observations of staff meetings. Data collection will explore the ways in which teams successfully deliver exceptionally safe transitional care and how they overcome the challenges faced in their everyday clinical work. Data will be thematically analysed using a pen portrait approach to identify the manifest (explicit) and latent (abstract) factors that facilitate success.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the University of Leeds. The study will help develop our understanding of how multidisciplinary staff within different healthcare settings successfully support care transitions for older people. Findings will be disseminated to academic and clinical audiences through peer-reviewed articles, conferences and workshops. Findings will also inform the development of an intervention to improve the safety and experience of older people during transitions from hospital to home.

Retirement, job satisfaction and attitudes towards mandatory accreditation: a Danish survey study in general practice

OBJECTIVES

This study aims to analyse the associations between general practitioner (GP) retirement, job satisfaction and attitudes towards a mandatory accreditation scheme. External interventions such as mandatory accreditation schemes may be perceived negatively by GPs, causing early retirement from practice. In Denmark, almost half of the GPs had negative attitudes prior to the implementation of a mandatory accreditation scheme, constituting a possible risk of early practice retirement.

SETTING

In January 2015 all 3,404 Danish GPs were invited to participate in a survey on attitudes towards a forthcoming mandatory accreditation programme.

PARTICIPANTS

1,906 GPs (56%) answered the questionnaire. In total, 391 (11%) retired from practice in the following period from 1 January 2015 to 31 January 2017. Of these, 193 GPs (49%) answered the questionnaire.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was GP retirement. Labour union data on practice retirement were linked with data from the questionnaire survey on job satisfaction and attitudes prior to implementation of mandatory accreditation. Logistic regression analyses were used to determine the associations between practice retirement and job satisfaction and attitudes towards accreditation.

RESULTS

Practice retirement was associated with job dissatisfaction (OR: 2.5, 95% CI 1.6 to 3.7). Retirement was not associated with any of the other surveyed attitudinal variables. Retirement rate was relatively high in the accreditation start-up period.

CONCLUSION

Practice retirement was associated with job dissatisfaction but not to a priori attitudes towards an upcoming mandatory accreditation programme. However, the retirement rate was relatively high in the start-up period of the accreditation programme. Future research should evaluate the effects of external interventions on preterm retirement from general practice.

TRIAL REGISTRATION NUMBER

NCT02762240.

[The contribution of an asthma diagnostic consultation service in obtaining an accurate asthma diagnosis for primary care patients: results of a real-life study]

OBJECTIVE

Previous studies showed that general practitioners (GPs) have problems in diagnosing asthma accurately, resulting in both under and overdiagnosis. To support GPs in their diagnostic process an asthma diagnostic consultation service (ADCS) was set up.

DESIGN

We evaluated the performance of this ADCS by analysing the (dis)concordance between the GPs working hypotheses and the ADCS diagnoses and possible consequences this had on the patients' pharmacotherapy.

METHOD

In total 659 patients were included in this study. At this service the patients' medical history was taken and a physical examination and a histamine challenge test were carried out. We compared the GPs working hypotheses with the ADCS diagnoses and the change in medication this incurred.

RESULTS

In 52% (n = 340) an asthma diagnosis was excluded. The diagnosis was confirmed in 42% (n = 275). Furthermore, chronic rhinitis was diagnosed in 40% (n = 261) of the patients whereas this was noted in 25% (n = 163) by their GP. The adjusted diagnosis resulted in a change of medication for more than half of all patients. In 10% (n = 63) medication was started because of a new asthma diagnosis. The 'one-stop-shop' principle was met with 53% of patients and 91% (n = 599) were referred back to their GP, mostly within 6 months. Only 6% (n = 41) remained under control of the ADCS because of severe unstable asthma.

CONCLUSION

In conclusion, the ADCS helped GPs significantly in setting accurate diagnoses for their patients with an asthma hypothesis. This may contribute to diminish the problem of over and underdiagnosis and may result in more appropriate treatment regimens.

Primary care access for mental illness in Australia: Patterns of access to general practice from 2006 to 2016

General practice has an important role within the Australian healthcare system to provide access to care and effective management of chronic health conditions. However, people with serious mental illness experience challenges associated with service access. The current paper seeks to examine drivers of access to general practice for people with common and serious mental disorders, compared with people who access care for type II diabetes, a common physical health problem managed in general practice. The Bettering the Evaluation and Care of Health (BEACH) programme provides the most comprehensive and objective measurement of general practitioner activity in Australia. Using BEACH data, this study compared general practice encounters for depression, anxiety, bipolar disorder, schizophrenia, and type II diabetes during a 10-year period between 2006 and 2016. Analysis revealed more frequent encounters for depression compared to anxiety, and a higher representation of women in encounters for bipolar disorder compared to men. The relationship between number of encounters and patient age was strongly associated with the life course and mortality characteristics associated with each disorder. The findings highlight specific challenges associated with access to primary care for people with serious mental illness, and suggest areas of focus to improve the ability of these patients to access and navigate the health system.

Physicians, sick leave certificates, and patients' subsequent employment outcomes

I analyze how general practitioners (GPs) indirectly affect their patients' employment outcomes by deciding the length of sick leaves. I use an instrumental variables framework where spell durations are identified through supply-side certification measures. I find that a day of sick leave certified only because the worker's GP has a high propensity to certify sick leaves decreases the employment probability persistently by 0.45-0.69 percentage points, but increases the risk of becoming unemployed by 0.28-0.44 percentage points. These effects are mostly driven by workers with low job tenure. Several robustness checks show that endogenous matching between patients and GPs does not impair identification. My results bear important implications for doctors: Whenever medically justifiable, certifying shorter sick leaves to protect the employment status of the patient may be beneficial.

General practitioners can increase participation in cervical cancer screening - a model program in Hungary

BACKGROUND

Cervical cancer is a preventable disease. Unfortunately, its mortality is high in Hungary: 9.2 deaths /100000 women/year in 2015. The Hungarian organized, nationwide cervical screening program was launched in 2003, but it could improve the coverage rate of cervical cancer screening only by a few percentage points. The vast majority of women still uses opportunistic screening and the organized screening program had little impact on participation by women who never or rarely consult their gynecologists. We assessed whether involving general practitioners in the cervical cancer screening process would increase participation.

METHODS

The study consisted of two parts: 1. A questionnaire-based health survey was conducted using a representative sample of women aged 25 to 65 years from 11 Hungarian counties, in which we studied where women obtained information about cervical cancer screening. 2. Additionally, a model program and its evaluation were implemented in the practices of general practitioners in one of the 11 counties (Zala county). In this program, general practitioners were informed of their patients' participation in the cervical cancer screening program, and they motivated those who refused the invitation.

RESULTS

Questionnaire-based health survey: A total of 74% (95% confidence interval (CI): 70-77%) of the target population had a screening examination within the previous 3 years. The majority (58, 95% CI: 54-62%) of the target population did not ask for information about cervical cancer screening at all. Only 21% (95% CI: 17-26%) consulted their general practitioners about cancer screening. Evaluation of the model program: the general practitioners effectively motivated 24 out of 88 women (27, 95% CI: 18-38%) who initially refused to participate in the screening program.

CONCLUSION

The majority of Hungarian women are not informed about cervical cancer screening beyond the invitation letter. General practitioners could play a more important role in mobilizing the population to utilize preventive services. The involvement of general practitioners in the organization of the cervical cancer screening program could increase the participation of those women who generally refuse the services.

Efficacy of nurse-led and general practitioner-led comprehensive geriatric assessment in primary care: protocol of a pragmatic three-arm cluster randomised controlled trial (CEpiA study)

INTRODUCTION

Older patients raise therapeutic challenges, because they constitute a heterogeneous population with multimorbidity. To appraise this complexity, geriatricians have developed a multidimensional comprehensive geriatric assessment (CGA), which may be difficult to apply in primary care settings. Our primary objective was to compare the effect on morbimortality of usual care compared with two complex interventions combining educational seminars about CGA: a dedicated geriatric hotline for general practitioners (GPs) and CGA by trained nurses or GPs.

METHODS AND ANALYSIS

The Clinical Epidemiology and Ageing study is an open-label, pragmatic, multicentre, three-arm, cluster randomised controlled trial comparing two intervention groups and one control group. Patients must be 70 years or older with a long-term illness or with unscheduled hospitalisation in the past 3 months (750 patients planned). This study involves volunteering GPs practising in French primary care centres, with randomisation at the practice level. The multifaceted interventions for interventional arms comprise an educational interactive multiprofessional seminar for GPs and nurses, a geriatric hotline dedicated to GPs in case of difficulties and the performance of a CGA updated to primary care. The CGA is systematically performed by a nurse in arm 1 but is GP-led on a case-by-case basis in arm 2. The primary endpoint is a composite criterion comprising overall death, unscheduled hospitalisations, emergency admissions and institutionalisation within 12 months after inclusion. Intention-to-treat analysis will be performed using mixed-effects logistic regression models, with adjustment for potential confounders.

ETHICS AND DISSEMINATION

The protocol was approved by an appropriate ethics committee (CPP Ile-de-France IV, Paris, France, approval April 2015;15 664). This study is conducted according to principles of good clinical practice in the context of current care and will provide useful knowledge on the clinical benefits achievable by CGA in primary care.

TRIAL REGISTRATION NUMBER

NCT02664454; Pre-results.

GPs' experiences of diagnosing and managing childhood eczema: a qualitative study in primary care

BACKGROUND

Eczema is common among children, and in the UK the majority are managed by GPs. The most common cause of poor disease control is incorrect use of topical treatments. There is a lack of research into the challenges faced by GPs in diagnosing and managing this condition.

AIM

To explore the experiences of GPs in assessing and managing children with eczema.

DESIGN AND SETTING

Qualitative study in primary care in England.

METHOD

Semi-structured interviews with 15 GPs were audiorecorded, transcribed verbatim, and analysed thematically using the framework method.

RESULTS

GPs described a paucity of dermatology training. Although most GPs were confident diagnosing uncomplicated eczema, they reported using a trial-and-error approach to prescribing emollients, and were uncertain about quantities of topical treatments to issue. Mild and moderate potency topical corticosteroids (TCS) were commonly used, but most GPs lacked confidence in recommending potent TCS, and viewed parents or carers to be fearful of using all strengths of TCS. GPs perceived adherence to treatments to be low, but provision of information to support self-care was variable. Routine review of medication use or disease control was uncommon, which GPs attributed to service constraints. Participants' views on the causes and management of eczema were perceived to be at odds with parents and carers, who were said to be overly focused on an underlying cause, such as allergy.

CONCLUSION

GP uncertainty in managing eczema, lack of routine information and review, and perceived dissonance with parents around causation and management may be contributing to low concordance with treatments.

Therapeutic inertia amongst general practitioners with interest in diabetes

INTRODUCTION

As the therapeutic options in the management of type 2 diabetes increase, there is an increase confusion among health care professionals, thus leading to the phenomenon of therapeutic inertia. This is the failure to escalate or de-escalate treatment when the clinical need for this is required. It has been studied extensively in various settings, however, it has never been reported in any studies focusing solely on primary care physicians with an interest in diabetes. This group is increasingly becoming the focus of managing complex diabetes care in the community, albeit with the support from specialists.

METHODS

In this retrospective audit, we assessed the prevalence of the phenomenon of therapeutic inertia amongst primary care physicians with an interest in diabetes in UK. We also assessed the predictive abilities of various patient level characteristics on therapeutic inertia amongst this group of clinicians.

RESULTS

Out of the 240 patients reported on, therapeutic inertia was judged to have occurred in 53 (22.1%) of patients. The full model containing all the selected variables was not statistically significant, p=0.59. So the model was not able to distinguish between situations in which therapeutic inertia occurred and when it did not occur. None of the patient level characteristics on its own was predictive of therapeutic inertia.

CONCLUSION

Therapeutic inertia was present only in about a fifth of patient patients with diabetes being managed by primary care physicians with an interest in diabetes.