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Mucus fishing syndrome is a chronic inflammatory ocular surface condition characterised by repetitive self-extraction of mucous strands from the eye.A man in his 30s presented with bilateral ocular redness, itch, irritation, tearing and sticky mucoid discharge for 3 months. Examination disclosed bilateral bulbar and tarsal conjunctival injection. Fluorescein staining disclosed a well-circumscribed area of tarsal conjunctival epithelial defect near the inferior lacrimal punctum in both eyes. The patient admitted to a habit of mechanically removing mucus from his eyes several times a day. Demonstration of the mucus extraction process disclosed direct contact of his fingers with the excoriated tarsal conjunctiva in each eye. He was diagnosed with mucus fishing syndrome and his condition resolved within a month after he stopped fishing mucus from his eyes and had a course of topical antibiotics and steroids.Mucus fishing syndrome is an important diagnostic consideration in patients with chronic conjunctivitis.

Background In the diagnostic work-up of deep vein thrombosis (DVT), the use of point-of-care-test (POCT) D-dimer assays is emerging as a promising patient-friendly alternative to regular D-dimer assays, but their cost-effectiveness is unknown. We compared the cost-effectiveness of two POCT-based approaches to the most common, laboratory-based, situation. Methods A patient-level simulation model was developed to simulate the diagnostic trajectory of patients presenting with symptoms of DVT at the general practitioner (GP). Three strategies were defined for further diagnostic work-up: one based on current guidelines (‘regular strategy’) and two alternative approaches where a POCT for D-dimer is implemented at the 1) phlebotomy service (‘DVT care pathway’) and 2) GP practice (‘fast-POCT strategy’). Probabilities, costs and health outcomes were obtained from the literature. Costs and effects were determined from a societal perspective over a time horizon of 6 months. Uncertainty in model outcomes was assessed with a one-way sensitivity analysis. Results The Quality-Adjusted Life Years (QALYs) scores for the three DVT diagnostic work-up strategies were all around 0.43 across a 6 month-time horizon. Cost-savings of the two POCT-based strategies compared to the regular strategy were €103/patient for the DVT care pathway (95% CI: -€117–89), and €87/patient for the fast-POCT strategy (95% CI: -€113–67). Conclusions Point-of-care-based approaches result in similar health outcomes compared with regular strategy. Given their expected cost-savings and patient-friendly nature, we recommend implementing a D-dimer POCT device in the diagnostic DVT work-up.

Background Internationally, there is an ‘evidence-practice gap’ in the rate healthcare professionals assess tobacco use and offer cessation support in clinical practice, including primary care. Evidence is needed for implementation strategies enacted in the ‘real-world’. Aim: To identify implementation strategies aiming to increase smoking cessation treatment provision in primary care, their effectiveness, cost-effectiveness and any perceived facilitators and barriers for effectiveness. Methods ‘Embase’, ‘Medline’, ‘PsycINFO’, ‘CINAHL’, ‘Global Health’, ‘Social Policy & Practice’, ‘ASSIA Applied Social Sciences Index and Abstracts’ databases, and grey literature sources were searched from inception to April 2021. Studies were included if they evaluated an implementation strategy implemented on a nation-/state-wide scale, targeting any type of healthcare professional within the primary care setting, aiming to increase smoking cessation treatment provision. Primary outcome measures: implementation strategy identification, and effectiveness (practitioner-/patient-level). Secondary outcome measures: perceived facilitators and barriers to effectiveness, and cost-effectiveness. Studies were assessed using the Risk Of Bias In Non-randomized Studies of Interventions (ROBINS-I) tool. A narrative synthesis was conducted using the Expert Recommendations for Implementing Change (ERIC) compilation and the Consolidated Framework for Implementation Research (CFIR). Results Of 49 included papers, half were of moderate/low risk of bias. The implementation strategy domains identified involved utilizing financial strategies, changing infrastructure, training and educating stakeholders, and engaging consumers. The first three increased practitioner-level smoking status recording and cessation advice provision. Interventions in the utilizing financial strategies domain also appeared to increase smoking cessation (patient-level). Key facilitator: external policies/incentives (tobacco control measures and funding for public health and cessation clinics). Key barriers: time and financial constraints, lack of free cessation medications and follow-up, deprioritisation and unclear targets in primary care, lack of knowledge of healthcare professionals, and unclear messaging to patients about available cessation support options. No studies assessed cost-effectiveness. Conclusions Some implementation strategy categories increased the rate of smoking status recording and cessation advice provision in primary care. We found some evidence for interventions utilizing financial strategies having a beneficial impact on cessation. Identified barriers to effectiveness should be reduced. More pragmatic approaches are recommended, such as hybrid effectiveness-implementation designs and utilising Multiphase Optimization Strategy methodology. Protocol registration PROSPERO:CRD42021246683

BACKGROUND AND OBJECTIVES: Case 2 best-worst scaling (BWS-2) is an increasingly popular method to elicit patient preferences. Because BWS-2 potentially has a lower cognitive burden compared with discrete choice experiments, the aim of this study was to compare treatment preference weights and relative importance scores.METHODS: Patients with neuromuscular diseases completed an online survey at two different moments in time, completing one method per occasion. Patients were randomly assigned to either first a discrete choice experiment or BWS-2. Attributes included: muscle strength, energy endurance, balance, cognition, chance of blurry vision, and chance of liver damage. Multinomial logit was used to calculate overall relative importance scores and latent class logit was used to estimate heterogeneous preference weights and to calculate the relative importance scores of the attributes for each latent class.RESULTS: A total of 140 patients were included for analyses. Overall relative importance scores showed differences in attribute importance rankings between a discrete choice experiment and BWS-2. Latent class analyses indicated three latent classes for both methods, with a specific class in both the discrete choice experiment and BWS-2 in which (avoiding) liver damage was the most important attribute. Ex-post analyses showed that classes differed in sex, age, level of education, and disease status. The discrete choice experiment was easier to understand compared with BWS-2.CONCLUSIONS: This study showed that using a discrete choice experiment and BWS-2 leads to different outcomes, both in preference weights as well as in relative importance scores, which might have been caused by the different framing of risks in BWS-2. However, a latent class analysis revealed similar latent classes between methods. Careful consideration about method selection is required, while keeping the specific decision context in mind and pilot testing the methods.

International audience; PURPOSE: The patient partner in teaching method is progressively developing for clinical training in France. Practice exchange groups (PEG) co-facilitated by patient partners in teaching are used during the training of family medicine (FM) residents. This study explored the FM residents’ perspectives about patient partner in teaching’s participation in co-facilitated PEGs and how they changed over time. STUDENTS AND METHODS: In 2020, qualitative focus groups were carried out with 26 FM residents before and after a 5-month intervention based on monthly PEGs co-facilitated by patient partners in teaching. A reflective thematic analysis of the focus group interviews was performed according to Braun and Clarke’s approach. RESULTS: FM residents supported patient partners in teaching’s facilitation role and had high expectations concerning their contribution to the development of their skills and competencies. They expected patient partners in teaching to bring their individual experience and also a collective knowledge. Some limitations mentioned by FM residents disappeared over time, such as the loss of the medical group feeling among physicians, while others persisted and required pedagogical support targeted to FM residents before PEG initiation. CONCLUSION: This study shows the good acceptance of patient partners in teaching by FM residents in the context of PEGs. Attention should be paid to make FM residents aware of patient partners in teaching’s missions before their introduction.[Box: see text].

Objective: To illustrate the views of chief physicians in Finnish primary healthcare health centres (HCs) on the existing research capacity of their centres, their attitudes to practice-based research network activity, and research topics of interest to them. Design: A cross-sectional survey study. Setting: Finnish HCs. Subjects: Chief physicians in Finnish HCs. Main outcome measures: We used a questionnaire that included five-point Likert scales and multiple choice and open-ended questions to identify the chief physician’s profile, the HC content, the attitudes of chief physicians towards engagement in research, research topics of interest to them, and factors that may influence their motivation. Descriptive methods were used for the analysis of the quantitative data, while the qualitative data were processed using inductive thematic analysis. Results: There was a relatively good representation of all hospital districts. One-third of HCs had at least one person doing research, and 61% of chief physicians would support research in their setting. Their stimulus for research was primarily testing new therapies, protocols, and care processes, as well as effectiveness and healthcare improvement. The expected benefits that motivate engagement in Practice-based research networks (PBRNs) are evidence-based practice and raised professional capacity and profile of the HC. Conclusions: Chief physicians regard research as an elementary part of the development of primary care practices and health policy. Their motivation to engage in PBRN activity is determined by the relevance of the research to their interests and the management of competing priorities and resource limitations. publishedVersion

Objective: To describe the development over time of the use of C-reactive protein (CRP) and rapid streptococcal detection test (RADT) point-of-care tests (POCT) in Danish general practice and to explore associations between patient characteristics and POCT use (i.e. CRP and RADT). Design and settings: A register-based study including all general practice clinic consultations in daytime and out-of-hours (OOH) settings in Denmark between 2003 and 2018. Subjects: All citizens who had at least one clinic consultation in daytime or OOH general practice within the study period. Main outcome measures: We estimated the total and relative use of CRP and RADT POCTs and described the development over time. Crude and adjusted proportion ratios (PRs) were calculated to explore associations between patient characteristics and POCT use. Results: Overall, the relative use of CRP POCTs increased. At OOH, a steep increase was noticed around 2012. The relative use of RADT decreased. Patient age 40–59 years and existing comorbidity were significantly associated with a higher use of CRP testing in both settings. A significantly lower use of CRP testing was found for patients with higher educational level. We found a significantly higher use of RADT testing for patients aged 0–19 years and with higher household educational level, whereas comorbidity was associated with a lower use of RADT testing. Conclusion: The use of CRP POCT increased over time, whereas the use of RADT POCT decreased. Perhaps the success of implementing CRP as a tool for reducing antibiotic use has reached it limit. Future studies should focus on how and when POCT are used most optimal.Key points CRP POC tests and RADT POCTs are frequently used diagnostic tools in general practice, both in daytime and in the out-of-hours setting. There was an increased use of CRP POCTs, particularly in out-of-hours general practice, whereas the use of RADT POCTs declined between 2003 and 2018. CRP POCTs were associated with age of 40–59 years and co-morbidity, while the use of RADT was mostly associated with younger age.

BackgroundTwo general practices close every week in the UK. Given the pressure on UK general practices, such closures are likely to persist. Yet little is known about the consequences. Closure refers to when a practice ceases to exist, merges, or is taken over.AimTo explore whether practice funding, list size, workforce composition, and quality change in surviving practices when surrounding general practices close.Design and settingA cross-sectional study of English general practices was undertaken, using data from 2016–2020.MethodThe exposure to closure for all practices existing on 31 March 2020 was estimated. This is the estimation proportion of a practice’s patient list that had been through a closure in the preceding 3 years, between 1 April 2016 and 3 March 2019. The interaction between the exposure to closure estimate and the outcome variables (list size, funding, workforce, and quality) was analysed through multiple linear regression, while controlling for confounders (age profile, deprivation, ethnic group, and rurality).ResultsA total of 694 (8.41%) practices closed. A 10% increase in exposure to closure resulted in 1925.6 (95% confidence interval [CI] = 1675.8 to 2175.4) more patients in the practice with £2.37 (95% CI = £4.22 to £0.51) less funding per patient. While numbers of all staff types increased, there were 86.9 (95% CI = 50.5 to 123.3), 4.3%, more patients per GP. Increases for other staff types were proportionate to increases in patients. Patient satisfaction with services declined across all domains. No significant difference in Quality and Outcomes Framework (QOF) scores was identified.ConclusionHigher exposure to closure led to larger practice sizes in remaining practices. Closure of practices changes workforce composition and reduces patient satisfaction with services.

ObjectiveThe aim was to compare rapid antigen detection test (RADT) and throat culture for group A streptococci (GAS) among patients recently treated with penicillin V for GAS pharyngotonsillitis.Design and settingThe study was a secondary analysis within a randomized controlled trial comparing 5 versus 10 days of penicillin V for GAS pharyngotonsillitis. Patients were recruited at 17 primary health care centres in Sweden.SubjectsWe included 316 patients >= 6 years of age, having 3-4 Centor criteria, a positive RADT and a positive throat culture for GAS at inclusion, and also having a RADT and throat culture for GAS taken at a follow-up visit within 21 days.Main outcome measuresRADT and conventional throat culture for GAS.ResultsThis prospective study showed 91% agreement between RADT and culture at follow-up within 21 days. Only 3/316 participants had negative RADT with a positive throat culture for GAS at follow-up, and 27/316 patients with positive RADT had a negative culture for GAS. Log rank test did not reveal any difference in the decline over time of positive tests between RADT and throat culture (p = 0.24). Agreement between RADT and throat culture for GAS at the follow-up was not associated with treatment duration, number of days from inclusion until follow-up, throat symptoms at follow-up, gender, or age.ConclusionRADT and culture for GAS agreed to a high extent also after recent penicillin V treatment. RADT for GAS means a low risk for missing the presence of GAS.

Research has shown improved health outcomes when patients are involved in managing their health conditions and when their individual needs are considered.This scoping review aimed to map the existing research regarding chronic disease patients' involvement in their encounters with general practice, with a specific focus on patients with Type 2 diabetes (TD2) or chronic obstructive pulmonary disease (COPD) and from the perspectives of both general practitioners and patients.Studies of any design, date, and language were included. A systematic search was conducted using the following databases: Medline, CINAHL, PsycInfo, Scopus, and EMBASE from August until October 2020 and renewed September 2021. Data were systematically charted by the following study characteristics: bibliographic aims; study aims; setting; area of interest; results; conclusion.Eighteen studies were included; they conducted qualitative methods, surveys or mixed methods. From the patients' perspectives, the importance of being more involved in treatment discussions during consultations as well as a friendly environment, was underscored. A good relationship and relational continuity make it easier for patients to be more involved in treatment decisions. From the general practitioner (GP) perspectives, they mentioned their high workload, long-standing relationships, knowledge about the patients and prepared patients as factors influencing their ability to involve patients in treatment discussions.A good GP-patient relationship was considered an important aspect to providing and facilitating for involvement of patients with COPD or TD2. Scoping review registration: https://osf.io/ynqt2.

AIMS: Heart failure (HF) is an important health problem for which multidisciplinary care is recommended, yet few studies involve primary care practitioners in the multidisciplinary management of HF. We set up a multifaceted prospective observational trial, OSCAR-HF, piloting audit and feedback, natriuretic peptide testing at the point of care, and the assistance of a specialist HF nurse in primary care. The aim was to optimize HF care in general practice. METHODS AND RESULTS: This is an analysis at 6 month follow-up of the study interventions of the OSCAR-HF pilot study, a nonrandomized, noncontrolled prospective observational trial conducted in eight Belgian general practices [51 general practitioners (GPs)]. Patients who were assessed by their GP to have HF constituted the OSCAR-HF study population. We used descriptive statistics and mixed-effects modelling for the quantitative analysis and thematic analysis of the focus group interviews. There was a 10.2% increase in the registered HF population after 6 months of follow-up (n = 593) compared with baseline (n = 538) and a 27% increase in objectified HF diagnoses (baseline n = 359 to 456 at T6 M). Natriuretic peptide testing (with or without referral) accounted for 54% (n = 60/111) of the newly registered HF diagnoses. There was no difference in the proportion of patients with HF with reduced ejection fraction who received their target dosage of renin-angiotensin-aldosterone system inhibitors or beta-blockers at 6 months compared with baseline (P = 0.9). Patients who received an HF nurse intervention (n = 53) had significantly worse quality of life at baseline [difference in Minnesota Living with Heart Failure Questionnaire (MLHFQ) score 9.2 points; 95% confidence interval (CI) 4.0, 14] and had a significantly greater improvement in quality-of-life scores at the 6 month follow-up [change in MLHFQ score -9.8 points; 95% CI -15, -4.5] than patients without an HF nurse intervention. GPs found audit and feedback valuable but time intensive. Natriuretic peptides were useful, but the point-of-care test was impractical, and the assistance of an HF nurse was a useful addition to routine HF care. CONCLUSIONS: The use of audit and feedback combined with natriuretic peptide testing was a successful strategy to increase the number of registered and objectified HF diagnoses at 6 months. GPs and HF nurses selected patients with worse quality-of-life scores at baseline for the HF nurse intervention, which led to a significantly greater improvement in quality-of-life scores at the 6 month follow-up compared with patients without an HF nurse intervention. The interventions were deemed feasible and useful by the participating GPs with some specific remarks that can be used for optimization. TRIAL REGISTRATION: ClinicalTrials.gov (NCT02905786), registered on 14 September 2016 at https://clinicaltrials.gov/. ispartof: ESC Heart Fail vol:10 issue:2 pages:907-916 ispartof: location:England status: published

BACKGROUND: This project was undertaken to improve the documentation of Just in Case (JiC) medication in a general practice. The outcome of a Strengths, Weaknesses, Opportunities, Threats (SWOT) analysis highlighted this as an area where awareness within the practice could be improved. OBJECTIVE: A Plan-Do-Study-Act (PDSA) approach was taken to the project and involved collaborative working and data collection from the general practice and relevant care homes. METHOD: JiC medications are used to promptly manage symptoms experienced at the end of a patient’s life and are part of the Gold Standard Framework (2006). RESULTS: Of the patients registered at the practice with JiC medication, 37.5% were incorrectly documented. This included errors/ inaccuracy with the clinical coding, or the medication. Three patients on practice generated searches had no JiC medication in the care homes, and 4 patients had JiC boxes in the care home that was not identified by the search. CONCLUSION: This evaluation has identified documentation errors and discrepancies between practice and community records of JiC medication. A newly generated practice specific flowchart was created, with an aim of reducing the discrepancies. A guide of how to carry out a QI project like this was created for the RCGP and can be found on their website. A seminar at Bristol, North Somerset, and South Gloucestershire (BNSSG) CCG to present this project took place in 2021.

BACKGROUND: Sleep disorders, including insomnia, are widespread problems, which have increased during the COVID-19 pandemic. Guidelines for the treatment of insomnia prioritize non-pharmacological interventions. Nevertheless, primary care professionals lack well-developed material for patient education, that could help implement the treatment guidelines in Flanders, Belgium. OBJECTIVE: This project's purpose is to develop complementary, written educational material, grounded in the principles of evidence-based practice, for primary care. PATIENT INVOLVEMENT: This co-design project involved patients and health professionals. Special attention was given to including patients with low health literacy, and empowering patients when designing in mixed groups. METHODS: Based on the framework of Sanders and Stappers (2014), data were collected and analyzed in four phases. Pre-design, needs were explored using think-aloud studies and focus groups. Next, for generative purposes, the design studio method was used. Then, evaluation of the prototype happened with another series of think-aloud studies. Finally, post-design, implementation of the product was evaluated with a short survey. RESULTS: Twenty-five participants (10 patients and 15 healthcare professionals) contributed to the development of an educational patient leaflet called Sssssst. How do you sleep (at night)? Out of 30 professionals who received the printed leaflet for use in practice, 17 provided feedback after six months. Generally, the leaflet was well received. Visual design aspects stimulated use in practice. DISCUSSION: Written and visual materials aid primary care professionals to educate patients on sleep and insomnia. This supporting tool also stimulates self-management in patients. Although inspiring and educational for all stakeholders, a co-design approach is no guarantee for the product to "fit all". ispartof: PATIENT EDUCATION AND COUNSELING vol:105 issue:12 pages:3558-3565 ispartof: location:Ireland status: published

The clinical working hours of early-career general practitioners (GPs) are an important factor in Australian GP workforce planning. This study aimed to establish the prevalence and associations of early-career GPs working full time (nine or more sessions per week) in clinical practice.This was a cross-sectional questionnaire-based study of alumni (from six months to two years post-Fellowship) from three regional training organisations. Multivariable logistic regression was used to establish factors associated with alumni working full time.Of 356 currently practising early-career alumni participants, 30% worked full time. Factors associated with working full time included spouse/partner employment and family structure and any examination failure. Factors associated with working less than full time included female gender, being an Australian medical graduate, provision of other medical work and having taken additional leave during training.A high proportion of early-career GPs working part time in clinical general practice has implications for workplace planning, as GPs seek workload diversity and flexibility across their career stages.

Acute open wounds constitute a significant part of general practice. With an expanding global market of dressing products, selection of wound dressings remains an area of concern among doctors entering general practice.The aim of this article is to describe a practical guide for choosing appropriate dressings when treating acute open wounds in general practice.Although dressing is an essential element of standard wound care, it is important to remember that dressing alone does not heal the wound. Judicious selection of dressings based on wound characteristics, physical properties of dressings and their costs, shelf life and availability are important for delivering appropriate care towards timely healing of acute wounds.

Domestic and family violence (DFV) is often difficult to recognise despite its high prevalence in the community. General practitioners require specialised skills to elicit a history of DFV, remain aware of the complex patterns of DFV, respond to potential risk and maintain engagement as part of a team involved in ongoing care.The aim of this article is to outline the principles of recognising, responding, referring, recording and reflecting on care for those who may be experiencing DFV.GPs have unique opportunities to identify, assess and respond to DFV because of the trusting therapeutic relationships they develop with patients. Managing DFV requires a safe place to disclose, skilled risk assessment, careful documentation, safety planning and ongoing therapeutic processes that soothe, validate, empower and connect to wider social supports. Trauma-informed general practice is a key element of integrated systems responses to DFV in our community.

Burnout interventions for trainee doctors have typically overlooked specialty-specific factors as well as presumed centralised training models. The aim of this study was to explore stakeholders' views of burnout interventions within Australian general practice training, where both factors are pertinent.Forty-seven trainees, supervisors, medical educators and program coordinators from a regional training organisation participated in interviews and focus groups. Template analysis, informed by grounded theory, was used.Strategies were identified for registrars (eg prioritising replenishing activities), practices (eg providing psychological supports), training organisations (eg engaging with trainees) and the medical system (eg destigmatising poor wellbeing). Ineffective strategies (eg tokenistic interventions) were also highlighted, albeit to a lesser extent.Stakeholders reiterated that burnout prevention and management require both individual and organisational-level change. Specific strategies for practices (eg consideration of workload issues and supports) and training organisations (eg structural changes to training requirements) are delineated, which, in combination, may enhance intervention efficacy within a decentralised training system.

Awareness of the significance of non‑fatal strangulation is increasing in health and justice settings. While approximately half of patients strangled will sustain no immediate physical injury, strangulation has potential significant sequelae such as carotid dissection, hypoxic brain injury and laryngeal injury. Non-fatal strangulation by an intimate partner increases homicide risk by 7.48 times. General practitioners have a key role in identification, education and appropriate treatment. OBJECTIVE: The aim of this article is to provide an understanding of strangulation and its associated risks, to inform decision making regarding assessment, investigation and appropriate patient referral and safety netting. DISCUSSION: Informing patients of the increased risk of future homicide if strangled by an intimate partner may prevent death. Awareness of the red flag signs and symptoms, from subtle bruises or petechiae to significant oedema, focal neurological deficits and cognitive impairment, aids decision making regarding referrals and imaging as well as informing documentation for legal purposes.

Background General practitioners (GPs) have recognized the presence of gut feelings in their diagnostic process. However, little is known about the frequency or determinants of gut feelings or the diagnostic value of gut feelings for cancer and other serious diseases. Objective To assess the prevalence of gut feelings in general practice, examine their determinants and impact on patient management, and measure their diagnostic value for cancer and other serious diseases. Design This prospective observational study was performed using the Gut Feelings Questionnaire (GFQ). Participants Participants included 155 GPs and 1487 of their patients, from four Spanish provinces. Main Measures Sociodemographic data from patients and GPs; the reasoning style of GPs; the characteristics of the consultation; the presence and kind of gut feeling; the patient’s subsequent contacts with the health system; and new cancer and serious disease diagnoses reported at 2 and 6 months post-consultation. Key Results GPs experienced a gut feeling during 97% of the consultations: a sense of reassurance in 75% of consultations and a sense of alarm in 22% of consultations. A sense of alarm was felt at higher frequency given an older patient, the presence of at least one cancer-associated symptom, or a non-urban setting. GPs took diagnostic action more frequently after a sense of alarm. After 2 months, the sense of alarm had a sensitivity of 59% for cancer and other serious diseases (95% CI 47–71), a specificity of 79% (95% CI 77–82), a positive predictive value of 12% (95% CI 9–16), and a negative predictive value of 98% (95% CI 86–98). Conclusions Gut feelings are consistently present in primary care medicine, and they play a substantial role in a GP’s clinical reasoning and timely diagnosis of serious disease. The sense of alarm must be taken seriously and used to support diagnostic evaluation in patients with a new reason for encounter.

SUMMARY OBJECTIVE: Malignant cutaneous melanoma is the most aggressive type of skin cancer, and its early detection and prompt initiation of treatment play an important role in reducing disease-associated morbidity and mortality. Many factors influence the diagnosis of melanoma, and its recognition is essential for the development of strategies for its early detection. This study was carried out to Identify the main variables related to the delay in diagnosis of Malignant Cutaneous Melanoma and correlate them with the time interval for making the definitive diagnosis. METHODS: Retrospective analysis of 103 patient records from January 2015 to December 2020 correlating social, economic, demographic, and cultural factors with the time elapsed between the onset of symptoms and the diagnosis of malignant cutaneous melanoma. RESULTS: The average time to seek medical services from the onset of symptoms was 29.54 months. The mean time for a referral from the primary to the referral service was 1.35 months, and the factors that contributed to a faster diagnosis were lesion Breslow (>1 mm), lesion growth, income range (≤1.5 minimum wages), lower phototypes (I and II), not having gone to the Basic Healthcare Units, profession (household), smoking, and type of housing. CONCLUSIONS: Our findings demonstrate that there is still a great delay in the recognition of signs and symptoms related to the diagnosis of malignant cutaneous melanoma in our country, influenced by several socioeconomic and demographic factors.

We explored whether having a variety of work roles and extra support during the first 2 years after qualifying would retain general practitioners (GPs) in London. Newly qualified GPs were offered a Fellowship comprising permanent salaried positions, part-time (portfolio) roles outside general practice and peer support for 1-2 years.We surveyed newly qualified GPs taking part in the Fellowship near the beginning of their Fellowship (91) and again after 8-10 months (93). We interviewed 34 newly qualified GPs taking part in the Fellowship and 20 who were not. We surveyed and interviewed representatives from employing practices (171), organisations hosting portfolio roles (20), those facilitating the Fellowship (10) and other stakeholders (43).Over a 2.5-year period, employers recruited and retained 425 newly qualified GPs to salaried posts using the Fellowship. Eighty-eight per cent of the newly qualified GPs taking part said they intended to stay working in local practices. They said that undertaking a portfolio role helped them feel valued, had more variety and integration with the wider professional community. Those with two or more portfolio sessions per week were the most positive.Portfolio roles and peer support may increase newly qualified GPs intention to stay working in salaried posts, however it is too early to say whether these intentions will translate into behaviour.Portfolio roles and monthly peer support helped newly qualified GPs feel supported and valued, which may influence their intention to stay working in general practice locally.

There is growing evidence regarding the effectiveness of registrar training through video cameras, which has relevance for quality supervision during times of crises such as the global COVID-19 pandemic.Interviews were conducted in 2012 with supervisors, registrars and patients evaluating video camera use for tele-supervision across six rural sites in Gippsland, Australia. Thematic analysis was employed in 2013 - and re-examined in 2021 in light of the global COVID-19 pandemic - to explore user experience with video technology.Participants identified advantages of video supervision addressing distance and temporal issues, also emphasising quality supervision and education. Challenges included patient confidentiality, internet stability and loss of serendipitous 'corridor conversations'.Remote supervision is no longer simply an issue for rural and remote training. During crises such as a global pandemic, tele-supervision becomes the purview of all. There are distinct merits and limitations in adopting video technology, warranting consideration of individual training contexts. These findings can help inform remote supervision via video in varied milieu.

BackgroundThere are inequalities in the geographical distribution of the primary care workforce in England. Primary Care Networks (PCNs), and the associated Additional Roles Reimbursement Scheme (ARRS) funding, has stimulated employment of new healthcare roles. However, it is not clear whether this will impact inequalities. AimTo examine whether the ARRS impacted inequality in the distribution of primary care workforce.Design and SettingA retrospective before-and-after study of English PCNs in 2019 and 2022MethodsWe combined workforce, population and deprivation data at network-level for March 2019 and March 2022. We estimated the change between 2019 and 2022 in the Slope Index of Inequality (SII) across deprivation of full-time equivalent general practitioners (total doctors, qualified GPs and doctors-in-training), nurses, other direct patient care (ARRS and non-ARRS staff), administrative, and total staff per 10,000 patients.Results1255 networks were included. Nurses and qualified GPs decreased in number whilst all other staff roles increased, with ARRS staff having the greatest increase. There was a pro-rich change in the SII for administrative staff (-0.482 (95% CI: -0.841, -0.122)) and a pro-poor change for doctors-in-training (0.161 (0.049, 0.274)). Changes in distribution of all other staff types were not statistically significant. ConclusionThe distribution of administrative staff became less pro-poor and of doctors-in-training became pro-poor between 2019 and 2022. The changes in inequality in all other staff groups were mixed. The introduction of PCNs has not substantially changed the longstanding inequalities in the geographical distribution of primary care workforce.

Urinary tract infection (UTI) is a common cause for prescription of antibiotics among women in general practice. Diagnosis is often established by inquiry into clinical history and symptoms, and these may be experienced differently depending on menopause status of the woman. The aim of this study was to assess differences in severity and bothersomeness of UTI symptoms between pre- and postmenopausal women. We used a convenience sample of 313 women with suspected UTIs and typical symptoms recruited in general practice. Each woman completed the Holm and Cordoba UTI score (HCUTI), measuring the severity and bothersomeness of the dimensions: dysuria, frequency, lower back, and general symptoms. The exposure was menopausal status. Differences in the various HCUTI dimensions between the menopause groups were investigated in linear regression models, adjusting for potential confounders. Premenopausal women had a significantly higher severity score for the item “feeling unwell” than postmenopausal women (mean difference −0.59, 95% CI −0.88 to −0.31). They also had a significantly higher bothersomeness score for the items “pain on urination” (mean difference −0.54, 95% CI −0.83 to −0.25), “feeling unwell” (mean difference −0.62, 95% CI −0.92 to −0.32), and for the dimension “dysuria” (mean difference −0.38, 95% CI −0.61 to −0.15) than postmenopausal women. This study found differences in some aspects of symptom severity and bothersomeness between pre- and postmenopausal women presenting in general practice with suspected UTIs. Menopausal status should be taken into account when using symptoms to diagnose and evaluate response to UTI treatment in both clinical practice and research.

Background: The CombiConsultation is a consultation with the community pharmacist for patients with diabetes, COPD and/or cardiovascular disease (CVD), aligned with the annual or quarterly consultation with the practice nurse (PN) or general practitioner (GP). The consultation is focused on the personal health-related goals of the patient. Objectives: To assess the number and types of personal health-related goals, drug-related problems (DRPs) and interventions identified by pharmacists during a CombiConsultation and to investigate which patients can benefit most from such consultation. Method: Twenty-one Dutch community pharmacies and associated GP practices were included in the CombiConsultation study. CombiConsultations were performed, involving patients with diabetes, COPD and/or (at risk of) CVD. The pharmacists set health-related goals together with the patients and identified DRPs. The number and types of personal health-related goals, DRPs and interventions were analysed. Associations between patient characteristics and the identification of at least one DRP were analysed by multivariate regression analysis. Results: In 834 patients (49% men, mean age: 70 years), 939 DRPs were identified, mostly (potential) side effects (33%), undertreatment (18%) and overtreatment (14%). In 71% of the patients, one or more DRPs were found, with a median of one DRP per patient. Pharmacists proposed 935 recommendations, of which 72% were implemented. DRPs were found more often in patients using a higher number of drugs for chronic conditions. A total of 425 personal health-related goals were set, of which 53% were (partially) attained. Conclusion: The CombiConsultation can be used as a compact health service contributing to safe and effective use of medication for patients with diabetes, COPD and/or (at risk of) CVD, also in patients under 65 or with less than 5 medications in use. The output of the CombiConsultation reflects its characteristics.

Background: The Ask-Advise-Connect approach can help primary care providers to increase the number of smokers that attempt to quit smoking and enrol into cessation counselling. The approach has not yet been implemented in general practice in the Netherlands. The aim of this study was to investigate the influence of a comprehensive implementation strategy on the delivery of Ask-Advise-Connect for smoking cessation within Dutch general practice during the COVID-19 pandemic. Methods: A pre-post study was conducted between late 2020 and early 2022, and included 106 Dutch primary care providers (GPs, practice nurses and doctor's assistants). Participation lasted nine months: during the first three months participants delivered smoking cessation care as usual (pre-intervention); the implementation strategy came into effect after three months and participants were followed up for another six months (post-intervention). The implementation strategy consisted of two meetings in which participants were educated about Ask-Advise-Connect, made agreements on the implementation of Ask-Advise-Connect and reflected on these agreements. Participants also received online educational materials and a desk card as reminder. The changes in the proportions of 'Ask' and 'Advise' over time were modelled using linear mixed effects models. A descriptive analysis was conducted with regard to referrals to cessation counselling. Results: Participants provided consultations to 29,112 patients (both smokers and non-smokers). Results of the linear mixed effects model show that the proportion of patients that were asked about smoking ('Ask') significantly decreased in the first three months (pre-intervention), but slightly increased again after the implementation strategy came into effect (post-intervention). No significant change over time was found with regard to the proportion of patients advised to quit smoking ('Advise'). Descriptive statistics suggested that more participants proactively (vs. passively) referred patients to cessation counselling post-intervention ('Connect'). Conclusions:The findings indicate that a comprehensive implementation strategy can support primary care providers in offering smoking cessation care to patients, even under stressful COVID-19 conditions. Additional implementation efforts are needed to increase the proportion of patients that receive a quit advice and proactive referral.

COVID-19 pandemic-related pressures on primary care may have driven the inappropriate continuation of antibiotic prescriptions. Yet, prescribing modality (repeat/non-repeat) has not previously been investigated in a pandemic context. With the approval of NHS England, we conducted a retrospective cohort study of >19 million English primary care patient records using the OpenSAFELY-TPP analytics platform. We analysed repeat/non-repeat prescribing frequency in monthly patient cohorts between January 2020 and 2022. In-depth analysis was conducted on January 2020 (“pre-pandemic”) and January 2021 (“pandemic”) cohorts (with a particular focus on repeat prescribing). Per-patient prescribing and clinical conditions were determined by searching primary care records using clinical codelists. Prescriptions in a 6-month lookback period were used to delineate repeat prescribing (≥3 prescriptions) and non-repeat prescribing (1–2 prescriptions). Associations between demographics (e.g., age, sex, ethnicity) and prescribing were explored using unadjusted risk ratios. The frequency of clinical conditions among prescribed patients was examined. Antibiotic prescribing declined from May 2020; non-repeat prescribing declined more strongly than repeat prescribing (maximum declines −26% vs. −11%, respectively). Older patients were at a higher risk of prescribing (especially repeat prescribing). Comorbidities were more common among repeat- vs. non-repeat-prescribed patients. In the pandemic cohort, the most common clinical conditions linked to repeat prescribing were COPD comorbidity and urinary tract infection. Our findings inform the ongoing development of stewardship interventions in England, targeting patient groups wherein there is a high prevalence of repeat prescribing.

BackgroundPractice-based pharmacists (PBPs) have been introduced into general practice across the UK to relieve some of the pressures within primary care. However, there is little existing UK literature that has explored healthcare professionals’ (HCPs’) views about PBP integration and how this role has evolved.AimTo explore the views and experiences of GPs, PBPs, and community pharmacists (CPs) about PBPs’ integration into general practice and their impact on primary healthcare delivery.Design and settingA qualitative interview study in primary care in Northern Ireland.MethodPurposive and snowball sampling were used to recruit triads (a GP, a PBP, and a CP) from across five administrative healthcare areas in Northern Ireland. Sampling of practices to recruit GPs and PBPs commenced in August 2020. These HCPs identified the CPs who had most contact with the general practices in which the recruited GPs and PBPs were working. Semi-structured interviews were recorded, transcribed verbatim, and analysed using thematic analysis.ResultsEleven triads were recruited from across the five administrative areas. Four main themes in relation to PBPs’ integration into general practices were revealed: evolution of the role; PBP attributes; collaboration and communication; and impact on care. Areas for development were identified such as patient awareness of the PBP role. Many saw PBPs as a ‘central hub–middleman’ between general practice and community pharmacies.ConclusionParticipants reported that PBPs had integrated well and perceived a positive impact on primary healthcare delivery. Further work is needed to increase patient awareness of the PBP role.

Objective: To characterise and explore the development in the number and content of urine samples sent from general practice in the North Denmark Region to the Department of Clinical Microbiology (DCM) at Aalborg University Hospital during a five-year period.Design: A register-based study.Setting: General practice.Subjects: Urine samples received at DCM, Aalborg University Hospital from general practice between 2017 and 2022.Main outcome measures: Number and content of urine samples.Results: A total of 255,271 urine samples from general practice were received at DCM, with 76.1% being from female patients. Uropathogens were identified in 43.0% of the samples. During the five-year period, a 23.0% increase in the number of urine samples per person (incidence rate ratio (IRR) 1.23, 95% CI 1.21-1.25) was observed. A slight increase in the proportion of positive cultures (risk ratio (RR) 1.03, 95% CI 1.01-1.05) was seen. No notable change in the patient population (age, gender) was observed. Overall, Escherichia coli was the most identified uropathogen (60.4%) followed by Klebsiella spp. (8.7%) and Enterococcus spp. (7.7%). Distribution of the various uropathogens differed slightly depending on patient gender and age, importantly E. coli was less frequently observed in males aged >65 years.Conclusion: During the past five years an increasing amount of urine cultures have been requested at DCM from general practice. Importantly, the cause(s) of this increasing demand needs to be explored further in future studies. Objective: To characterise and explore the development in the number and content of urine samples sent from general practice in the North Denmark Region to the Department of Clinical Microbiology (DCM) at Aalborg University Hospital during a five-year period.Design: A register-based study.Setting: General practice.Subjects: Urine samples received at DCM, Aalborg University Hospital from general practice between 2017 and 2022.Main outcome measures: Number and content of urine samples.Results: A total of 255,271 urine samples from general practice were received at DCM, with 76.1% being from female patients. Uropathogens were identified in 43.0% of the samples. During the five-year period, a 23.0% increase in the number of urine samples per person (incidence rate ratio (IRR) 1.23, 95% CI 1.21-1.25) was observed. A slight increase in the proportion of positive cultures (risk ratio (RR) 1.03, 95% CI 1.01-1.05) was seen. No notable change in the patient population (age, gender) was observed. Overall, Escherichia coli was the most identified uropathogen (60.4%) followed by Klebsiella spp. (8.7%) and Enterococcus spp. (7.7%). Distribution of the various uropathogens differed slightly depending on patient gender and age, importantly E. coli was less frequently observed in males aged >65 years.Conclusion: During the past five years an increasing amount of urine cultures have been requested at DCM from general practice. Importantly, the cause(s) of this increasing demand needs to be explored further in future studies.

Background Integrating psychiatric care into the general practice of primary care doctors (PCDs) is necessary to overcome the shortage of human resources to cater to the burgeoning public mental health needs of India. The traditional psychiatry curriculum is often top–down and specialist-based that contributes little in terms of skill quotient. We designed an innovative, digitally driven, distance education-based, part-time, modular-based Primary Care Psychiatry Programme (PCPP, skill-based). It is being implemented across many states of India to equip PCDs with skills to provide first-line psychiatry treatment. We discuss the rationale and guiding principles behind designing the curriculum of PCPP. Discussion There are nine guiding principles behind designing and implementing PCPP to provide pragmatic, acceptable, feasible modules of higher translational quotient (TQ) that are essential to upskill PCDs. There is a shift in training the location of PCDs in their live brief general consultations utilizing innovative telemedicine-based ‘on-consultation training’ (OCT) augmented with collaborative video consultations. A monolithic treatment protocol-driven, trans-diagnostic approach is used to design a concise, all-inone, point-of-care manual containing a culturally sensitive, rapid, validated screener and taxonomy, called ‘Clinical Schedules for Primary Care Psychiatry’. This incorporates the PCDs’ style of clinical practice that helps in picking up the most commonly prevalent adult psychiatric disorders presenting to primary care. Conclusion This PCPP curriculum contains pragmatic modules with higher TQ. This curriculum is dynamic as the learning is bi-directional. This can be used by policy-makers, innovators and academia for integration with national health programmes such as those for non-communicable diseases and reproductive and child health.

BackgroundPostural hypotension is a common condition associated with adverse outcomes in older adults. General practice plays an important role in identification of the condition.AimTo examine the incidence of postural hypotension between 2008 and 2018 in general practice and how trends vary by age, sex, year, and social deprivation.Design and settingRetrospective cohort study using electronic health records from the IQVIA Medical Research Data (IMRD) between 2008 and 2018.MethodPatients were included if they were aged ≥50 years. Incident postural hypotension was identified as a new (first) recording of a postural hypotension code. Recording of incident postural hypotension was estimated per 10 000 person–years at risk (PYAR) according to age, sex, year, and social deprivation. Incident rate ratios were estimated by multivariable Poisson regression.ResultsOf 2 911 260 patients, 24 973 had an electronic record indicating a new diagnosis of postural hypotension between 2008 and 2018. This was equivalent to 17.9 cases per 10 000 PYAR in males (95% confidence interval [CI] = 17.6 to 18.2) and 16.2 cases per 10 000 PYAR in females (95% CI = 15.9 to 16.5). A significant age–sex interaction was identified. Recorded postural hypotension rate increased with age and social deprivation, and reduced between 2008 and 2018. The rate was higher in males compared with females, particularly in older age groups (>80 years).ConclusionTo the authors’ knowledge, this is the first study to quantify incident recorded postural hypotension in general practice. The rate is lower than expected compared with studies in screened older populations. Potential barriers to identification include underreporting, underdetection owing to lack of time and/or poorly standardised methods of measurement, and poor coding. Future research should investigate current practice and approaches for increased detection such as education, practical methods of screening, and standardised measurement of postural blood pressure.

Health literacy is a social determinant of health, with lower levels linked to suboptimal health outcomes. There is a gap in the literature regarding the value of health literacy assessment among Aboriginal and Torres Strait Islander peoples and best methods with which to perform such assessments in general practice.Literature was reviewed to determine what is known regarding health literacy of Aboriginal and Torres Strait Islander peoples, the availability of assessment tools and the implications for general practice.Despite its effect on health outcomes, the health literacy of Aboriginal and Torres Strait Islander peoples is poorly understood, with no validated assessment tools specifically tailored to this population. Culturally insensitive screening of health literacy has potentiality to disaffect; thus, practitioners should consider assessments aligned with Indigenous methodologies such as conversational or yarning approaches or the use of a small number of screening questions. Practitioners are encouraged to adopt a universal precautions approach and use culturally appropriate conversational styles to optimise communication and healthcare outcomes.

To assess the cost-effectiveness of app-based treatment for female stress, urgency or mixed urinary incontinence (UI) compared with care-as-usual in Dutch primary care.A pragmatic, randomised controlled, superiority trial.Primary care in the Netherlands from 2015 to 2018, follow-up at 12 months.Women with ≥2 UI-episodes per week, access to mobile apps, wanting treatment.The standalone app included conservative management for UI with motivation aids (e.g. reminders). Care-as-usual delivered according to the Dutch GP guideline for UI.Costs and cost-effectiveness and -utility were assessed from a societal perspective, based on incontinence impact adjusted life years (IIALYs), quality adjusted life years (QALYs) and medical, non-medical and productivity costs. Information on costs was obtained with the iMCQ and iPCQ questionnaires (medical consumption and productivity cost questionnaires).In all, 262 women were andomised equally to app or care-as-usual; 89 (68%) and 83 (63%) attended follow-up, respectively. Costs were lower for app-based treatment with € -161 (95% confidence interval [CI -180 to -151) per year. Cost-effectiveness showed small mean differences in effect for IIALY (0.04) and QALY (-0.03) and thus larger incremental cost-effectiveness ratios (ICER: -€3696) and incremental cost-utility ratios (ICUR: €6379).App-based treatment is a cost-effective alternative to care-as-usual for women with UI in Dutch primary care.App-treatment for female urinary incontinence cost-effective compared to care-as-usual in general practice after 12 months.

In March 2020, 56 temporary Medicare Benefits Schedule telehealth item numbers were introduced for Australian general practitioners (GPs) in response to COVID-19. Telehealth is now a permanent part of Australian primary care and, as such, an adequate understanding of the benefits, barriers and facilitators is essential for GPs.The aim of this article is to examine the use of telehealth in general practice in Australia and to explore the benefits, barriers and facilitators to performing telehealth consultations. A narrative review was performed.Benefits of telehealth include increased access to healthcare and reduced risk of COVID-19 transmission. Barriers can include lack of technological infrastructure, limitations to performing physical examination and concerns regarding privacy and confidentiality. Facilitators include tailored GP training and sustainable funding models. Further research and training are needed to ensure that telehealth is used optimally and equitably in Australia.

Introduction This paper assesses the nature of the general dentist–specialist relationship, as perceived by general dentists in Canada. Methods A cross-sectional web-based survey was administered to general dentists across Canada who are part of the Canadian Dental Association register and who have consented to receiving email surveys (N ≈ 11,300). Information including sociodemographic and practitioner- and practice-related factors was collected using a 47-item questionnaire. The general dentist–specialist relationship was conceptualised on the basis of 4 factors: communication, confidence, competition, and referrals. Descriptive analysis was conducted. Results The response rate for the survey was 11.7% (n = 1328). Most general dentists specified that specialists sent timely information/reports (93%), were partners in delivering care (64%), presented little competitive pressure (87%), and were strongly collegial (85%). Conclusions In general, the study demonstrated that Canadian general dentists held a positive perception of their relationship with the specialists.

It is important that research conducted in general practice is ethical and technically robust. Electronic health records (EHRs) have high potential to contribute to research and policy that benefits both individual patients and the broader community. General practitioners are increasingly approached to make EHRs available for research, but they also have ethical and legal obligations to ensure personal information remains confidential and is handled safely.The aim of this article is to discuss the ethical considerations associated with the pooling of general practice EHRs for research.There are associated benefits and potential risks to patients and practices when using pooled EHR data for research. Careful consideration and judgement are required to ensure ethical requirements are met, with particular attention to informed consent, data quality and confidentiality.

OBJECTIVE: To validate and refine typologies of consultation performance from previous research to identify learning needs associated with each typology.METHODS: We performed a qualitative study in a General Practice Specialty Training programme, using a two-stage design. First, we selected four exemplars from 80 videotaped consultations of 7 first-year and 6 third-year trainees that reflected the four typologies. We subsequently held individual interviews with clinical supervisors (N = 20) who observed these consultations to identify recurrent trainee behaviours.RESULTS: The 'doctor-patient interaction' dimension from previous research was specified to encompass relationship-building, exploring, structuring, and shared decision-making competencies. Medical expertise was a moderating factor. The attitude and consultation behaviours included in the typologies were validated and we formulated directions for learning based on learning needs identified per typology.CONCLUSION: Supervisors have a shared frame of reference for the behaviours reflecting proficient consultation performance. Serving as a developmental road map, all learning needs emphasised contextual adaptation, calling for an improved balance between patient-centred relationship building and application of medical expertise.PRACTICE IMPLICATIONS: By providing rich and tailored feedback on consultation performance, the refined typologies - albeit subject to additional refinement in future research - may promote the monitoring of individual competence development over time.

Introduction Health systems internationally have developed new models of primary care to address health-care challenges. One such model is the Health Care Home (HCH),which has been widely adopted across New Zealand. Aim To explore the facilitators and barriers to implementation of the HCH in the southern health district (Otago and Southland). Methods Interviews with staff (n = 15) from seven general practices were undertaken. A rapid thematic analysis informed by the Consolidated Framework for Implementation Research (CFIR) was conducted using the framework method. Results A number of implementation facilitators and barriers across three CFIR domains were identified: intervention characteristics, inner setting and implementation process. The intervention – the HCH – has well-designed core components (eg clinician triage, patient portals), but the adaptable periphery also needs addressing to ensure the core components fit the local context. In the inner setting, a positive implementation climate and readiness for change (a strong need for the change, compatibility, strong leadership, availability of resources, and a clear understanding of the HCH and timely practical support) were key for successful implementation. Although the HCH practices had detailed planning and performance monitoring systems in place, a successful implementation process required having a change management plan and ensuring whole-of-practice engagement. Discussion This evaluation has identified facilitators and barriers to implementing the HCH in one health district using implementation science theory (CFIR). It is imperative to tailor the HCH model to local needs and individual general practices for successful implementation.

The European General Practice Research Network (EGPRN) has recently published an updated research strategy with the overall aim being to promote relevant research of the highest quality within general practice/family medicine (GP/FM). The Research Strategy indicates a global direction and serves as a basis for more detailed plans in individual countries that will take into account the characteristics of a country, its specific needs and the level of current research capacity. This paper aims to provide a summary of the EGPRN Research Strategy. The Research Strategy suggests that it is necessary to consider what the knowledge deficits are and to set research priorities. Research capacity building (RCB) is required at all levels. Research in GP/FM will also have to reflect the changes in the profession. An innovative and sustainable-oriented approach to conducting research is needed. Use of existing toolkits and engagement with patient platforms and representative groups are necessary to ensure meaningful user involvement. Knowledge transfer and exchange (KTE) is an important component to ensure a process of exchange between researchers and knowledge users. Working to improve leadership, to support the creation of a research culture in GP/FM and to increase national and international networking are considered as fundamental to ensuring a portfolio of high-quality research and for improving the impact of GP/FM research. The recommendations in the Research Strategy are based on a review of the literature on general practice research from 2010 to 2019 and are set in the context of a theoretical framework.

Background People with severe mental illness have a higher rate of premature death than the general population, largely due to primary care preventable diseases. There has been little research on the health profile of this population attending Australian general practices. Methods In this nationwide cross-sectional study, MedicineInsight data for adult patients regularly attending general practices in 2018 were analysed to estimate the prevalence of schizophrenia or bipolar disorders (SBD) and investigate the health profile of people with SBD compared with other patients. Multilevel models clustered by practice (n = 565) and patient, and practice characteristics were created. Results The prevalence of recorded SBD was 1.91% (95% CI = 1.88%–1.94%) among the 618 849 patients included. Patients with recorded SBD were more likely than other patients to have records of health risk factors, particularly smoking (aOR = 3.8, 95% CI = 3.6–3.9) and substance use (aOR = 5.9, 95% CI = 5.6–6.3), and higher probabilities of comorbidities including cardiovascular diseases (aOR = 1.3, 95% CI = 1.2–1.4), cancer (aOR = 1.1, 95% CI = 1.0–1.2), diabetes mellitus type 2 (aOR = 2.2, 95% CI = 2.0–2.3), chronic kidney diseases (aOR = 1.7, 95% CI = 1.5–2.0), chronic liver diseases (aOR = 3.3, 95% CI = 2.6–4.0) and chronic respiratory diseases (aOR = 1.7, 95% CI = 1.7–1.8). Conclusions The higher prevalence of health risk factors and comorbidities among patients with recorded SBD underscores the need for proactive health risk monitoring and preventive care to address this health inequity.

Background Recognising patients who need immediate hospital treatment for sepsis while simultaneously limiting unnecessary referrals is challenging for GPs. Aim To Develop and validate a sepsis prediction model for adult patients in primary care. Design and setting This was a prospective cohort study in tour out-of-hours primary care services in the Netherlands, conducted between June 2018 and March 2020. Method Adult patients who were acutely ill and received home visits were included. A total of nine clinical variables were selected as candidate predictors, next to the biomarkers C-reactive protein, procalcitonin, and lactate. The primary endpoint was sepsis within 72 hours of inclusion, as established by an expert panel. Multivariable logistic regression with backwards selection was used to design an optimal model with continuous clinical variables. The added value of the biomarkers was evaluated. Subsequently, a simple model using single cut-off points of continuous variables was developed and externally validated in two emergency department populations. Results A total of 357 patients were included with a median age of 80 years (interquartile range 71-86), of which 151 (42%) were diagnosed with sepsis. A model based on a simple count of one point for each of six variables (aged >65 years; temperature >38 degrees C; systolic blood pressure 110/min; saturation Conclusion Based on this study's GP out-of-hours population, a simple model can accurately predict sepsis in acutely ill adult patients using readily available clinical parameters.

Chlamydia is the most commonly diagnosed bacterial sexually transmissible infection (STI) in Australia. Partner management is key to reducing transmission and a cornerstone of best practice chlamydia management. While most patients will opt for telling their partner(s) themselves, patient-delivered partner therapy (PDPT) offers an alternative way to inform and treat partners where usual management is inappropriate or unlikely to be undertaken. Guidelines for PDPT vary across Australia. Recent research found that general practitioners (GP)s want practical guidance for using PDPT in appropriate situations.The aim of this article is to provide an overview of the process of offering PDPT and note the challenges GPs may face in its provision.PDPT is one option for partner management when sexual partner(s) are unlikely or unable to seek timely care themselves. However, there are challenges to the use of PDPT in general practice. The provision of clear guidelines is an essential step to promote its appropriate use.

BACKGROUND: Recognising patients who need immediate hospital treatment for sepsis while simultaneously limiting unnecessary referrals is challenging for GPs.AIM: To develop and validate a sepsis prediction model for adult patients in primary care.DESIGN AND SETTING: This was a prospective cohort study in four out-of-hours primary care services in the Netherlands, conducted between June 2018 and March 2020.METHOD: Adult patients who were acutely ill and received home visits were included. A total of nine clinical variables were selected as candidate predictors, next to the biomarkers C-reactive protein, procalcitonin, and lactate. The primary endpoint was sepsis within 72 hours of inclusion, as established by an expert panel. Multivariable logistic regression with backwards selection was used to design an optimal model with continuous clinical variables. The added value of the biomarkers was evaluated. Subsequently, a simple model using single cut-off points of continuous variables was developed and externally validated in two emergency department populations.RESULTS: A total of 357 patients were included with a median age of 80 years (interquartile range 71-86), of which 151 (42%) were diagnosed with sepsis. A model based on a simple count of one point for each of six variables (aged >65 years; temperature >38°C; systolic blood pressure ≤110 mmHg; heart rate >110/min; saturation ≤95%; and altered mental status) had good discrimination and calibration (C-statistic of 0.80 [95% confidence interval = 0.75 to 0.84]; Brier score 0.175). Biomarkers did not improve the performance of the model and were therefore not included. The model was robust during external validation.CONCLUSION: Based on this study's GP out-of-hours population, a simple model can accurately predict sepsis in acutely ill adult patients using readily available clinical parameters.

Opioid dependence is an important public health issue with high rates of relapse. This study, conducted in a suburban Australian general practice, reports treatment retention for patients on long-acting depot buprenorphine injections.Patients were offered monthly buprenorphine depot from 11 December 2019 to 31 July 2020; data collection ceased on 30 November 2020. Overall retention at 168 days was estimated, and retention when discontinuation was defined as2 or4 weeks' delay between injections (2/4 WTD).For 126 patients treated (mean age: 40.2 years [range: 20-65 years], 32% women, 98% with history of heroin dependence), the overall retention rate was 62% (53% and 40% using 2WTD and 4WTD definitions of discontinuation). Eleven patients returned to previous treatment; 10 patients with planned discontinuations were censored.Depot buprenorphine supported more than half of patients to remain in treatment, while allowing some flexibility in dose interval. Predictive power is limited by the small sample and observational design.

Resume Introduction L’hospitalisation sous contrainte est une mesure psychiatrique lourde et complexe. En Seine-Saint-Denis (faible densite medicale), l’evaluation du patient en decompensation psychiatrique incombe aux medecins generalistes mandates par le Samu. Leur ressenti est le non-aboutissement de la procedure, une fois le patient aux urgences. L’objectif etait d’evaluer le devenir des patients a la suite d’une demande de soins psychiatriques a la demande d’un tiers emanant de ces medecins generalistes. Methodes Nous avons realise une etude retrospective a partir des demandes de soins psychiatriques a la demande d’un tiers au Samu 93, durant l’annee 2016. Les caracteristiques de l’appel et du patient ainsi que les decisions du regulateur et du medecin generaliste etaient recueillies. Le devenir etait recherche pour les patients adresses aux urgences pour soins psychiatriques a la demande d’un tiers. Resultats Parmi les 7541 appels pour decompensation, 539 concernaient une demande de soins psychiatriques a la demande d’un tiers. Ces appels survenaient durant les heures non ouvrees dans 55 % des cas. Un medecin generaliste etait mandate dans deux tiers des cas et a organise une demande de soins psychiatriques a la demande d’un tiers pour 240/304 (79 %) patients. Les patients etaient des hommes dans 56 % des cas avec une moyenne d’âge de 40 (± 16) annees. Le psychiatre a confirme l’hospitalisation sous contrainte pour 132 (61 %) patients. Ce taux n’est pas different de celui de 65 %, rapporte dans la litterature (Z-test, p = 0,26). Une hospitalisation libre etait realisee pour 37 (17 %) autres patients. Discussion Le taux de soins psychiatriques a la demande d’un tiers realise a la suite de la demande des medecins generalistes mandates par le Samu etait comparable a celui suite aux demandes des medecins traitant, validant leur intervention dans ce contexte critique.

BACKGROUND: Recognising patients who need immediate hospital treatment for sepsis while simultaneously limiting unnecessary referrals is challenging for GPs. AIM: To develop and validate a sepsis prediction model for adult patients in primary care. DESIGN AND SETTING: This was a prospective cohort study in four out-of-hours primary care services in the Netherlands, conducted between June 2018 and March 2020. METHOD: Adult patients who were acutely ill and received home visits were included. A total of nine clinical variables were selected as candidate predictors, next to the biomarkers C-reactive protein, procalcitonin, and lactate. The primary endpoint was sepsis within 72 hours of inclusion, as established by an expert panel. Multivariable logistic regression with backwards selection was used to design an optimal model with continuous clinical variables. The added value of the biomarkers was evaluated. Subsequently, a simple model using single cut-off points of continuous variables was developed and externally validated in two emergency department populations. RESULTS: A total of 357 patients were included with a median age of 80 years (interquartile range 71-86), of which 151 (42%) were diagnosed with sepsis. A model based on a simple count of one point for each of six variables (aged >65 years; temperature >38°C; systolic blood pressure ≤110 mmHg; heart rate >110/min; saturation ≤95%; and altered mental status) had good discrimination and calibration (C-statistic of 0.80 [95% confidence interval = 0.75 to 0.84]; Brier score 0.175). Biomarkers did not improve the performance of the model and were therefore not included. The model was robust during external validation. CONCLUSION: Based on this study's GP out-of-hours population, a simple model can accurately predict sepsis in acutely ill adult patients using readily available clinical parameters.

BackgroundRecognising patients who need immediate hospital treatment for sepsis while simultaneously limiting unnecessary referrals is challenging for GPs.AimTo Develop and validate a sepsis prediction model for adult patients in primary care.Design and settingThis was a prospective cohort study in tour out-of-hours primary care services in the Netherlands, conducted between June 2018 and March 2020.MethodAdult patients who were acutely ill and received home visits were included. A total of nine clinical variables were selected as candidate predictors, next to the biomarkers C-reactive protein, procalcitonin, and lactate. The primary endpoint was sepsis within 72 hours of inclusion, as established by an expert panel. Multivariable logistic regression with backwards selection was used to design an optimal model with continuous clinical variables. The added value of the biomarkers was evaluated. Subsequently, a simple model using single cut-off points of continuous variables was developed and externally validated in two emergency department populations.ResultsA total of 357 patients were included with a median age of 80 years (interquartile range 71-86), of which 151 (42%) were diagnosed with sepsis. A model based on a simple count of one point for each of six variables (aged >65 years; temperature >38 degrees C; systolic blood pressure 110/min; saturationConclusionBased on this study's GP out-of-hours population, a simple model can accurately predict sepsis in acutely ill adult patients using readily available clinical parameters.

To explore how General Practice Nurses experience implementing change at pace and scale in delivering care during consecutive waves of the COVID-19 pandemic. To evaluate the impact of changes to general practice nurses' working practices on professional wellbeing.In response to the COVID-19 pandemic, general practice rapidly and extensively changed care delivery. There has been little exploration of the experiences of General Practice Nurses and care delivery, job satisfaction, workload, stress and professional support.A qualitative case study design of three to five general practice case sites will explore General Practice Nurses' experiences during the Covid-19 pandemic. The study was funded and approved by the General Nursing Council Trust in June 2021. University ethics approval was gained in July 2021. Health Research Authority approval has been obtained [IRAS:30353. Protocol number: R23982. Ref 21/HRA/5132. CPMS: 51834].Data will consist of focus groups and/or semi-structured interviews with General Practice Nurses, primary healthcare team members and other key informants. Business/strategy and nurse team meetings relating to workforce planning/review will be observed. Documents will be analysed and routinely collected general practice data will provide descriptive contextualisation at each site. The study will be theoretically underpinned by the Non-adoption, Abandonment, Scale-up, Spread and Sustainability Framework and data analysed using framework analysis.General Practice Nurses have a unique sphere of knowledge and undertake specific work in primary care. This workforce is challenged by recruitment, retention and retirement issues, leading to the loss of highly experienced and knowledgeable professionals. It is important to explore how working practices brought about by Covid-19 affect General Practice Nurses.This study will explore working practices brought about by the Covid-19 pandemic to inform care delivery, patient care and support General Practice Nursing workforce wellbeing and will highlight and mitigate negative aspects of novel and changing care delivery. Key factors in implementing and supporting future practice and change implementation will be developed.CPMS: 51834.