Search

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.

No abstract available.

Background In the UK, about 14% of community-dwelling adults aged 65 and over are estimated to be at risk of malnutrition. Screening older adults in primary care and treating those at risk may help to reduce malnutrition risk, reduce the resulting need for healthcare use and improve quality of life. Interventions are needed to raise older adults’ risk awareness, offer relevant and meaningful strategies to address risk and support general practices to deliver treatment and support. Methods Using the Person-based Approach and input from Patient and Public Involvement representatives, we developed the ‘Eat well, feel well, stay well’ intervention. The intervention was optimised using qualitative data from think aloud and semi-structured process evaluation interviews with 23 and 18 older adults respectively. Positive and negative comments were extracted to inform rapid iterative modifications to support engagement with the intervention. Data were then analysed thematically and final adjustments made, to optimise the meaningfulness of the intervention for the target population. Results Participants’ comments were generally positive. This paper focuses predominantly on participants’ negative reactions, to illustrate the changes needed to ensure that intervention materials were optimally relevant and meaningful to older adults. Key factors that undermined engagement included: resistance to the recommended nutritional intake among those with reduced appetite or eating difficulties, particularly frequent eating and high energy options; reluctance to gain weight; and a perception that advice did not align with participants’ specific personal preferences and eating difficulties. We addressed these issues by adjusting the communication of eating goals to be more closely aligned with older adults’ beliefs about good nutrition, and acceptable and feasible eating patterns. We also adjusted the suggested tips and strategies to fit better with older adults’ everyday activities, values and beliefs. Conclusions Using iterative qualitative methods facilitated the identification of key behavioural and contextual elements that supported engagement, and issues that undermined older adults’ engagement with intervention content. This informed crucial revisions to the intervention content that enabled us to maximise the meaningfulness, relevance and feasibility of the key messages and suggested strategies to address malnutrition risk, and therefore optimise engagement with the intervention and the behavioural advice it provided.

BackgroundGPs are well placed to enhance shared decision making (SDM) about treatment for patients with advanced cancer. However, to date, little is known about GPs’ views about their contribution to SDM.AimTo explore GPs’ perspectives on their role in SDM about palliative cancer treatment and the requirements they report to fulfil this role.Design and settingQualitative interview study among Dutch GPs.MethodGPs were sampled purposefully and conveniently. In-depth, semi-structured interviews were conducted, recorded, and transcribed verbatim. Transcripts were analysed by thematic analysis.ResultsFifteen GPs took part in this study. Most of them reported practices that potentially support SDM: checking the quality of a decision, complementing SDM, and enabling SDM. Even though most of the GPs believed that decision making about systemic cancer treatment is primarily the oncologist’s responsibility, they did recognise their added value in the SDM process because of their gatekeeper position, the additional opportunity they offer patients to discuss treatment decisions, and their knowledge and experience as primary healthcare providers at the end of life. Requirements for them to support the SDM process were described as: good collaboration with oncologists; sufficient information about the disease and its treatment; time to engage in conversations about treatment; a trusting relationship with patients; and patient-centred communication.ConclusionGPs may support SDM by checking the quality of a decision and by complementing and enabling the SDM process to reach high-quality decisions. This conceptualisation of the GP’s supporting role in SDM may help us to understand how SDM is carried out through interprofessional collaboration and provide tools for how to adopt a role in the interprofessional SDM process.

Background Rising health care burden has increased demand for general practice nurses. Exploring final-year nursing students’ perceived levels of confidence, interest and intention to work in this area can inform preparation and recruitment of new graduates into this workforce. Aim To explore final-year nursing students’ confidence, interest and intention to work in general practice. Methods Final-year nursing students from five universities situated in New South Wales, Australia were surveyed between March and June 2019. The survey comprised investigator-developed questions and validated tools adapted for use in general practice. Findings Of the 355 included responses, 34.1% respondents had a clinical placement in general practice. Work experience was a significant predictor of confidence in working as a Registered or General Practice Nurse. Being enrolled as an international student, general practice placement experience and high confidence to work in general practice were significant predictors of interest and intention to work in this setting. Analysis showed a strong positive relationship between interest and intention to work in general practice, and a small but positive relationship between confidence and intention to work in general practice. Discussion Despite generally positive views around their confidence, interest and intention to work in general practice, some respondents indicated uncertainties around these, and the usefulness of their undergraduate preparation towards PHC employment. This may be attributable to the inconsistent exposure to general practice nursing within Australian undergraduate nursing programs. Conclusion Increasing students’ theoretical and clinical exposure to general practice enhances confidence and interest to pursue a career in this setting.

BackgroundOsgood–Schlatter disease (OSD) is a non-traumatic knee problem that is primarily observed in sports-active children and adolescents aged 8–15 years.AimTo determine the incidence of OSD and to gain an insight into the management of children and adolescents with OSD in general practice.Design and settingA retrospective cohort study was conducted using a healthcare database containing full electronic health records of over 200 000 patients in general practice in and around the Dutch city of Rotterdam.MethodPatients with a new diagnosis of OSD from 1 January 2012 to 31 December 2017 were extracted using a search algorithm based on International Classification of Primary Health Care coding and search terms in free text. Data on the management of OSD were manually interpreted.ResultsThe mean incidence over the study period was 3.8 (95% confidence interval [CI] = 3.5 to 4.2) per 1000 person–years in those aged 8–18 years. Boys had a higher incidence rate of 4.9 (95% CI = 4.3 to 5.5) compared with girls (2.7, 95% CI = 2.3 to 3.2). Peak incidence was at 12 years of age for boys and 11 years for girls. Advice was the most commonly applied strategy (55.1%), followed by rest (21.0%), referral for imaging (19.5%), and physiotherapy (13.4%).ConclusionTo the authors’ knowledge, for the first time the incidence of OSD has been calculated using GP electronic medical files. There is a discrepancy, especially for imaging and referral to a medical specialist, between the current Dutch general practice guidelines and how GPs actually manage the condition in clinical practice.

Objective A genomic test to predict personal risk of colorectal cancer (CRC) that targets screening and could be feasibly implemented in primary care. We explored informed decision-making and attitudes towards genomic testing in this setting. Methods A CRC genomic test was offered to 150 general practice patients with brief discussion of its implications. We measured informed choice about the test, consisting knowledge, attitudes and test uptake. Sixteen purposively-sampled participants were interviewed. Results Of 150, 142 (95%) completed the informed choice measure and of 27 invited, 16 (59%) completed an interview. 73% made an informed choice about the test. Interviews revealed that participants with inadequate knowledge on the informed choice scale still understood the gist of the test. While positive attitudes were most prevalent, some had concerns, and many were indifferent to the test. Positive attitudes included: that risk information could facilitate risk reduction; negative attitudes included: that risk results could cause worry and be used for insurance discrimination; indifferent attitudes included: that the test seemed benign and it was easy to do. Conclusions Our study adds to the evidence that genomic tests for CRC risk do not pose significant concern to patients in community settings. Practice implications As genomic tests become more prevalent, this study’s findings can be used to facilitate informed decision-making and ensure equitable access.

At article it is submitted the review of modern scientific approaches to the organization of effective system of training for primary link of health care. New approaches with application of educational clusters, transmitting medicine are presented. Efficiency of educational and research and production clusters in health system for ensuring high-quality preparation and further professional activity of the doctor on the basis of integration of medical science, education and practical health care is shown. The structure and functionality of the scientific and practical center of continuous professional development of doctors of the general practice - family medicine, as bases for providing qualitative system of training is presented.

Цукровий діабет 2 типу (ЦД 2 типу) є найбільш поширеним захворюванням. Прогресування макро- і мікроваскулярних ускладнень виводить це захворювання на третє місце серед причин смерті після серцево-судинної та онкологічної патології. Мета. Визначити особливості застосування гліклазиду у хворих на цукровий діабет 2-го типу в практиці сімейного лікаря. Матеріали і методи - проведений системний огляд публікацій з 1990 р. по теперішній час у пошукових системах JAMA, Scholar, NCBI, Cochrane Library та PubMed, а також у журналах та виданнях матеріалів конференцій, які найбільше відповідали розкриттю поставленої мети. Результати. Згідно з проведеним аналізом встановлено, що гліклазид, як препарат сульфанілсечовини 2 покоління, має не тільки виражений цукрознижуючих ефект, а й знижує окислювальний стрес, перекисне окислювання ліпідів, адгезію моноцитів та тромбоцитів, нормалізує активність фібринолітичної системи крові та функцію ендотелію, здійснює захисну дію на кровоносні судини. Препарат має низький ризик виникнення гіпоглікемій та приймається один раз на день. Висновки. Сімейний лікар може вільно призначати гліклазид хворим на цукровий діабет 2 типу, оскільки він має достатньо високий поріг безпечності та ефективності та є дієвим не тільки як цукрознижуючий препарат, а й має ангіопротекторну дію.

Background Increasing participation in the Australian National Bowel Cancer Screening Program (NBCSP) is the most efficient and cost-effective way of reducing mortality associated with colorectal cancer by detecting and treating early-stage disease. Currently, only 44% of Australians aged 50–74 years complete the NBCSP. This efficacy trial aims to test whether this SMS intervention is an effective method for increasing participation in the NBCSP. Furthermore, a process evaluation will explore the barriers and facilitators to sending the SMS from general practice. Methods We will recruit 20 general practices in the western region of Victoria, Australia to participate in a cluster randomised controlled trial. General practices will be randomly allocated with a 1:1 ratio to either a control or intervention group. Established general practice software will be used to identify patients aged 50 to 60 years old who are due to receive a NBCSP kit in the next month. The SMS intervention includes GP endorsement and links to narrative messages about the benefits of and instructions on how to complete the NBCSP kit. It will be sent from intervention general practices to eligible patients prior to receiving the NBCSP kit. We require 1400 eligible patients to provide 80% power with a two-sided 5% significance level to detect a 10% increase in CRC screening participation in the intervention group compared to the control group. Our primary outcome is the difference in the proportion of eligible patients who completed a faecal occult blood test (FOBT) between the intervention and control group for up to 12 months after the SMS was sent, as recorded in their electronic medical record (EMR). A process evaluation using interview data collected from general practice staff (GP, practice managers, nurses) and patients will explore the feasibility and acceptability of sending and receiving a SMS to prompt completing a NBCSP kit. Discussion This efficacy trial will provide initial trial evidence of the utility of an SMS narrative intervention to increase participation in the NBCSP. The results will inform decisions about the need for and design of a larger, multi-state trial of this SMS intervention to determine its cost-effectiveness and future implementation. Trial registration Australian New Zealand Clinical Trials Registry ACTRN12620001020976. Registered on 17 October 2020.

INTRODUCTION This paper argues that particular experiences in the workplace are more important than others and can lead to transformational learning. This may enable practitioners to cross ‘vocational thresholds’ to new ways of being. AIM A notion of ‘vocational thresholds’ is developed, aiming to help build an understanding of the most powerful learning experiences of general practitioners (GPs). Vocational thresholds takes its cue from the idea of ‘threshold concepts’ - concepts that transform perspectives and integrate previously disconnected or hidden knowledge, sometimes in ways that are ‘troublesome’ to previously held beliefs. METHODS The paper is based on a thematic analysis of 57 GPs’ brief written accounts of a particularly powerful learning experience during their development. Accounts were provided in a conference session about an ongoing study of workplace-based structured learning arrangements in the fields of general practice medicine, engineering, and building. FINDINGS Most GPs’ accounts focused on development of dispositional attributes that moved them to a new understanding of themselves in relation to their work and patients. Just under two-thirds picked out informal and formal collegial relationships within purposeful learning arrangements as pivotal. A third picked out direct experiences with patients as shifting their perspective. CONCLUSION The emergent idea of vocational thresholds is offered as a way to frame the most important learning experiences identified by GPs. It supports a focus in early and ongoing development beyond accumulating clinical expertise and skills (knowing and doing), to dispositional capability (being) - vital for practitioners negotiating inherent and daily uncertainty. KEYWORDS General practitioners; Medical education; Vocational education; Identity; Learning experiences; Threshold concepts

Introduction The increased use of long-acting reversible contraceptives (LARCs), such as intrauterine devices and hormonal implants, has the potential to reduce unintended pregnancy and abortion rates. However, use of LARCs in Australia is very low, despite clinical practice guidance and statements by national and international peak bodies advocating their increased use. This protocol paper describes the Australian Contraceptive ChOice pRojet (ACCORd), a cluster randomised control trial that aims to test whether an educational intervention targeting general practitioners (GPs) and establishing a rapid referral service are a cost-effective means of increasing LARC uptake. Methods and analysis The ACCORd intervention is adapted from the successful US Contraceptive CHOICE study and involves training GPs to provide ‘LARC First’ structured contraceptive counselling to women seeking contraception, and implementing rapid referral pathways for LARC insertion. Letters of invitation will be sent to 600 GPs in South-Eastern Melbourne. Using randomisation stratified by whether the GP inserts LARCs or not, a total of 54 groups will be allocated to the intervention (online ‘LARC First’ training and rapid referral pathways) or control arm (usual care). We aim to recruit 729 women from each arm. The primary outcome will be the number of LARCs inserted; secondary outcomes include the women's choice of contraceptive method and quality of life (Short Form Health Survey, SF-36). The costs and outcomes of the intervention and control will be compared in a cost-effectiveness analysis. Ethics and dissemination The ACCORd study has been approved by the Monash University Human Research Ethics Committee: CF14/3990-2014002066 and CF16/188-2016000080. Any protocol modifications will be communicated to Ethics Committee and Trial Registration registry. The authors plan to disseminate trial outcomes through formal academic pathways comprising journal articles, nation and international conferences and reports, as well as using more ‘popular’ strategies including seminars, workshops and media engagements. Trial registration number ACTRN12615001346561.

Background and Aims: Clinicians could promote e-cigarettes for harm reduction to people who smoke but cannot stop, but many clinicians feel uneasy doing so. In a randomised controlled trial (RCT), primary care clinicians offered free e-cigarettes and encouraged people with chronic diseases who were unwilling to stop smoking to switch to vaping. We interviewed clinicians and patients to understand how to adopt harm reduction in routine practice. Design: Qualitative analysis nested within an RCT, comprising thematic analysis of semi-structured interviews with primary care clinicians who delivered the trial intervention, and patients who took part. Setting: Primary care clinics in England. Participants/Cases: 21 patients and 11 clinicians, purposively sampled from an RCT. Measurements: We qualitatively explored patients’ and clinicians’ experiences of: being offered/offering an e-cigarette, past and current perceptions about e-cigarettes, and applying a harm reduction approach. Findings: Four themes captured clinicians’ and patients’ reported perspectives. These were: (1)Concepts of safety/risk, with clinicians concerned about recommending a product with unknown long-term risks and patients preferring the known risks of cigarettes, (2)Clinicians felt they were going out on a limb by offering these as though they were prescribing them, whereas patients did not share this view, (3)Equating quitting with success, as both patients and clinicians conceptualised e-cigarettes as quitting aids, and (4)Unchanged views, as clinicians reported that training did not change their existing views about e-cigarettes. These themes were united by the higher order concept ‘The old and familiar meets the new and unknown,’ as a contradiction between this new approach and long-established methods underpinned these concerns. Conclusions: A qualitative analysis found barriers obstructing clinicians and patients from easily accepting e-cigarettes for harm reduction, rather than as aids to support smoking cessation: clinicians had difficulty reconciling harm reduction with their existing ethical models of practice, even following targeted training, and patients saw e-cigarettes as quitting aids.

BACKGROUND Longitudinal Integrated Clerkships exist in undergraduate medicine courses. A pilot Pharmacy Longitudinal Clerkship (pPLC) was funded to investigate delivery of this model of clinical education for student pharmacists. OBJECTIVE(S) To investigate the development, implementation and initial evaluation of a pPLC. METHODS The 11-week pPLC was delivered to two students in two GP practices in Scotland. Mixed theory-based methods were used to gather information on the pPLC structures and processes required and qualitative semi-structured Theoretical Domains Framework (TDF) based interviews explored outcomes with key stakeholders. Informed written consent was obtained. Interviews were audio-recorded, transcribed verbatim and analysed thematically. University Ethics approval was granted. RESULTS Data were generated on resources and processes required for a pPLC including funds budgeted for and actually spent on staffing, student travel/subsistence and student clinical 'Kit Bags', learning outcomes, curriculum and training timetable, GP Practice/University contracts. Interviews were completed with the two students, three linked GP clinical supervisors and two Regional Tutors involved. The seven themes were identified and mapped to seven TDF domains including: increased levels of student confidence, and increased student enthusiasm for a career in pharmacy, need for definition of the role of the Regional Tutor for the PLC and GP positivity towards the expected outcomes of clerkship model versus traditional placements. CONCLUSION Findings are limited by the small number of participants and settings, but evaluation was positive and the work garnered information on requirements for resources and processes. This will inform 'roll out' of the PLC.

usc Background: A significant proportion of the atrial fibrillation (AF) population attending Australian primary care is not receiving guideline-adherent oral anticoagulant (OAC) treatment. This study aimed to explore reasons for non-adherence to thromboprophylaxis guidelines in AF from the perspectives of general practitioners (GPs) and to map these reasons to the Capability, Opportunity, Motivation-Behaviour (COM-B) model to identify potential opportunities to support practice change. Methods: An exploratory qualitative descriptive study among GPs practising in Western Australia was conducted using semi-structured interviews, from November 2020 to February 2021. The Framework Method was employed to facilitate thematic analysis, using NVivo software. Interview responses were also mapped to the COM-B model. Results: Nine of the 10 GPs initially consented participated in the semi-structured interview (Male = 56%, median age = 52 years, data saturation reached with 6 participants). Two themes emerged from analysis of the interview transcripts: (1) GPs' decision-making process and (2) Patient refusal to take OACs. The COM-B model mapping identified behavioural factors that could impact adherence: capability (GPs' knowledge and understanding of AF guideline recommendations), opportunity (access to a cardiologist, and patients' refusal to take OACs), and motivation (using formal bleeding risk assessment tools). Conclusion: GPs identified various reasons contributing to non-adherence to thromboprophylaxis guidelines in patients with AF. Multifaceted interventions should consider behavioural opportunities to improve adherence, including education and training, electronic decision support, clinical audits by allied health professionals, partnership between general practices and local hospitals, and cardiologist-led interventions to support GPs. Further studies are needed to capture patients' reasons for refusing OACs. Refereed/Peer-reviewed

Aims Heart failure (HF) causes significant morbidity and mortality, but the rates and characteristics of people with HF in Australia are not well studied. SHAPE set out to describe the characteristics of HF patients seen in the real‐world setting. Methods We analysed anonymized patient data extracted from the clinical software of 43 participating GP clinics for the 5 year period from 1 July 2013 to 30 June 2018. Patients were stratified into ‘definite’ and ‘probable’ HF based on a hierarchy of selection criteria and analysed for their clinical characteristics. Symptoms and signs of HF and ejection fraction data were searched for within the free text of the medical notes. Results Of the 1.12 million adults seen regularly, 20 219 were classified as having definite or probable HF. The mean age of the population was 69.8 years, 50.6% were female, and mean body mass index was 31.2 kg/m2. Fewer than 1 in 6 had the HF diagnosis optimally recorded. Only 3.2% (650 patients) had their left ventricular ejection fraction (EF) quantified: 40.9% had an EF ≥50% and 59.1% had an EF

Background and objectives LactaMap is an online lactation care support system designed to assist general practitioners (GPs) caring for breastfeeding women and infants. The aim of this study was to qualitatively evaluate GPs' experience of the prototype LactaMap website. Method The study was conducted in Perth, Western Australia, with five GPs in 2018/2019 by integrating a Think Aloud protocol and a semi-structured interview. Data were transcribed and uploaded to ATLAS.ti 8 Qualitative Data Analysis Software. Descriptive coding was themed deductively and analysed. Results All participants responded positively to the LactaMap website and indicated that it was valuable. A small number of critical usability issues were identified. Discussion Integrating two qualitative approaches provided information about what may influence LactaMap's adoption by GPs. The integrated data allowed evaluation of LactaMap as it is and also considered what might be possible, facilitating a customised lactation decision support tool for general practice.

BACKGROUND AND OBJECTIVES Australian information on the physical health of general practice patients with a mental illness is limited. The aim of this study was to explore the physical health of patients with a severe and/or long-term mental illness (SMI). METHOD Analysis was performed of routinely collected data from patients visiting one of 452 general practice sites participating in the national MedicineInsight program during 2017-18. RESULTS Of the 173,861 participants, 9.1% had recorded SMI. Almost three-quarters had a record of the selected long-term physical health conditions, compared with half of patients without recorded SMI (adjusted odds ratio: 2.2, 95% confidence interval: 2.1, 2.3). Patients with SMI were also more likely to have a history of smoking or moderate-to-heavy drinking. DISCUSSION More patients with SMI had records of the investigated health conditions than those without SMI. They also had higher rates of modifiable risk factors. As patients with SMI are likely to visit their general practitioners often, this presents an opportunity for intervention that may improve patient outcomes.

The literature on the history of family medicine as an academic discipline locates its beginning with the establishment of two faculties linked to the Royal College of General Practice in 1958. However, the history of Community Oriented Primary Care documents, how the Kark’s moved from Pholela in KwaZulu-Natal, were involved with the establishment of the Natal Medical School in Durban. As part of this a Department of Social, Preventative and Family Medicine was established in 1956 with Dr Sidney Kark as its first Head of Department. The South African Academy of Family Practice and Primary Care established in 1980 explicitly orientated itself in relation to public healthcare (PHC). We need to re-claim the history of Community Oriented Primary Care as part of the history of family medicine and proudly trace our current ethos and values to the seminal work of the Kark’s.

No abstract available.

The restoration of teeth treated endodontically and having undergone significant loss of substance remains a challenge for dental surgeons. It represents one of the most frequent clinical sequences of general practice on a daily basis. This act is so common and so repetitive that the practitioner often performs it automatically, almost reflexively, applying the same mode of restoration to most clinical situations. Metal coronoradicular restorations (RCR) have long been considered the standard for restoring depulpated posterior teeth, as this type of restorations offer increased mechanical resistance to the occlusal stresses to which posterior teeth are subjected. The advent of adhesive dentistry has revolutionized the restoration of depulpated posterior teeth. It has become possible today to combine aesthetics, mechanical resistance and biocompatibility thanks to the fiber-based coronoradicular restoration of the posterior sector. In this article, we will detail the clinical protocol for an esthetic restoration of two premolars treated endodontically and severely damaged.

BackgroundLittle is known about variations in the provision of chronic care services in primary care.AimTo describe the frequency of chronic care services provided by GPs and analyse the extent of non-random variation in service provision.Design and settingNationwide cohort study undertaken in Denmark using data from 2016.MethodInformation on chronic care services was obtained from national health registers, including annual chronic care consultations, chronic care procedures, outreach home visits, and talk therapy. The associations between services provided, patient morbidity, and socioeconomic factors were estimated. Service variations were analysed, and excess variation related to practice-specific factors was estimated while accounting for random variation.ResultsChronic care provision was associated with increasing patient age, increasing number of long-term conditions, and indicators of low socioeconomic status. Variation across practices ranged from 1.4 to 128 times more than expected after adjusting for differences in patient population and random variation. Variation related to practice-specific factors was present for all the chronic care services that were investigated. Older patients with lower socioeconomic status and multimorbidity were clustered in practices with low propensity to provide certain chronic care services.ConclusionChronic care was provided to patients typically in need of health care, that is, older adults, those with multimorbidity, and those with low socioeconomic status, but service provision varied more than expected across practices. GPs provided slightly fewer chronic care services than expected in practices where many patients with multimorbidity and low socioeconomic status were clustered, suggesting inverse care law mechanisms.

The Positive Deviance (PD) approach focuses on identifying and learning from those who demonstrate exceptional performance despite facing similar resource constraints to others. Recently, it has been embraced to improve the quality of patient care in a variety of healthcare domains. PD may offer one means of enacting effective quality improvement in primary care.This review aimed to synthesize the extant research on applications of the PD approach in primary care.Seven electronic databases were searched; MEDLINE, CINAHL, Embase, PsycINFO, Academic Search Complete, Psychology and Behavioral Sciences Collection, and Web of Science. Studies reporting original data on applications of the PD approach, as described by the PD framework, in primary care were included, and data extracted. Thematic analysis was used to classify positively deviant factors and to develop a conceptual framework. Methodological quality was appraised using the Quality Assessment with Diverse Studies (QuADS).In total, 27 studies were included in the review. Studies most frequently addressed Stages 1 and 2 of the PD framework, and targeted 5 core features of primary care; effectiveness, chronic disease management, preventative care, prescribing behaviour, and health promotion. In total, 268 factors characteristic of exceptional care were identified and synthesized into a framework of 37 themes across 7 system levels.Several useful factors associated with exceptional care were described in the literature. The proposed framework has implications for understanding and disseminating best care practice in primary care. Further refinement of the framework is required before its widespread recommendation.The positive deviance approach is focused on identifying people/organizations performing particularly well, in spite of having similar challenges and resources to others, and learning about how they work so well. Recently, this approach has been used in healthcare to learn about how to improve the quality and safety of care for patients. This review aims to explore how the positive deviance approach has been used in primary care settings and to summarize the findings from this research. Overall, 27 studies were included in the review. We found that studies typically focused on identifying positive deviants (i.e. those performing particularly well) and finding out what helps them do that, without looking to see if these same practices work elsewhere or teaching others about them. The positive deviance approach was used to improve several different parts of primary care including; care effectiveness, management of chronic diseases, preventative care, prescribing, and health promotion. Several success strategies were identified from the studies’ findings and were organized into a framework describing what practices contribute to particularly good performance in primary care. This framework will be useful for those looking to improve quality of care in primary care.

Background Good primary care for people with substance use disorders (SUDs) is crucial given the high prevalence of SUDs and overdose deaths. Objective To explore general practice care for people with a history of SUDs from the perspectives of women involved with the criminal justice system. Methods Qualitative interview study with pre- and postrelease interviews, undertaken in Australian prisons and community settings. We utilized thematic analysis informed by constructivist grounded theory. Results We undertook 65 interviews with 39 women. Access to and experience of general practitioner (GP) care was affected by perceived welcomeness, decisions around disclosure, and consultation experiences related to medication prescription. Participants reported that they were not as welcome as other patients, welcome could be conditional on not disclosing SUDs or only requesting unrelated healthcare, and GPs did not always differentiate between past and current drug use. Participants perceived difficulty finding general practices where the potential benefit of disclosing SUDs outweighed the risks of stigmatized reactions and lack of GP skills and interest. Participants did not always recognize that care beyond physical health could occur in general practice. The pejorative implications of labelling patients as “doctor shoppers” were challenged by participants, as they considered it could be necessary to attend multiple GPs to find a welcoming practice. Conclusions People with histories of SUDs do not uniformly experience welcomeness in general practice, perpetuating poor engagement in healthcare and poor outcomes related to SUDs. Programmes targeting prescription drug misuse through general practice should also promote welcomeness for people with SUDs.

The availability of direct-acting antivirals (DAAs) sparked efforts to eliminate hepatitis C virus (HCV) in Australia. We evaluated whether an educational intervention of a 1-h discussion among staff using audit and feedback data from the MedicineInsight GP programme would improve DAA uptake. Of 296 eligible general practices in MedicineInsight, 11% opted out. Randomization stratified by practice caseload allocated 130 practices to the intervention arm and 129 to control. The primary outcome was the number of patients started on DAAs over 6 months using the negative binomial regression model adjusted for DAA prescription history and clustering by practice. Data for analysis were available for 78% of practices, which included 101 practices and 2469 DAA-naive patients with confirmed/possible HCV in the intervention arm, and 100 practices and 2466 patients in the control arm. At baseline, 49.5% of practices had prescribed ≥1 DAA in the past year; 18.9% of HCV patients had already been treated with DAAs; the mean age of DAA-naive HCV patients was 43 years old, and 57% were men. Over 6 months, 43 patients in the intervention arm and 36 in the control arm started DAAs (adjusted IRR 1.19; 95% CI 0.67-2.11, p = 0.55). In the first 3 months, 27 vs 16 patients started DAAs (adjusted IRR 1.77, 0.88-3.58; p = 0.111). Few patients were started on DAAs, and a facilitated discussion in HCV management did not lead to a significant increase. Alternative measures, such as incentivizing GP initiations or patients, are suggested to address remaining barriers to DAA uptake in Australian primary care. Australian New Zealand Clinical Trial Registry (ANZCTR) Registration Number: ACTRN12619000508178p.

Zusammenfassung Ziel der Studie Darstellung der Kommunikationswege und -hürden zwischen Hausärzten (HÄ) und Pflegeheimen 2019 aus Sicht von HÄ und deren Perspektiven auf digitale Lösungen. Methodik Eine fragebogenbasierte Querschnittstudie unter 600 zufällig ausgewählten HÄ in Sachsen-Anhalt. Ergebnisse Die Antwortquote war 20% (n=114). Das mittlere Alter der teilnehmenden HÄ lag bei 53 Jahren, zwei Drittel waren Frauen (65%). HÄ nutzen hauptsächlich Fax (92%) oder Telefon (87%) zur Kommunikation mit Pflegeheimen. Digitale Kommunikationswege wie E-Mail (7%), Praxis-EDV (6%) und Chat-Dienste (1%) werden seltener genutzt. Etwa die Hälfte der HÄ beschreiben nicht notwendige (52%) oder unklare (51%) Heimbesuchsanforderungen, sowie fehlende Informationen über Medikationsplanänderungen durch andere Ärzte (51%) als häufiges, vermeidbares Problem. Ärzte möchten zukünftig mit E-Medikationsplänen (85%), E-Folgeverordnungen (79%) und E-Überweisungen (69%) arbeiten. 33% der HÄ haben vollständig digitale Patientenakten. Nur 9% arbeiten ausschließlich auf Papierbasis. Schlussfolgerung Obwohl HÄ eine Offenheit für digitalisierte Kommunikation mit Pflegeheimen zeigen, werden fast ausschließlich Fax und Telefon genutzt. HÄ bevorzugen es, weniger komplexe Aufgaben, wie Medikationsplanänderung und Überweisungen, digital zu bearbeiten. Wenige HÄ können es sich vorstellen, komplexere Prozeduren wie die Versorgung akuter Gesundheitsprobleme und Kurvenvisiten digital abzuwickeln. Nur 8% möchten nicht digital arbeiten.

Objectives Australian guidelines for dementia cover 109 recommendations for dementia care. Knowing which recommendations to implement poses a challenge for general practitioners (GPs). This study aimed to gather general practice perspectives of priority recommendations for GPs in their practice. Methods To explore which recommendations are most important and those requiring the greatest support in GP implementation, a Delphi study was conducted. Thirty-six GPs, 4 practice nurses and 1 medical services director completed two rounds of email questionnaires. Results Recommendations requiring support for GP implementation relate to early assessment of behavioural and psychological symptoms; mental health interventions tailored to the person's preferences and abilities; language and cultural barriers in access to information and services; and cognitive and learning needs in treatment delivery. Conclusion It is critical to understand where support may be needed for GPs to successfully implement recommendations to improve care provided to people with dementia and their carers.

Background Opioid prescribing has escalated, particularly long-term in chronic noncancer pain. Innovative models of care have been recommended to augment regulatory and harm-minimisation strategies and to review the safety and benefits of opioids for the individual patient. Medication stewardship and pharmacist integration are evolving approaches for general practice. Aim To explore enablers, barriers, and outcomes of a pharmacist-led intervention to improve opioid management in general practice, from the perspectives of general practitioners (GPs) and practice personnel. Method The study was part of a mixed-methods investigation into a general practice pharmacist pilot. Qualitative data relevant to opioids were analysed. Data from 13 semi-structured interviews were coded, analysed iteratively and thematically, and interpreted conceptually through the framework of Opioid Stewardship fundamentals proposed by the National Quality Forum. Results Seven themes and 14 subthemes aligned with stewardship fundamentals. Participants considered organisational policy, supported by leadership and education, fostered collaboration and consistency and improved practice safety. Patient engagement with individualised resources, 'agreements' and 'having the conversation' with the pharmacist enabled person-centred opioid review and weaning. GPs reported greater accountability and reflection in their practices, in the broader context of opioid prescribing and dilemmas in managing patients transitioning through care. Receiving feedback on practice deprescribing outcomes encouraged participants' ongoing commitment. Patient communication was deemed an early barrier; however, learnings were applied when transferring the model to other high-risk medicines. Conclusion Improved opioid management was enabled through implementing pharmacist-led coordinated stewardship. The findings offer a practical application of guideline advice to individualise opioid deprescribing.

COPD prevalence is likely to be underestimated in the UK. Anne Rodman explores the current evidence base for diagnosing COPD Chronic obstructive pulmonary disease (COPD) is an umbrella term for several different pathological processes in the lungs of susceptible individuals. COPD should be considered in any patient who has symptoms and a history of exposure to risk factors for the disease. The cornerstone of COPD diagnosis is to identify risk factors for this preventable condition, recognise and investigate any symptoms that are not commonly found in COPD, and confirm that obstruction is present with correctly performed and interpreted spirometry. This article explores the current evidence base for diagnosing COPD, how to differentiate it from asthma and other conditions with similar symptoms, and the rationale for specialist referral.

Summary Aim To describe the ambulatory changes in drug prescriptions 3 months after hospital discharge among elderly patients aged 75 and over, and to identify the reasons for these changes. Methods A prospective cohort study was conducted on subjects, discharged between 09/2016 and 01/2017 from the Bordeaux University Hospital. Prescription forms were collected from patients’ pharmacists. The main outcome was the occurrence of at least one significant change (SC) defined as an initiation, a discontinuation, a switch or change in drug daily dosage as regards the drugs prescribed upon hospital discharge and those prescribed 3 months after. Whenever drug SC occurred, general practitioners were requested to elicit reasons for such changes. Results Among the 126 patients included in our study, 73 underwent a 3-month follow-up period, without death or being re-hospitalised. 87.7% of them had at least one SC 3 months after discharge, with an average of 3.1 ± 2.5 SC per patient. Main changes involved: discontinuation or dose decrease of anxiolytics, hypnotics, antalgics, betablockers and calcium channel blockers; start or dose increase of diuretics, ACE inhibitors and angiotensin receptor blockers. In patients with a 3-month follow-up period, 27.4% underwent at least one ADR-induced SC. Conclusion Most elderly patients experience drug prescription changes after discharge. Some, according to drug iatrogenic, could be avoided through better cooperation between hospital and ambulatory prescribers.

BackgroundCervical cancer disproportionately affects women ≥65 years, especially those not screened regularly. Speculum use is a key barrier.AimTo assess if offering non-speculum clinician-taken sampling and self-sampling increases uptake for lapsed attenders aged 50–64 years.Design and settingPragmatic randomised control trial conducted at 10 general practices in East London, UK.MethodParticipants were 784 women aged 50–64 years, last screened 6–15 years before randomisation. Intervention participants received a letter offering the choice of non-speculum clinician- or self-sampling. Control participants received usual care. The main outcome measure was uptake within 4 months.ResultsScreening uptake 4 months after randomisation was significantly higher in the intervention arm: 20.4% (n = 80/393) versus 4.9% in the control arm (n = 19/391, absolute difference 15.5%, 95% confidence interval [CI] = 11.0% to 20.0%, Pn = 120/393) versus control 13.6% (n = 53/391) (absolute difference 17.0%, 95% CI = 11.3% to 22.7%, Pn = 50/393) and control 13.6% (n = 53/391) arms. Ethnic differences were seen in screening modality preference. More White women opted for self-sampling (50.7%, n = 38/75), whereas most Asian and Black women and those from other ethnic backgrounds opted for conventional screening.ConclusionOffering non-speculum clinician-taken sampling and self-sampling substantially increases uptake in older lapsed attendee women. Non-speculum clinician sampling appeals to women who dislike the speculum but still prefer a clinician to take their sample. Providing a choice of screening modality may be important for optimising cervical screening uptake.

Zusammenfassung Hintergrund Die chronische Niereninsuffizienz (CKD) ist eine häufige Diagnose im höheren Alter, meistens bedingt durch die Grunderkrankungen Diabetes mellitus und arterielle Hypertonie. Sie verläuft lange asymptomatisch und nur ein geringer Patiententeil wird im Verlauf eine terminale Niereninsuffizienz entwickeln und eine Nierenersatztherapie benötigen. Betroffene werden primär von Hausärzten behandelt. Ziel Ziel der Studie war es, das Management von Patienten mit einer nicht dialysepflichtigen chronischen Niereninsuffizienz aus Sicht von Hausärzten zu untersuchen. Methoden Es wurden 5 Gruppendiskussionen mit jeweils maximal 5 Hausärzten (n = 22) durchgeführt. Das Material wurde aufgenommen und transkribiert, um inhaltsanalytisch ausgewertet zu werden. Ergebnisse Als wichtigste Behandlungsmaßnahmen bei der CKD wurden die Optimierung der Grunderkrankungen, die Medikamentenanpassung und die Überweisung an einen Nephrologen genannt. Die Hausärzte betonten, beim Management die Individualität ihrer CKD-Patienten zu berücksichtigen. Allerdings gibt es Themenbereiche, bei denen die Zusammenarbeit als nicht positiv betrachtet wird, beispielsweise bei palliativen Patienten oder der häufigen Wiedervorstellung bei älteren Patienten. Bei den meisten älteren und multimorbiden Patienten mit einer oft eingeschränkten Lebenserwartung müssen Hausärzte individuell entscheiden, für welche Patienten eine Überweisung zum Nephrologen am ehesten nützlich ist. Diskussion Die befragten Hausärzte berichteten, dass sie ihre Entscheidungen zum Management von CKD auf individuelle Patientenfaktoren, wie beispielsweise ein höheres Patientenalter oder Multimorbidität, basierten.

BackgroundChest X-ray (CXR) is the first-line test for lung cancer in many settings. Previous research has suggested that higher utilisation of CXR is associated with improved outcomes.AimTo explore the associations between characteristics of general practices and frequency of investigation with CXR.Design and settingRetrospective observational study of English general practices.MethodA database was constructed of English general practices containing number of CXRs requested and data on practices for 2018, including patient and staff demographics, smoking prevalence, deprivation, and patient satisfaction indicators. Mixed-effects Poisson modelling was used to account for variation because of chance and to estimate the amount of remaining variation that could be attributed to practice and population characteristics.ResultsThere was substantial variation in GP CXR rates (median 34 per 1000 patients, interquartile range 26–43). Only 18% of between-practice variance in CXR rate was accounted for by recorded characteristics. Higher practice scores for continuity and communication skills, and higher proportions of smokers, Asian and mixed ethnic groups, and patients aged >65 years were associated with increased CXR rates. Higher patient satisfaction scores for access and greater proportions of male patients and patients of Black ethnicity were associated with lower CXR rates.ConclusionSubstantial variation was found in CXR rates beyond that expected by chance, which could not be accounted for by practices’ recorded characteristics. As other research has indicated that increasing CXR rates can lead to earlier detection, supporting practices that currently investigate infrequently could be an effective strategy to improve lung cancer outcomes.

BackgroundMost antibiotics are prescribed in primary care. Locum or sessional GPs (locums) are perceived as contributing to higher prescribing and may face barriers to engaging with antimicrobial stewardship (AMS).AimTo identify how locums’ antibiotic prescribing compares with other general practice prescribers, and how they perceive their role in antibiotic prescribing and AMS.Design and settingMixed-methods study in primary care.MethodData on antibiotic prescribing, diagnoses, and patient and prescriber characteristics were extracted from The Health Improvement Network database. A mixed-effects logistic model was used to compare locums’ and other prescribers’ antibiotic prescribing for conditions that do not usually benefit from antibiotics. Nineteen semi-structured telephone interviews were conducted with locums in England and analysed thematically.ResultsLocums accounted for 11% of consultations analysed. They prescribed antibiotics more often than other GPs and nurse prescribers for acute cough, sore throat, asthma and chronic obstructive pulmonary disease exacerbations, and acute bronchitis. The number of patients receiving antibiotics for these conditions was 4% higher (on absolute scale) when consulting with locums compared with when they consulted with other GPs. Four themes capture the perceived influences on prescribing antibiotics and AMS: antibiotic prescribing as a complex but individual issue, nature and patterns of locum work, relationships between practices and locums, and professional isolation.ConclusionLocums contribute to higher antibiotic prescribing compared with their peers. They experience challenges but also opportunities for contributing to AMS, which should be better addressed. With an increasing proportion of locums in general practice, they have an important role in antibiotic optimisation and AMS.

BackgroundHealth services are increasingly using digital tools to deliver care, and online consultations are being widely adopted in primary care settings. The intended consequences of online consultations are to increase patient access to care and increase the efficiency of care.AimTo identify and understand the unintended consequences of online consultations in primary care.Design and settingQualitative interview study in eight general practices using online consultation tools in South West and North West England between February 2019 and January 2020.MethodThematic analysis of semi-structured interviews with 19 patients and 18 general practice staff.ResultsConsequences of online consultations were identified that restricted patient access to care by making it difficult for some patients to communicate effectively with a GP and disadvantaging digitally-excluded patients. This stemmed from patient uncertainty about how their queries were dealt with, and whether practices used online consultations as their preferred method for patients to contact the practice. Consequences were identified that limited increases in practice efficiency by creating additional work, isolation, and dissatisfaction for some staff.ConclusionUnintended consequences often present operational challenges that are foreseeable and partly preventable. However, these challenges must be recognised and solutions resourced sufficiently. Not everyone may benefit and local decisions will need to be made about trade-offs. Process changes tailored to local circumstances are critical to making effective use of online consultation tools. Unintended consequences also present clinical challenges that result from asynchronous communication. Online consultation tools favour simple, well-formulated information exchange that leads to diffuse relationships and a more transactional style of medicine.

Die palliative Betreuung von Patientinnen mit nicht-onkologischen, chronischen Erkrankungen liegt grostenteils in den Handen der Hausarzte. Derzeit verwenden praktische Arztinnen aber kaum standardisierte Fragebogen, um den Bedarf zu ermitteln. Vielmehr ist es eine intuitive, individuelle Entscheidung, zu welchem Zeitpunkt und in welchem Ausmas eine Palliativbetreuung zu Hause stattfindet. Anhand des Beispiels eines Patienten mit chronischer Herzinsuffizienz wird der Frage nachgegangen, ob und mit welchen Assessment-Tools der Bedarf einer (spezialisierten) Palliativbetreuung in der Allgemeinmedizin erkannt werden kann.

Background Early diagnosis of pediatrics urinary tract infections in the outpatient settings is challenging but essential to prevent hospitalization and kidney damage. Objective We aimed to evaluate the diagnostic test accuracy of a selection of point-of-care tests for pediatric urinary tract infections in general practice. Methods A prospective cross-sectional study in 26 general practices in Flanders, Belgium (clinicaltrials.gov, NCT03835104). Urine was sampled systematically from children between 3 months to 18 years presenting with an acute illness of maximum 10 days. Samples were analyzed at the central laboratory with a routine dipstick test, the Utriplex test, the Uriscreen test and the Rapidbac as index tests, and with urine culture showing more than 105 colony-forming units per milliliter of one pathogen as reference standard. For each test, we calculated sensitivity, specificity, positive and negative likelihood ratios, and predictive values with 95% confidence intervals. Results Three-hundred urine samples were available for analysis of which 30 samples were culture positive (10%). Sensitivities and specificities were 32% (95% CI 16%–52%) and 86% (95% CI 82%–90%) for the dipstick test, 21% (95% CI 8%–40%) and 94% (95% CI 91%–97%) for the Utriplex test, 40% (95% CI 16%–68%) and 83% (95% CI 75%–88%) for the Rapidbac test, and 67% (95% CI 38%–88%) with 69% (95% CI 60%–76%) for the Uriscreen test. Conclusion All 4 point-of-care tests were suboptimal for use in the broad range of children presenting with acute illnesses to general practice. General practitioners need novel methods for obtaining reliable urine samples during the time of the consultation, especially for children not yet toilet-trained.

The number of frail home-dwelling elderly is increasing, and they are likely to retain their own dentition longer when ageing. With increasing age, the number of dental visits declines, while the number of visits to the general practitioners' (GP) clinics increases. The aim of this study was to assess the oral health status and dental visits of frail home-dwelling elderly that visit their GP. The study consisted of questionnaires and an oral examination. Subjective and objective oral health was determined by the Geriatric Oral Health Assessment Index-NL and the Oral Health Assessment Tool. Almost half of the frail elderly had not visited the dentist for over 2 years and a quarter had objective oral health problems. The educational level and the dental status were of influence on the dental visits and on their oral health. In about a third of the subjects, a subjective oral health problem was observed, which was influenced by the extent of the subject's frailty. A multidisciplinary approach can improve the oral health status of frail home-dwelling elderly.Het aantal thuiswonende kwetsbare ouderen neemt toe en zij behouden vaker op hoge leeftijd hun eigen dentitie. Het is bekend dat met stijgende leeftijd het tandartsbezoek af-en het huisartsbezoek juist toeneemt. Het doel van dit onderzoek was het in kaart brengen van de mondgezondheid en het tandartsbezoek van kwetsbare ouderen die patiënt zijn bij een huisartsenpraktijk. Het onderzoek bestond uit vragenlijsten en een mondonderzoek. De subjectieve en objectieve mondgezondheid werden vastgesteld door respectievelijk de Geriatric Oral Health Assessment Index-NL en de Oral Health Assessment Tool. Bijna de helft van de kwetsbare ouderen bleek al meer dan 2 jaar niet naar een tandarts te zijn geweest en bij een kwart werd een objectief mondgezondheidsprobleem gezien. Opleidingsniveau en gebitsstatus waren van invloed op het tandartsbezoek en de mondgezondheid. Bij ongeveer een derde werd een subjectief mondgezondheidsprobleem gezien waarbij de mate kwetsbaarheid van invloed was. Multidisciplinaire aanpak kan de mondgezondheid van kwetsbare ouderen verbeteren.

Background The COVID-19 pandemic has resulted in the diversion of health resources away from routine primary care delivery. This disruption of health services has necessitated new approaches to providing care to ensure continuity. Objectives To summarize changes to the provision of routine primary care services during the pandemic. Methods Rapid literature review using PubMed/MEDLINE, SCOPUS, and Cochrane. Eligible studies were based in primary care and described practice-level changes in the provision of routine care in response to COVID-19. Relevant data addressing changes to routine primary care delivery, impact on primary care functions and challenges experienced in adjusting to new approaches to providing care, were obtained from included studies. A narrative summary was guided by Burns et al.’s framework for primary care provision in disasters. Results Seventeen of 1,699 identified papers were included. Studies reported on telehealth use and public health measures to maintain safe access to routine primary care, including providing COVID-19 screening, and establishing dedicated care pathways for non-COVID and COVID-related issues. Acute and urgent care were prioritized, causing disruptions to chronic disease management and preventive care. Challenges included telehealth use including disparities in access and practical difficulties in assessing patients, personal protective equipment shortages, and financial solvency of medical practices. Conclusions Substantial disruptions to routine primary care occurred due to the COVID-19 pandemic. Primary care practices’ rapid adaptation, often with limited resources and support, demonstrates agility and innovative capacity. Findings underscore the need for timely guidance and support from authorities to optimize the provision of comprehensive routine care during pandemics., Lay Summary The COVID-19 pandemic has resulted in considerable disruption to health services including regular primary care. As a consequence, primary care practices have had to adopt new ways of providing care to ensure ongoing availability of services. However, little is known about the type of measures taken by care providers and challenges encountered in reorganizing services. The aim of this research was to provide a detailed understanding of changes in the way primary care was delivered and to identify difficulties experienced by patients and providers in adjusting to new approaches. The 17 studies included in the review indicate that primary care providers quickly put in place strategies including telehealth (e.g. telephone and video consultations) and infection control measures to ensure safe access to care. Furthermore, urgent and short-term care were prioritized resulting in interruptions to other services, including management of preexisting or long-term illnesses. Challenges included barriers to accessing telehealth such as inadequate internet connection and practical difficulties in examining patients, personal protective equipment shortages, and financial losses by practices. Adequate support from authorities is needed to enhance the provision of comprehensive primary care during pandemics.

NHS primary care staff can now access coaching for themselves and for managing a team. Dave Hancock explores some of the available options

In this article, Sarah Jane Palmer discusses the importance of the prevention of skin tears and the role practice nurses can play Skin tears can present a complex and chronic problem for an older patient with fragile skin, and can be very disabling, reducing quality of life dramatically in some cases. The right care is essential from all members of the wider team caring for older patients, in order to identify risk factors for skin tears, as well as formulating a care plan of prevention that relates to these risk factors. Good skin care is essential, as well as patient education, and identifying ongoing issues with the patient's health that present a factor to consider when caring for them, such as mobility issues. Self-care should be encouraged where possible, and the correct use and choice of emollients that are pH balanced is crucial. By preventing skin tears we not only give the patient a far better quality of life, but we also reduce the need for very limited NHS resources.

Introduction Reversal of enamel-only proximal caries by non-invasive treatments is important in preventive dentistry. However, detecting such caries using bitewing radiography is difficult and the subtle patterns are often missed by dental practitioners. Aims To investigate whether the ability of dentists to detect enamel-only proximal caries is enhanced by the use of AssistDent artificial intelligence (AI) software. Materials and methods In the ADEPT (AssistDent Enamel-only Proximal caries assessmenT) study, 23 dentists were randomly divided into a control arm, without AI assistance, and an experimental arm, in which AI assistance provided on-screen prompts indicating potential enamel-only proximal caries. All participants analysed a set of 24 bitewings in which an expert panel had previously identified 65 enamel-only carious lesions and 241 healthy proximal surfaces. Results The control group found 44.3% of the caries, whereas the experimental group found 75.8%. The experimental group incorrectly identified caries in 14.6% of the healthy surfaces compared to 3.7% in the control group. The increase in sensitivity of 71% and decrease in specificity of 11% are statistically significant (p, Key points Enamel-only proximal caries is often missed by dentists when examining bitewing radiographs.The use of AssistDent artificial intelligence software results in a 71% increase in ability to detect enamel-only proximal caries accompanied by a 11% decrease in specificity.Artificial intelligence software could be considered as a tool to support preventive dentistry in general practice.

ObjectivesThis study aimed to investigate the hospitalisation rates and the reasons for hospitalisation in patients with polymyalgia rheumatica (PMR). Furthermore, it aimed to clarify the impact of a newly established Fast Track Clinic (FTC) approach on hospitalisation rates in connection with PMR diagnosis.MethodsPatients diagnosed with PMR at South-West Jutland Hospital, Denmark, between 2013 and 2018 were included retrospectively. Only patients fulfilling the 2012 EULAR/ACR classification criteria were included in our cohort. An FTC for patients suspected of having PMR was established in the rheumatologic department of South-West Jutland Hospital in January 2018.ResultsOver 6 years (2013 to 2017), 254 patients were diagnosed with PMR, 56 of them while hospitalised. Hospitalised patients were more likely to have a higher initial CRP mean ± standard deviation (SD) 99.53 ± 59.36 vs 45.82 ± 36.96 mg/lt (p p = 0.0018). After implementing the FTC, a significant decrease in hospitalisation rates (from 20.4% to 3,5%) and inpatient days of care (mean ± SD 4.15 ± 3.1 vs 1 ± 0) were observed. No differences between the two groups were observed regarding clinical symptoms, laboratory values and initial prednisolone dose.ConclusionA substantial number of patients are hospitalised in connection with the PMR diagnosis. The FTC approach can decrease the hospitalisation rates significantly among these patients.Trial registrationRetrospectively registered.

BackgroundOsteopathy is a type of complementary medicine based on specific manual techniques. In many countries, including Germany, the profession is not officially regulated, and evidence for the effectiveness of osteopathy is insufficient for most diseases. Nevertheless, many health insurances in Germany offer reimbursement for therapy costs, if osteopathy is recommended by a physician.This cross-sectional survey of German general practitioners (GPs) explored beliefs and attitudes towards osteopathic medicine and described their daily interactions with it.MethodsA random sample of 1000 GPs from all federal states was surveyed by mail using a self-designed questionnaire. We collected data on sociodemographics, personal experiences with osteopathy, and attitudes and expectations towards osteopathy. In particular, participants were asked about indications for osteopathic treatment and their beliefs about its effectiveness for different patient groups and diagnoses. A self-designed score was used to estimate general attitudes towards osteopathy and identify factors correlated with greater openness. Additionally, we performed logistic regression to reveal factors associated with the frequency of recommending osteopathy to patients.ResultsResponse rate was 34.4%. 46.5% of participants were women, and the median age was 56.0 years. 91.3% of GPs had referred patients to an osteopath, and 88.0% had recommended osteopathy to their patients. However, 57.5% acknowledged having little or no knowledge about osteopathy. Most frequent reasons for a recommendation were spinal column disorders (46.2%), other complaints of the musculoskeletal system (18.2%) and headaches (9.8%). GPs estimated the highest benefit for chronically ill and middle-aged adults. Female gender (OR 2.09; 95%CI 1.29–3.38) and personal treatment experiences (OR 5.14; 95%CI 2.72–9.72) were independently positively associated with more frequent treatment recommendation.ConclusionGPs in Germany have frequent contact with osteopathy, and the vast majority have recommended osteopathic treatment to some extent in their practice, with foci and opinions comparable to other Western countries. The discrepancy between GPs making frequent referrals for osteopathic treatment while self-assessing to have little knowledge about it demonstrates need for intensified research on the collaboration with osteopaths and how to best integrate osteopathic treatments. Our results may help to focus future effectiveness studies on most relevant clinical conditions in general practice.

BACKGROUND AND OBJECTIVES Strong integration between primary and secondary healthcare is essential. Health services across Australia have developed General Practice Liaison (GPL) services to improve communication and understanding between general practitioners (GPs) and hospitals. The aim of this study was to explore GPs' experiences of and interaction with a health service's GPL service and capture perspectives concerning future service expansion. METHOD This descriptive qualitative study used semi-structured interviews with 10 GPs in the catchment area of a large urban health service in Melbourne in 2018. Data were analysed thematically. RESULTS While GPs accepted the value of a GPL service, few had direct experience. Acknowledging the challenge of negotiating complex healthcare systems, they saw GPL services ideally staffed by a health professional, not necessarily a GP. DISCUSSION The results provide insight into what GPs want from a GPL service. This can inform development of the GPL role within health services.

Background Hypertension (HTN) affects approximately 25% of the UK population and is a leading cause of mortality. Associated annual health care costs run into billions. National treatment guidance includes initial lifestyle advice, followed by anti-hypertensive medication if blood pressure (BP) remains high. However, adoption and adherence to recommended exercise guidelines, dietary advice and anti-hypertensive medication is poor. Four short bouts of isometric exercise (IE) performed 3 days per week (d/wk) at home elicits clinically significant reductions in BP in those with normal to high-normal BP. This study will determine the feasibility of delivering personalised IE to patients with stage 1 hypertension for whom lifestyle changes would be recommended before medication within NHS primary care. Methods This is a randomised controlled feasibility study. Participants were 18+ years, with stage 1 hypertension, not on anti-hypertensive medication and without significant medical contraindications. Trial arms will be standard lifestyle advice (control) or isometric wall squat exercise and standard lifestyle advice. Primary outcomes include the feasibility of healthcare professionals to deliver isometric exercise prescriptions in a primary care NHS setting and estimation of the variance of change in systolic BP. Secondary outcomes include accuracy of protocol delivery, execution of and adherence to protocol, recruitment rate, attrition, perception of intervention viability, cost, participant experience and accuracy of home BP. The study will last 18 months. Sample size of 100 participants (50 per arm) allows for 20% attrition and 6.5% incomplete data, based upon 74 (37 each arm) participants (two-sided 95% confidence interval, width of 1.33 and standard deviation of 4) completing 4 weeks. Ethical approval IRAS ID is 274676. Discussion Before the efficacy of this novel intervention to treat stage 1 hypertension can be investigated in any large randomised controlled trial, it is necessary to ascertain if it can be delivered and carried out in a NHS primary care setting. Findings could support IE viability as a prophylactic/alternative treatment option. Trial registration ISRCTN13472393, registered 18 August 2020

This study aimed to describe prescription of antibiotics to the elderly population in general practice in Denmark from 2010–2017. This is a national register-based observational study. General practice, Denmark The main outcome measure was prescriptions/1,000 inhabitants/day (PrID) in relation to year, age and sex, indication, and antibiotic agent. In this study, we included inhabitants of Denmark, ≥65 years of age between 01st July 2010–30th June 2017. A total of 5,168,878 prescriptions were included in the study. Antibiotic prescriptions decreased from 2.2 PrID to 1.7 (-26.9%, CI95% [-31.1;-22.4]) PrID during the study. The decrease in PrID was most noticeable among 65–74-year-olds (-25%). The ≥85-year-olds were exposed to twice as many PrID than the 65–74-year-olds, but only accounted for 20% of the total use. Urinary tract infection (UTI) was the most common indication for antibiotic prescription and increased with advancing age. The most commonly prescribed antibiotics were pivmecillinam and phenoxymethylpenicillin. Prescribing with no informative indication was present in one third of all cases. The prescription of antibiotics in the elderly population in general practice decreased from 2010 to 2017. The oldest age group was exposed twice as frequently to antibiotic prescriptions as the 65–74-year-olds. The smallest reduction was observed for the ≥85-year-olds, suggesting targeting interventions at this group.Key PointsHigh antibiotic use among elderly is well known and studies indicate mis- and overuse within this population. Our study shows.The prescription rate is decreasing within all age groups of the elderly population.The ≥85-year-olds receive twice as many prescriptions/1000/day as the 65–74-years-olds. High antibiotic use among elderly is well known and studies indicate mis- and overuse within this population. Our study shows. The prescription rate is decreasing within all age groups of the elderly population. The ≥85-year-olds receive twice as many prescriptions/1000/day as the 65–74-years-olds.

Purpose: To describe the pattern of the nerves in the inferocentral whorl region of the human corneal subbasal nerve plexus (SBNP) in health and diseases known to affect the subbasal nerves. Methods: Laser-scanning in vivo confocal microscopy (IVCM) was used to image the SBNP bilaterally in 91 healthy subjects, 39 subjects with type 2 diabetes mellitus (T2DM), and 43 subjects with Parkinsons disease (PD). Whorl regions were classified according to nerve orientation relative to age and health/disease status. Results: Of 346 examined eyes, 300 (86.7%) had an identifiable whorl pattern. In healthy subjects, a clockwise nerve orientation of the whorl was most common (67.9%), followed by non-rotatory or seam morphology (21.4%), and counterclockwise (10.7%). The clockwise orientation was more prevalent in healthy subjects than in T2DM or PD (P < 0.001). Healthy individuals below 50 years of age had a predominantly clockwise orientation (93.8%) which was reduced to 51.9% in those over 50 years (P < 0.001). Age but not disease status explained whorl orientation in T2DM and PD groups. Moreover, whorl orientation is bilaterally clockwise in the young, but adopts other orientations and becomes asymmetric across eyes with age. Finally, we report reflective dot-like features confined to the whorl region of the subbasal plexus, sometimes appearing in close association with subbasal nerves and present in 84-93% of examined eyes regardless of disease status, eye or sex. Conclusion: Subbasal nerves in the inferocentral whorl region are predominantly clockwise in young, healthy corneas. With aging and conditions of T2DM and PD, counterclockwise and non-rotatory configurations increase in prevalence, and bilateral symmetry is lost. Mechanisms regulating these changes warrant further investigation. Funding Agencies|Hofgrens fond, NEURO Sweden