Integrated GP care for patients with persistent physical symptoms: feasibility cluster randomised trial

Meenal Patel,Anthony S David,Mark Ashworth,Rona Moss‐Morris ,Kirsty James,Paul Mccrone,Matthew Hotopf,Mujtaba Husain,Sabine Landau,Trudie Chalder

doi:10.1186/s12875-020-01269-9

Abstract

BackgroundPatients continue to suffer from medically unexplained symptoms otherwise referred to as persistent physical symptoms (PPS). General practitioners (GPs) play a key role in the management of PPS and require further training. Patients are often frustrated with the care they receive. This study aims to assess the acceptability of an ‘integrated GP care’ approach which consists of offering self-help materials to patients with PPS and offering their GPs training on how to utilise cognitive behavioural skills within their consultations, as well as assessing the feasibility of conducting a future trial in primary care to evaluate its benefit.MethodsA feasibility cluster randomised controlled trial was conducted in primary care, South London, UK. GP practices (clusters) were randomly allocated to ‘integrated GP care plus treatment as usual’ or ‘treatment as usual’. Patients with PPS were recruited from participating GP practices before randomisation. Feasibility parameters, process variables and potential outcome measures were collected at pre-randomisation and at 12- and 24-weeks post-randomisation at cluster and individual participant level.ResultsTwo thousand nine hundred seventy-eight patients were identified from 18 GP practices. Out of the 424 patients who responded with interest in the study, 164 fully met the eligibility criteria. One hundred sixty-one patients provided baseline data before cluster randomisation and therefore were able to participate in the study. Most feasibility parameters indicated that the intervention was acceptable and a future trial feasible. 50 GPs from 8 GP practices (randomised to intervention) attended the offer of training and provided positive feedback. Scores in GP knowledge and confidence increased post-training. Follow-up rate of patients at 24 weeks was 87%. However estimated effect sizes on potential clinical outcomes were small.ConclusionsIt was feasible to identify and recruit patients with PPS. Retention rates of participants up to 24 weeks were high. A wide range of health services were used. The intervention was relatively low cost and low risk. This complex intervention should be further developed to improve patients’/GPs’ utilisation of audio/visual and training resources before proceeding to a full trial evaluation.Trial registrationNCT02444520 (ClinicalTrials.gov).

Highlights

Patients continue to suffer from medically unexplained symptoms otherwise referred to as persistent physical symptoms (PPS)
89 were from General Practitioner (GP) practices later randomised to the intervention and 72 from GP practices allocated to treatment as usual (TAU). (i) Questionnaires were returned by 142 (88%) participants at 12 weeks and 140 (87%) participants at 24 weeks
A patient may have been identified through a read code as having back pain, this may be due to a slipped disc and the pain was explained

Summary

Introduction

Patients continue to suffer from medically unexplained symptoms otherwise referred to as persistent physical symptoms (PPS). Clinician uncertainty in diagnosing these symptoms, often leads to over investigation and unnecessary treatments [9, 10], a recent study found that GPs did not experience clinical uncertainty They were more likely to provide a diagnosis of PPS if a) they were cognizant of the patient’s medical and social history, b) a discrepancy between the symptoms presented by the patient and objective findings were apparent c) patients reported several symptoms and lacked clarity about the nature of their symptoms [11]. Patients with PPS tend to feel dissatisfied with the care they receive and often feel misunderstood [12, 13] They can be referred to specialist services, referrals are often associated with barriers such as geographical restrictions, costs and stigma [14, 15]. GPs often feel powerless to influence patients’ understanding of their illness [4, 9, 16], despite understanding the importance of good communication in terms of exploring psychosocial cues and engaging in a more patient centred approach [17]

Objectives

Methods

Results

Discussion

Conclusion