Common Conditions In Primary Care Research Articles

Attitudes, beliefs, behaviours and perspectives on barriers and enablers of Australian general practitioners towards non-drug interventions: a national survey

BackgroundMany guidelines recommend non-drug interventions (NDIs) for managing common conditions in primary care. However, compared with drug interventions, NDIs are less widely known, promoted and used. We aim to (1)...

Adoption of new medicines in primary care: A comparison between the uptake of new oral anticoagulants and diabetes medicines.

To gain insight in the uptake and practice variation in the prescription of 2 new medicine groups for common conditions in primary care (direct-acting oral anticoagulants [DOACs] and incretin-based therapies) from introduction, around 2007, to 2019 and the correlation between the adoption of those medicines in primary care. Prescription data from general practices in the Dutch Nivel Primary Care Database from 2007 to 2019 were used. The percentage of patients with prescriptions for DOACs of all patients with prescriptions for DOACs and vitamin K antagonists was calculated per practice per year, as was the percentage of patients prescribed incretin-based therapies as a proportion of all patients with diabetes medication. Multilevel models were used to estimate practice variation for DOACs and incretin-based therapies, expressed as intraclass correlation coefficients. Linear regression analysis was used to study the association between the prescription of DOACs and incretin-based therapies. Per year, 46-424 general practices and 179 933-1654 376 patients were included. In 2019, the mean percentage of patients per practice using DOACs or incretin-based therapies was 54.9 and 9.7%, respectively. The intraclass correlation coefficient decreased from 0.75 to 0.024 for DOACs and from 0.33 to 0.074 for incretin-based medicines during the study period. No clear correlation was found between the prescription of DOACs and incretin-based therapies. DOACs and incretin-based therapies have different adoption profiles and practice variation is large, especially in the years before these medicines were introduced in guidelines. Early adopters of both medicine classes differ.

2204. Excess Antibiotic Therapy for 5 Common Conditions in Primary Care: Low-Hanging Fruit for Outpatient Antibiotic Stewardship

Abstract Background Improving duration can be a key intervention in outpatient antibiotic stewardship as most conditions require only 5 days of therapy or less. Cellulitis, acute otitis media (AOM), sinusitis, community-acquired pneumonia (CAP), and uncomplicated urinary tract infections (UTI) encounters account for the majority of outpatient antibiotic prescriptions and have been associated with durations longer than necessary. We characterized the duration of antibiotic prescriptions associated with these conditions in our primary care (PC) network. Methods We retrospectively evaluated prescribing practices for cellulitis, AOM, sinusitis, CAP, and UTI encounters among patients ≥ 3 years-old from January 1st, 2022 – December 31st, 2022 in the Intermountain Health (IH) PC network. IH is an integrated healthcare system operating 119 PC clinics (69 family medicine, 22 internal medicine, 23 pediatric). System-specific evidence-based ambulatory guidelines for the conditions of interest during the study recommended 5-7 days of therapy. Encounters, patient characteristics, and prescription information were electronically extracted from the electronic health record. We analyzed duration of therapy by categories (≤5 days, 6-9 days, 10-14 days, or 14+ days) for each condition in pediatric (≥ 3-18 years-old) and adult (≥ 19 years-old) patients. Results There were 14,918 and 38,790 encounters for the studied conditions among pediatric and adult patients, respectively. The mean age of pediatric patients was 9.0 years and among adults, 56.8. Pediatric and adult patients were predominantly White, non-Hispanic, female, and preferred speaking English (Table 1). Overall, only 10.4% (8,965) of all prescriptions were ≤ 5 days and consistent with the recommended duration. Duration of prescriptions associated with each condition are presented in Figure 1. UTI exhibited the highest percentage of ≤ 5 day prescriptions (22.1% pediatrics, 29.1% adults) while sinusitis had the lowest (0.9% pediatrics, 2.6% adults).Table 1.Total encounters for all studied conditions and patient characteristicsFigure 1.Duration of antibiotic prescriptions associated with cellulitis, acute otitis media (AOM), sinusitis, community-acquired pneumonia (CAP), and uncomplicated urinary tract infection (UTI) encounters for patients 3-18 years-old (pediatric) and ≥19 years-old (adult) in the Intermountain Health primary care network. Conclusion Duration of therapy for cellulitis, AOM, sinusitis, CAP, and UTIs is almost always longer than the recommended 5 days of therapy in our PC network. There is substantial opportunity to improve duration for these conditions. Disclosures Payal K. Patel, MD MPH, qiagen: Honoraria

Prevalence of co-morbidity and history of recent infection in patients with neuromuscular disease: A cross-sectional analysis of United Kingdom primary care data.

People with neuromuscular disease (NMD) experience a broader range of chronic diseases and health symptoms compared to the general population. However, no comprehensive analysis has directly quantified this to our knowledge. We used a large UK primary care database (Clinical Practice Research Datalink) to compare the prevalence of chronic diseases and other health conditions, including recent infections between 23,876 patients with NMD ever recorded by 2019 compared to 95,295 age-sex-practice matched patients without NMD. Modified Poisson regression estimated Prevalence Ratios (PR) to summarise the presence of the disease/condition ever (or for infections in 2018) in NMD patients versus non-NMD patients. Patients with NMD had significantly higher rates for 16 of the 18 conditions routinely recorded in the primary care Quality and Outcomes Framework (QOF). Approximately 1-in-10 adults with NMD had ≥4 conditions recorded (PR = 1.39, 95%CI 1.33-1.45). Disparities were more pronounced at younger ages (18-49). For other (non-QOF) health conditions, significantly higher recorded levels were observed for rarer events (pulmonary embolism PR = 1.96 95%CI 1.76-2.18, hip fractures PR = 1.65 95%CI 1.47-1.85) as well as for more common primary care conditions (constipation PR = 1.52 95%CI 1.46-1.57, incontinence PR = 1.52 95%CI 1.44-1.60). The greatest co-morbidity burden was in patients with a myotonic disorder. Approximately 1-in-6 (17.1%) NMD patients had an infection recorded in the preceding year, with the risk of being hospitalised with an infection nearly double (PR = 1.92, 95%CI 1.79-2.07) compared to non-NMD patients. The burden of chronic co-morbidity among patients with NMD is extremely high compared to the general population, and they are also more likely to present in primary and secondary care for acute events such as infections.

Accuracy of self-diagnosis in conditions commonly managed in primary care: diagnostic accuracy systematic review and meta-analysis

ObjectivesTo assess the diagnostic accuracy of self-diagnosis compared with a clinical diagnosis for common conditions in primary care.DesignSystematic review. Meta-analysis.Data sourcesMedline, Embase, Cochrane CENTRAL, Cochrane Database of Systematic Reviews and...

The association between video or telephone telemedicine visit type and orders in primary care

IntroductionTelemedicine is increasingly relied upon for care delivery in primary care, but the impact of visit type on clinical ordering behavior is uncertain.MethodsWithin Kaiser Permanente Northern California, we identified patients who self-scheduled and completed telemedicine encounters with their personal primary care provider or another available primary care provider in the same medical group, between April 1st, 2020, and October 31st, 2020, while physical distancing restrictions for COVID-19 were in place. We collected patient sociodemographic and clinical characteristics, measures of technology access, and categorized the most common primary encounter diagnoses. We measured proportions of patient-scheduled video versus telephone visits for each of eight diagnosis groups (Skin & Soft Tissue, Musculoskeletal Pain, Back Pain, General Gastrointestinal, Hypertension & Diabetes, Mental Health, Upper Respiratory, and Abdominal Pain), and compared physician orders for medications, antibiotics, lab and imaging studies by visit type within each diagnosis group.ResultsThere were 273,301 included encounters, with 86,676 (41.5%) video visits and 122,051 (58.5%) telephone visits. Of the diagnosis groups, Skin & Soft Tissue conditions had the highest proportion of video visits (59.7%), while Mental Health conditions had the highest proportion of telephone visits (71.1%). After adjusting for covariates, the overall rates of medication orders (46.6% vs. 44.5%), imaging orders (17.3% vs. 14.9%), lab orders (19.5% vs. 17.2%), and antibiotic orders (7.5% vs. 5.2%) were higher during video visits as compared to telephone visits (p < 0.05). The largest difference within diagnosis groups was for Skin & Soft Tissue conditions, where the rate of medication orders was 9.1% higher than during video visits than telephone visits (45.5% vs. 36.5%, p < 0.05).ConclusionsWe observed statistically significant differences in clinician orders by visit type during telemedicine encounters for common primary care conditions. Our findings suggest that, for certain conditions, visual information conveyed during video visits may promote clinical work-up and treatment.

School-Based Health Center Utilization During COVID-19 Pandemic-Related School Closures.

BackgroundLittle is known regarding utilization of school‐based health centers (SBHCs) during prolonged school closures, such as those that occurred during the COVID‐19 pandemic. We sought to compare SBHC utilization before and after pandemic‐related school closures across a network of SBHCs affiliated with a large Southern Californian urban school district.MethodsWe conducted a secondary analysis of encounter data extracted from electronic health records from 12 SBHCs that remained open despite school closures, including patient demographics and diagnostic and billing codes. We used the Clinical Classifications Software Refined to group encounters for common primary care conditions. Utilization before and during pandemic‐related school closures was compared using logistic regression with cluster‐robust standard errors to account for clustering within clinics, after adjusting for month of encounter.ResultsDuring the pandemic, study SBHCs conducted 52,530 encounters and maintained ∼4040 encounters/month. The frequency of encounters for annual preventative health exams increased for school‐aged patients but decreased for other age groups while the frequency of encounters for mental health problems increased for all age groups.Implications for School Health Policy, Practice, and EquityDespite pandemic‐related school closures, SBHCs appeared play a critical role in providing primary care to vulnerable communities.ConclusionsSBHCs may hold value beyond their co‐location with academic instruction.

Addressing social determinants of health in primary care: a quasi-experimental study using unannounced standardised patients to evaluate the impact of audit/feedback on physicians' rates of identifying and responding to social needs

BackgroundAlthough efforts are underway to address social determinants of health (SDOH), little is known about physicians’ SDOH practices despite evidence that failing to fully elicit and respond to social needs...

Barriers to the provision of non-communicable disease care in Zimbabwe: a qualitative study of primary health care nurses

BackgroundNon-communicable diseases (NCDs) contribute significantly to the global disease burden, with low-and middle-income (LMICs) countries disproportionately affected. A significant knowledge gap in NCDs exacerbates the high burden, worsened by perennial health system challenges, including human and financial resources constraints. Primary health care workers play a crucial role in offering health care to most people in LMICs, and their views on the barriers to the provision of quality care for NCDs are critical. This study explored perceived barriers to providing NCDs care in primary health care facilities in Zimbabwe.MethodsIn-depth, individual semi-structured interviews were conducted with general nurses in primary care facilities until data saturation was reached. We focused on diabetes, hypertension, and depression, the three most common conditions in primary care in Zimbabwe. We used thematic content analysis based on an interview guide developed following a situational analysis of NCDs care in Zimbabwe and views from patients with lived experiences.ResultsSaturation was reached after interviewing 10 participants from five busy urban clinics. For all three NCDs, we identified four cross-cutting barriers, a) poor access to medication and functional equipment such as blood pressure machines, urinalysis strips; b) high cost of private care; c)poor working conditions; and d) poor awareness from both patients and the community which often resulted in the use of alternative potentially harmful remedies. Participants indicated that empowering communities could be an effective and low-cost approach to positive lifestyle changes and health-seeking behaviours. Participants indicated that the Friendship bench, a task-shifting programme working with trained community grandmothers, could provide a platform to introduce NCDs care at the community level. Also, creating community awareness and initiating screening at a community level through community health workers (CHWs) could reduce the workload on the clinic nursing staff.ConclusionOur findings reflect those from other LMICs, with poor work conditions and resources shortages being salient barriers to optimal NCDs care at the facility level. Zimbabwe's primary health care system faces several challenges that call for exploring ways to alleviate worker fatigue through strengthened community-led care for NCDs. Empowering communities could improve awareness and positive lifestyle changes, thus optimising NCD care. Further, there is a need to optimise NCD care in urban Zimbabwe through a holistic and multisectoral approach to improve working conditions, basic clinical supplies and essential drugs, which are the significant challenges facing the country's health care sector. The Friendship Bench could be an ideal entry point for providing an integrated NCD care package for diabetes, hypertension and depression.

The Association Between High and Unnecessary Antibiotic Prescribing: A Cohort Study Using Family Physician Electronic Medical Records.

Approximately 25% of outpatient antibiotic prescriptions are unnecessary among family physicians in Canada. Minimizing unnecessary antibiotics is key for community antibiotic stewardship. However, unnecessary antibiotic prescribing is much harder to measure than total antibiotic prescribing. We investigated the association between total and unnecessary antibiotic use by family physicians and evaluated inter-physician variability in unnecessary antibiotic prescribing. This was a cohort study based on electronic medical records of family physicians in Ontario, Canada, between April 2011 and March 2016. We used predefined expected antibiotic prescribing rates for 23 common primary care conditions to calculate unnecessary antibiotic prescribing rates. We used multilevel Poisson regression models to evaluate the association between total antibiotic volume (number of antibiotic prescriptions per patient visit), adjusted for multiple practice- and physician-level covariates, and unnecessary antibiotic prescribing. There were 499 570 physician-patient encounters resulting in 152 853 antibiotic prescriptions from 341 physicians. Substantial inter-physician variability was observed. In the fully adjusted model, we observed a significant association between total antibiotic volume and unnecessary prescribing rate (adjusted rate ratio 2.11 per 10% increase in total use; 95% CI 2.05-2.17), and none of the practice- and physician-level variables were associated with unnecessary prescribing rate. We demonstrated substantial inter-physician variability in unnecessary antibiotic prescribing in this cohort of family physicians. Total antibiotic use was strongly correlated with unnecessary antibiotic prescribing. Total antibiotic volume is a reasonable surrogate for unnecessary antibiotic use. These results can inform community antimicrobial stewardship efforts.

Multimorbidity and patient-reported diagnostic errors in the primary care setting: multicentre cross-sectional study in Japan

ObjectivesThere is lack of evidence for the association between multimorbidity and diagnostic errors. Information on diagnostic errors from patients’ perspectives is crucial to improve the diagnostic process. In this study,...

Screening for Adverse Drug Events: a Randomized Trial of Automated Calls Coupled with Phone-Based Pharmacist Counseling.

Medication adverse events are important and common yet are often not identified by clinicians. We evaluated an automated telephone surveillance system coupled with transfer to a live pharmacist to screen potentially drug-related symptoms after newly starting medications for four common primary care conditions: hypertension, diabetes, depression, and insomnia. Cluster randomized trial with automated calls to eligible patients at 1 and 4months after starting target drugs from intervention primary care clinics compared to propensity-matched patients from control clinics. Primary and secondary outcomes were physician documentation of any adverse effects associated with newly prescribed target medication, and whether the medication was discontinued and, if yes, whether the reason for stopping was an adverse effect. Of 4876 eligible intervention clinic patients who were contacted using automated calls, 776 (15.1%) responded and participated in the automated call. Based on positive symptom responses or request to speak to a pharmacist, 320 patients were transferred to the pharmacist and discussed 1021 potentially drug-related symptoms. Of these, 188 (18.5%) were assessed as probably and 479 (47.1%) as possibly related to the medication. Compared to a propensity-matched cohort of control clinic patients, intervention patients were significantly more likely to have adverse effects documented in the medical record by a physician (277 vs. 164 adverse effects, p < 0.0001, and 177 vs. 122 patients discontinued with documented adverse effects, p < 0.0001). Systematic automated telephone outreach monitoring coupled with real-time phone referral to a pharmacist identified a substantial number of previously unidentified potentially drug-related symptoms, many of which were validated as probably or possibly related to the drug by the pharmacist or their physicians. Multiple challenges were encountered using the interactive voice response (IVR) automated calling system, suggesting that other approaches may need to be considered and evaluated. ClinicalTrials.gov : NCT02087293.

Association of Primary Care Practice Location and Ownership With the Provision of Low-Value Care in the United States

Hospital-employed physicians provide primary care within the hospital or within community-based office practices. Yet, little is understood regarding the influence of hospital location and ownership on the delivery of low-value care. To assess the association of hospital location and hospital ownership with the provision of low-value health services. This study compared low-value service use after primary care visits at hospital-based outpatient practices from January 1, 1997, to December 31, 2011, vs community-based office practices and at hospital-owned vs physician-owned community-based office practices from January 1, 1997, to December 31, 2013. Logistic regression models adjusted for patient and health care professional characteristics and year, and weighted results were used to reflect population estimates. Results were also stratified by symptom acuity and whether a generalist physician (eg, general internist or family practitioner) was the patient's primary care provider. This study used nationally representative data from the National Ambulatory Medical Care Survey (January 1, 1997, to December 31, 2013) and the National Hospital Ambulatory Medical Care Survey (January 1, 1997, to December 31, 2011) on outpatient visits to generalist physicians. Participants were patients seen with 3 common primary care conditions, namely, upper respiratory tract infection, back pain, and headache. The use of antibiotics (for upper respiratory tract infection), computed tomography or magnetic resonance imaging (for back pain and headache), radiographs (for upper respiratory tract infection and back pain), and specialty referrals (for all 3 conditions). This study identified 31 162 visits for upper respiratory tract infection, back pain, and headache, representing an estimated 739 million US primary care visits from 1997 to 2013. Compared with visits with community-based physicians, patients in visits to hospital-based physicians were younger (mean age, 44.5 vs 49.1 years; P < .001) and less frequently saw their primary care provider (52.7% vs 81.9%, P < .001). Although antibiotic use was similar in both settings, hospital-based visits had more orders for computed tomography and magnetic resonance imaging (8.3% vs 6.3%, P = .01), radiographs (12.8% vs 9.9%, P < .001), and specialty referrals (19.0% vs 7.6%, P < .001) than community-based visits. Multivariable adjustment and symptom acuity stratification revealed similar findings. Visits with a generalist other than the patient's primary care provider were associated with greater provision of low-value care but mainly within hospital-based settings. Practice patterns were similar among hospital-owned vs physician-owned community-based practices with the exception of specialty referrals, which were more frequent in hospital-owned community-based practices. Visits to US hospital-based practices are associated with greater use of low-value computed tomography and magnetic resonance imaging, radiographs, and specialty referrals than visits to community-based practices, and visits to hospital-owned community-based practices had more specialty referrals than visits to physician-owned community-based practices. These findings raise concerns about the provision of low-value care at hospital-associated primary care practices.

Development and validation of a condition-specific diary to measure severity, bothersomeness and impact on daily activities for patients with acute urinary tract infection in primary care

BackgroundUrinary tract infection (UTI) is a common condition in primary care. Patient-reported outcome measures (PROMs) are crucial in the evaluation of interventions to improve diagnosis, treatment and prognosis of UTI. The aim of this study was to identify an existing condition-specific PROM to measure symptom severity, bothersomeness and impact on daily activities for adult patients with suspected urinary tract infection in primary care; or, in the absence of such a PROM, to test items identified from existing PROMs for coverage and relevance in single and group interviews and to psychometrically validate the resulting PROM.MethodsThe literature was searched for existing PROMs covering the three domains. Items from the identified PROMs were tested in single and group interviews. The resulting symptom diary was psychometrically validated using the partial credit Rasch model for polytomous items in a cohort of 451 women participating in two studies regarding UTI.ResultsNo existing PROM fulfilled the inclusion criteria. Content validation resulted in one domain concerning symptom severity (18 items), one concerning bothersomeness (18 items), and one concerning impact on daily activities (7 items). Psychometrical validation resulted in four dimensions in each of the first two domains and one dimension in the third domain.ConclusionsDomains were not unidimensional, which meant that we identified dimensions of patient-experienced UTI that differed substantially from those previously found. We recommend that future studies on UTI, in which PROMs are to be used, should ensure high content validity of their outcome measures and unidimensionality of the included dimensions.

Clinical decision support content development for common conditions in primary care

Introduction: Clinical decision support (CDS) tools are not frequently implemented in health care settings such as clinics and hospitals. Without access to updated guidelines at the point-of-care, physicians and other health care professionals have to often rely on memory recall to make clinical decisions. Objectives: To develop a CDS system. Specific objectives for this study are to develop and test summaries of clinical guidelines in a format that is optimal for clinicians. Materials and methods: Research ethics committee approval was obtained (AAMDHREC 13/64). CDS tools were developed using a planned, iterative cycle with three phases: (1) compile pre-existing guidelines from established sources, critically appraising each using selected items from the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument; (2) design CDS tools that summarize pertinent points, especially those that have a strong evidence-based recommendation or are established quantitative criteria; (3) refine each summary using a collaborative approach to build concise, usable CDS tools with a focus on usability and rapid access to information. Results: CDS tools for selected topics were developed using an iterative compile–design–refine cycle. The process was to compile guideline summaries on common conditions encountered in primary care by physicians seeing patients in clinics. An attempt was made to restrict the length of each summary to one A4 page to improve conciseness and focus on high-yield evidence-based recommendations. Conclusion: CDS tools can be developed for common medical conditions in an iterative cyclical process. Further research is needed to test these materials in health care settings. Acknowledgements: Funding support from UAEU CMHS Faculty grant NP/13/20.

A retrospective non-comparative analysis of the quality of care for osteoarthritis at the general out-patient department of Jos University Teaching Hospital, Nigeria.

Background:Osteoarthritis is a common condition in primary care and is often associated with disability and limitation of function requiring holistic care.Aim:The aim of this audit was to assess the quality of care provided by family physicians in the management of osteoarthritis at the General Out-patient Department (GOPD) of Jos University Teaching Hospital (JUTH) as well as ascertain if such care was in line with evidence-based medicine.Methods:This was a retrospective noncomparative study. The recommendations of the Nigerian Standard Treatment Guidelines 2008 and the National Institute for Health and Care Excellence 2014 guidelines were used to form standard targets for each of the structural, process and outcome components of the care process. Each of the consultation rooms was inspected for the structure components of the care process. For the process and outcome components of care, the medical records of all patients being managed for osteoarthritis at the GOPD of JUTH over a 1-year period were retrieved and studied.Results:For one aspect of the structural component (i.e. availability of weighing scale for each consultation room), 80% of the standard target was met which was below the standard target of 100%. The highest performance under the process component was for the documentation of risk associated with the use of nonsteroidal anti-inflammatory drugs (NSAIDs) and documentation for NSAID/cyclooxygenase-2 inhibitors use with a gastro-protective agent. For both of these, 22.4% of the standard target was met; less than the standard target of 100% and 80% respectively. None of the standard targets for the outcome component were met.Conclusion:The quality of care for patients with osteoarthritis in this practice setting was sub-optimal. More can be done by family physicians with regards provision of comprehensive care for patients suffering from osteoarthritis.

Development of a search filter for identifying studies completed in primary care.

Identifying articles relevant to primary care is challenging for busy clinicians. Setting specific search strategies can be used to help clinicians find pertinent studies in a timely fashion. To develop search filters for identifying research studies of relevance to primary care in MEDLINE (OvidSP). We conducted a search of MEDLINE (OvidSP) for articles published in five core medical journals at five yearly intervals. We identified a gold standard set of primary care relevant articles which was divided into two subsets. The first subset was used to identify frequently occurring words and phrases through textual analysis. Search filters were developed from these words and phrases and internally validated against records in the second subset. We evaluated the filters performance in a search for articles on two common primary care conditions in MEDLINE (OvidSP). Of the 12 045 articles retrieved, 9028 records were reviewed, of which 371 articles were relevant to primary care (gold standard). When the search filters generated from textual analysis were internally validated, filter specificity peaked at 99% with 60% sensitivity, 67% precision and 97% accuracy. When evaluated against a set of articles on two common primary care conditions, the best performing combination search filter specificity maximized at 99.7% with sensitivity reaching 15% (precision 90%; accuracy 89%). The best performing combination search filter works well in reducing the number of irrelevant papers retrieved in a MEDLINE (OvidSP) search if a busy clinician needs to focus on research relevant to primary care.

A framework for the non-antibiotic management of upper respiratory tract infections: towards a global change in antibiotic resistance

Antibiotic resistance has become a critical health issue on a global scale, with much of the problem resulting from inappropriate use of antibiotics in primary care. To change this practice, the global respiratory infection partnership has formulated a pentagonal (five P) framework for the non-antibiotic management of upper respiratory tract infections (URTIs) - one of the most common conditions in primary care for which antibiotics are prescribed. The framework presents the rationale for focusing on URTIs to promote antibiotic stewardship in primary care and elaborates on five key areas to focus on to bring about change: policy, prevention, prescribers, pharmacy and patients. The ultimate aim is to adopt a patient-centred symptomatic management strategy using a flexible framework that can be adapted across countries to create a consistent global approach to change behaviour.

"How Do You Feel about Antibiotics for This?" A Qualitative Study of Physician Attitudes towards a Context-Rich Communication Skills Method.

To explore experiences with and views of general practitioners (GPs) on a physician communication training method in primary care and its applicability and implementation in daily practice, we performed a semi-structured qualitative study of GPs’ experience of training in and implementing a communication skills training program for managing lower respiratory tract infection (LRTI) which included a seminar, simulated patient consultation together with providing and receiving feedback on ones own transcript, and a seminar in a structured approach to the LRTI consultation. Seventeen out of 20 eligible GPs who had participated in the IMPAC3T trial and were allocated to receiving enhanced physician communication training for managing lower respiratory tract infection participated. GPs’ experiences with the physician communication training method and its specific components were positive. The method gave GPs additional tools for managing LRTI consultations and increased their sense of providing evidence-based management. During the study, GPs reported using almost all communication items covered in the training, but some GPs stated that the communication skills diluted over time, and that they continued to use a selected set of the skills. The general communication items were most regularly used. Implementation of the method in daily practice helped GPs to prescribe fewer antibiotics in LRTI with the only perceived disadvantage being time-pressure. This study suggests that GPs felt positive about the physician communication training method for enhanced management of LRTI in primary care. GPs continued to use some of the communication items, of which general communication items were the most common. Furthermore, GPs believed that implementation of the communication skills in daily practice helped them to prescribe fewer antibiotics. The context-rich communication method could have wider application in common conditions in primary care.

Types and Origins of Diagnostic Errors in Primary Care Settings

Diagnostic errors are an understudied aspect of ambulatory patient safety. To determine the types of diseases missed and the diagnostic processes involved in cases of confirmed diagnostic errors in primary care settings and to determine whether record reviews could shed light on potential contributory factors to inform future interventions. We reviewed medical records of diagnostic errors detected at 2 sites through electronic health record-based triggers. Triggers were based on patterns of patients' unexpected return visits after an initial primary care index visit. A large urban Veterans Affairs facility and a large integrated private health care system. Our study focused on 190 unique instances of diagnostic errors detected in primary care visits between October 1, 2006, and September 30, 2007. Through medical record reviews, we collected data on presenting symptoms at the index visit, types of diagnoses missed, process breakdowns, potential contributory factors, and potential for harm from errors. In 190 cases, a total of 68 unique diagnoses were missed. Most missed diagnoses were common conditions in primary care, with pneumonia (6.7%), decompensated congestive heart failure (5.7%), acute renal failure (5.3%), cancer (primary) (5.3%), and urinary tract infection or pyelonephritis (4.8%) being most common. Process breakdowns most frequently involved the patient-practitioner clinical encounter (78.9%) but were also related to referrals (19.5%), patient-related factors (16.3%), follow-up and tracking of diagnostic information (14.7%), and performance and interpretation of diagnostic tests (13.7%). A total of 43.7% of cases involved more than one of these processes. Patient-practitioner encounter breakdowns were primarily related to problems with history-taking (56.3%), examination (47.4%), and/or ordering diagnostic tests for further workup (57.4%). Most errors were associated with potential for moderate to severe harm. Diagnostic errors identified in our study involved a large variety of common diseases and had significant potential for harm. Most errors were related to process breakdowns in the patient-practitioner clinical encounter. Preventive interventions should target common contributory factors across diagnoses, especially those that involve data gathering and synthesis in the patient-practitioner encounter.