General Practice Consultations Research Articles

Exploring the acceptability, barriers, and facilitators to psychosis screening in the integrated behavioral health primary care setting: a qualitative study

BackgroundA longer duration of untreated psychosis (DUP) is associated with poorer treatment outcomes. Screening for psychosis spectrum disorders in the primary care setting could help support the earlier detection and treatment of individuals in need. However, the acceptability of screening for psychosis in this setting as part of routine care is currently unknown.MethodsWe conducted a qualitative interview study with providers and service users who participated in an early psychosis screening program conducted in an integrated behavioral health primary care (IBH-PC) setting. Interviews were recruited from one of eight WellSpace Federally Qualified Health Center IBH-PC clinics in the Sacramento, CA area. Transcripts of the recorded interviews were analyzed using thematic analysis.ResultsIn total, 12 providers and eight service users participated in the interviews. Most service user and provider participants were supportive of psychosis screening in an IBH-PC setting, but not as part of the general practitioner consultation due to the brief, non-behavioral health nature of many of the appointments, and the expected low prevalence of psychosis in this population. The support of leadership, adequate training and support, staff turnover, and organizational changes were all seen to impact the successful implementation of the program. Different barriers and facilitators were considered important at each stage of the process from introducing the screening procedures to service users; to determining when, where, and how to screen; and how to effectively manage the referral and post-referral stages.ConclusionsDespite the additional challenges of screening in an IBH-PC setting relative to secondary mental health services, the process was considered acceptable and feasible to providers and service users. Services that plan to conduct psychosis screening in their clinics need to consider the challenges and their potential solutions to implementation at each stage of the screening process.

Hepatitis B clinical care provision in pregnancy: A whole-of-population linkage study in Victoria, Australia.

Pregnancy is a key setting for engagement in chronic hepatitis B (CHB) care, due to the implications for transmission to the infant and antenatal diagnosis representing an opportunity for ongoing follow-up. This study aimed to identify the coverage and predictors of clinical care for women with CHB during and after pregnancy in a population-level cohort. Notified CHB cases in Victoria, Australia, were linked with hospitalizations, medical services, and prescribing data, covering the period 1991-2018. Women with an admission for a live birth were identified and services provided during pregnancy were assessed, including general practitioner (GP) or specialist visits, viral load and serology testing, and antiviral treatment. Viral load and serology testing coverage ware also assessed for the 2-year period following pregnancy. Demographic and clinical predictors of viral load testing during pregnancy were assessed. A total of 11015 birth events occurred for 6090 women with CHB. During pregnancy most had a GP consultation (91.6%); however, only 39.5% had viral load testing and 41.4% had a gastroenterology or infectious diseases specialist consultation. Viral load testing and serology testing in the 2years after pregnancy occurred in approximately half (47.9% and 52.2%, respectively) with increases over time. Viral load testing was more likely in those born overseas, those with more than one previous birth, and those living in Melbourne. Despite improvements over time, key gaps were identified in the provision of CHB clinical care during and after pregnancy, with implications for ongoing transmission and adverse outcomes.

Evaluation of natural history communication and shared decision making for self-limiting conditions: Analysis of UK primary care consultations

ObjectiveTo analyse communication about the natural course of self-limiting illnesses, as part of shared decision-making (SDM), in general practice consultations. MethodsNatural history communication and SDM (using Observing Patient Involvement in Decision-Making (OPTION-12) and Assessing Communication about Evidence and Patient Preferences (ACEPP) items) were rated by two raters using transcripts from the UK ‘One in a Million’ database. ResultsOf 55 eligible consultations, a ‘wait and see’ option was mentioned in 27 consultations (49 %), using varying terminology, with a general recovery timeframe provided in 21. Mean OPTION-12 score (of 100) was 25.2 (SD=7.4), indicating a low level of SDM. Mean ACEPP score (out of 5) was 1.2 (SD=0.5), indicating minimal communication about the options’ benefits and harms. Recovery likelihood was quantified in only two consultations, while harms were quantified in none. ConclusionCommunication about the natural history of self-limiting illnesses was generally limited. The ‘wait and see’ approach, along with its benefits and harms, was typically not explicitly presented as an option for patients to consider. Practice ImplicationsImproving clinicians’ awareness of the importance of and skills for communicating the natural history of self-limiting illnesses, as part of SDM, may facilitate informed decision-making in managing these conditions.

GP remote consultations with marginalised patients and the importance of place during care: a qualitative study of the role of place in GP consultations.

Since COVID-19 there been an increase in the use of remote consultations in General Practice in the UK. This leads to the displacement of the consultation outside of the physical GP practice, and its 'emplacement' elsewhere, with underexplored consequences for inequities of healthcare in marginalised groups. This paper examines the place-making demands that remote consultations make on patients, and the ways that these affect their experiences of care, with a focus on the impact on patients from marginalised groups. Ethnography and interview study (n=15) undertaken at three sites in London: a foodbank, a community development organisation, and a drop-in advice centre for migrants. Additionally, GPs (n=5) working at practices in London Digital Health Hub staff (n=4) and staff at fieldwork sites (n=3) were interviewed. Ethnographic observation (n=84 hours) and semi-structured interviews (n=27). Interviews were conducted in-person and over the phone and data were analysed through reflexive thematic analysis. The core themes emerging from the data included challenges securing privacy during remote consultations, and the loss of formal healthcare spaces as important places of care. These findings were closely tied to resource access, leading to inequities in experiences of care. Remote GP consultations are not "place-less" encounters, and inequities in access to suitable spaces may lead to inequities in experiences of care. Attention should be given to ensuring that patients without appropriate spaces for remote consultations are offered in-person care, or consultation times made more specific to allow for organisation of private space.

Healthcare interpreting as relational practice: Understanding the interpreter’s role in facilitating rapport in health interactions

This article explores the extent to which healthcare interpreting can be considered “relational practice.” It describes an interactional sociolinguistic study conducted in Australia, based on video recordings of two naturally occurring interpreted general practice consultations. Participants were hearing Australian Sign Language (Auslan)/English interpreters, deaf patients, and hearing doctors. Analysis of these recordings was supplemented by reflective interviews with participants. The study examines the ways in which interpreters facilitate good working relationships between participants, and to explore the extent to which their decision-making is driven by relational considerations. The analyses presented in this article provide evidence that relational work is an important aspect of the healthcare interpreter’s role. Some of the ways in which it is achieved, however, may challenge our ideas about “appropriate” interpreter behaviour. Thus, the skilled and experienced interpreters in the study were seen to modify face threats, directly influence the flow of interaction, and actively facilitate social talk and humour, occasionally even engaging in it themselves. It is argued that interpreters’ decisions can only be understood within the discursive context in which they occur, and such behaviour can highlight interpreters’ attentiveness to the maintenance of good rapport.

Last general practitioner consultation during the final month of life: a national medical record review of suicides in Sweden

ObjectivesIndividuals who die by suicide often consult their general practitioners (GPs) in their final weeks of life. The aim of this study was to gain a deeper knowledge of the clinical characteristics and GP assessments and treatments among individuals who consulted their GPs during the month preceding suicide. Further, we compared these features in those with and without contact with psychiatric services (PC and NPC, respectively) during the two years that preceded the suicide.DesignA nationwide retrospective explorative study investigating medical records.SettingPrimary care in Sweden.ParticipantsIndividuals who died by suicide in Sweden in 2015 with a GP visit within 30 days of death.ResultsThe study cohort corresponds to one fifth (n = 238) of all suicides that occurred in Sweden in 2015 (n = 1179), representing all those with available primary care records showing contact with a GP during the final 30 days of life (NPC: n = 125; PC: n = 113). The mean age was 58 years ± 19. Patients in the NPC group were older (NPC: 63 years ± 19 vs. PC: 53 years ± 18, p < 0.0001) and presented psychiatric symptoms less often (NPC: 50% vs. PC: 67%, p < 0.006). Somatic symptoms were as common as psychiatric symptoms for the whole sample, being present in more than half of individuals. Suicide risk was noted in only 6% of all individuals. Referral to psychiatric services occurred in 14%, less commonly for the NPC group (NPC: 6% vs. PC: 22%, p < 0.001). Cardiovascular or respiratory symptoms were noted in 19%, more often in the NPC group (NPC: 30% vs. PC: 6%, p < 0.001), as were diagnoses involving the circulatory system (all 10%, NPC:14% vs. PC: 5%, p < 0.020).ConclusionA high level of somatic symptoms was observed in primary care patients both with and without psychiatric contact, and this might have influenced GPs’ management decisions. Psychiatric symptoms were noted in two thirds of those with psychiatric contact but only half of those without. While GPs noted psychiatric symptoms in over half of all individuals included in the study, they seldom noted suicide risk. These findings highlight the need for increased attention to psychiatric symptoms and suicide risk assessment, particularly among middle-aged and older individuals presenting with somatic symptoms.Strengths and limitations of this studyThe National Cause of Death Register has excellent coverage of suicide deaths and access to medical records was very good. The medical record review provided detailed information regarding primary care utilization before death by suicide. Because of the lack of statistical power, due to the limited number of persons with GP contact during the last month of life, we chose not to correct for multiple comparisons. Our study approach did not capture the reasons behind GPs’ documentation of elevated suicide risk. No systematic inter-rater reliability (IRR) testing was made, however, reviewers received training and continuous support from the research group.

GP consultations for menstrual disorders after COVID-19 vaccination – A self-controlled cohort study based on routine healthcare data from the Netherlands

IntroductionSeveral studies described that COVID-19 vaccinations can cause menstrual disorders. Our study aimed to describe whether this also resulted in more general practitioner (GP) consultations for menstrual disorders after COVID-19 vaccination, based on a large cohort study. MethodsA retrospective self-controlled cohort study was performed including vaccinated women in 2021 aged 12–49 years from two large, representative GP databases in the Netherlands. Incidence rates and incidence rate ratio’s (IRR) were calculated using Poisson regression, adjusting for SARS-CoV-2 infection as time-varying confounder. The exposed period was set at maximum six months after each COVID-19 vaccination and the non-exposed period was defined as all-time outside the exposed period. ResultsThe cohort included 631,802 women, of which 18,986 (3 %) consulted the GP for a menstrual disorder during 2021. Increased GP consultations were observed among 12–14 year olds for amenorrhea/hypomenorrhea/oligomenorrhea (IRR: 1.85, 95 % CI: 1.30–2.65) and irregular/frequent menstruation (IRR: 1.33, 95 % CI: 1.06–1.69) after COVID-19 vaccination in general, and after Pfizer/BioNTech vaccination (IRR: 1.87, 95 % CI: 1.31–2.67 for amenorrhea/hypomenorrhea/oligomenorrhea and IRR: 1.35, 95 % CI: 1.06–1.70 for irregular/frequent menstruation). Persons from this age group were in general also vaccinated with Pfizer/BioNTech. No increase in the frequency of GP consultations were observed for older age groups, other vaccine brands, and potential risk groups. ConclusionFor the majority of women, no increased GP consultations for menstrual disorders was found. Solely for the youngest age group (12–14 year olds) increased GP consultations for specific types of menstrual disorders was found after Pfizer/BioNTech vaccination.

The impact of patient registration on utilisation and quality of care: a propensity score matching and staggered difference-in-differences analysis of a cohort of 16,775 people with type 2 diabetes

BackgroundIn 2012, Luxembourg introduced a Referring Doctor (RD) policy, whereby patients voluntarily register with a primary care practitioner, who coordinates patients’ health care and ensures optimal follow-up. We contribute to the limited evidence base on patient registration by evaluating the effects of the RD policy.MethodsWe used data on 16,775 people with type 2 diabetes on oral medication (PWT2D), enrolled with the Luxembourg National Fund from 2010 to 2018. We examined the utilisation of primary and specialist outpatient care, quality of care process indicators, and reimbursed prescribed medicines over the short- (until 2015) and medium-term (until 2018). We used propensity score matching to identify comparable groups of patients with and without an RD. We applied difference-in-differences methods that accounted for patients’ registration with an RD in different years.ResultsThere was low enrolment of PWT2D in the RD programme. The differences-in-differences parallel trends assumption was not met for: general practitioner (GP) consultations, GP home visits (medium-term), HbA1c test (short-term), complete cholesterol test (short-term), kidney function (urine) test (short-term), and the number of repeat prescribed cardiovascular system medicines (short-term). There was a statistically significant increase in the number of: HbA1c tests (medium-term: 0.09 (95% CI: 0.01 to 0.18)); kidney function (blood) tests in the short- (0.10 (95% CI: 0.01 to 0.19)) and medium-term (0.11 (95% CI: 0.03 to 0.20)); kidney function (urine) tests (medium-term: 0.06 (95% CI: 0.02 to 0.10)); repeat prescribed medicines in the short- (0.19 (95% CI: 0.03 to 0.36)) and medium-term (0.18 (95% CI: 0.02 to 0.34)); and repeat prescribed cardiovascular system medicines (medium-term: 0.08 (95% CI: 0.01 to 0.15)). Sensitivity analyses also revealed increases in kidney function (urine) tests (short-term: 0.07 (95% CI: 0.03 to 0.11)) and dental consultations (short-term: 0.06, 95% CI: 0.00 to 0.11), and decreases in specialist consultations (short-term: -0.28, 95% CI: -0.51 to -0.04; medium-term: -0.26, 95% CI: -0.49 to -0.03).ConclusionsThe RD programme had a limited effect on care quality indicators and reimbursed prescribed medicines for PWT2D. Future research should extend the analysis beyond this cohort and explore data linkage to include clinical outcomes and socio-economic characteristics.

The prediagnostic general practitioner care of sarcoma patients: A real-world data study.

Limited understanding exists regarding early sarcoma symptoms presented during general practitioner(GP) consultations. The study explores GP visit patterns and recorded diagnoses in the 12 months preceding sarcoma diagnosis. Sarcoma cases diagnosed from 2010 to 2020 were identified through the Netherlands Cancer Registry alongside general practice data. Sarcoma cases were age and gender matched to cancer-free controls (2:1 or 1:1 ratio). A total of 787 individuals with soft-tissue sarcoma (STS)and 188 individuals with bone sarcoma (BS)were identified. There was a significant difference in monthly GP contacts from 4 months to the last month before STS diagnosis, and 2 months before BS diagnosis between cases and controls. Most prevalent diagnoses recorded by the GP for STS cases included musculoskeletal neoplasm (26.6%), uncomplicated hypertension (15.6%), and cystitis/other urinary infections (12.2%). For BS cases, musculoskeletal neoplasm (42.8%), knee symptoms/complaints (9.7%), and shoulder symptoms/complaints (9.7%) were most frequent. A significant difference in GP contacts between cases and controls preceding sarcoma diagnosis. STS cases were predominantly diagnosed with nonspecific symptoms, whereas BS cases with diagnoses more suggestive of BS. Better understanding of the prediagnostic trajectory could aid GPs in early identification of sarcoma.

Experiences and observations from a care point for displaced Ukrainians: a community case study in Antwerp, Belgium.

A total of 7,307 Ukrainian refugees moved to Antwerp, Belgium, during the study period (01 April 2022 to 31 December 2022). The city's administration set up three care centers where these people were introduced to the Belgian primary care system, a medical file was created, and acute/preventive/chronic care was delivered. This community case study analyzes the organization and contents of care and reflects upon its meaning for the mainstream healthcare system. This is an observational study using routine electronic medical record data to measure the uptake of care. For a sample of 200 subjects, a retrospective chart review was conducted. All refugees with a medical file at one of the three participating care centers were included. For the observational study, 2,261 patients were reached (30% of the potential users), and 6,450 contacts were studied. The nurses (including midwives) conducted 4,929 out of 6,450 (76%) of all consultations, while the general practitioners (GPs) conducted 1,521 out of 6,450 (24%). Of the nurse consultations, 955 (19%) were followed by another nurse consultation and 866 (18%) by a GP consultation. In the structured case reviews, most contacts were concerned with acute problems (609 out of 1,074, 57%). The most prevalent reasons for encounters and diagnoses were typical primary care issues. The nurses were able to manage half of the cases independently (327, 55%), referred 37% (217) of cases to the GP, and consulted a GP (live, by telephone, or a dedicated app) for 8% (48) of cases. GPs mostly prescribed drugs, referred to a medical specialist, and advised over-the-counter drugs, while nurses more often advised over-the-counter drugs (mostly paracetamol, nose sprays, and anti-inflammatory drugs), provided non-medical advice, or ordered laboratory tests. The medical care points delivered mostly typical acute primary care in this first phase, with a key role for nurses. The care points did not sufficiently take up chronic diseases and mental health problems. These results will inform policymakers on the use of primary care centers for newly arriving patients in times of a large influx. A nurse-first model seems feasible and efficient, but evaluation of safety and quality of care is needed. Once the acute phase of this crisis fades away, questions about the comprehensiveness, continuity, and integration of care for migrants remain relevant.

Impact of modifications to antidementia drug reimbursement in France: Analysis of the FRA-DEM cohort.

Alzheimer's disease and related diseases (ADRD) is a progressive and inexorable disease. In France, acetylcholinesterase inhibitors and memantine were reimbursed for subjects with ADRD, until 2 modifications of their reimbursement rate (2012, 2018). We aimed to study the consequences of these measures on ADRD subjects' healthcare use. We analysed data from the FRA-DEM cohort, including subjects with presumed incident ADRD identified since 2011 in the French health insurance system. We studied the healthcare use of subjects identified with incident ADRD in 2011, 2013, 2015, 2017 and 2019, notably the annual number of defined daily doses of various psychotropic groups. We performed 2 multivariate multinomial logistic regressions with the subcohort year as the dependent variable. In total, 165 120 subjects were included. A progressive decrease in exposure to antidementia drugs was observed between 2011 and 2019. Consultations with private neurologists or psychiatrists, and exposure to risperidone, antidepressants and benzodiazepines increased in the 2019 subcohort, following the 2018 reimbursement withdrawal. Meanwhile, the use of nursing/allied healthcare and emergency care increased over the subcohort years, whereas we observed a decrease in general practitioner consultations. These results suggest increases in private neurologist or psychiatrist consultations and exposure to recommended drugs after the reimbursement withdrawal, contrary to the fears expressed. However, antidementia drug exposure decreased long before the reimbursement modifications, probably due to the growing evidence of the modest effect of these drugs, and exposure to benzodiazepines increased after the reimbursement withdrawal.

Emergency physicians' and nurses' perception on the adequacy of emergency calls for nursing home residents: a non-interventional prospective study.

A considerable percentage of daily emergency calls are for nursing home residents. With the ageing of the overall European population, an increase in emergency calls and interventions in nursing homes (NH) is to be expected. A proportion of these interventions and hospital transfers may be preventable and could be considered as inappropriate by prehospital emergency medical personnel. The study aimed to understand Belgian emergency physicians' and emergency nurses' perspectives on emergency calls and interventions in NHs and investigate factors contributing to their perception of inappropriateness. An exploratory non-interventional prospective study was conducted in Belgium among emergency physicians and emergency nurses, currently working in prehospital emergency medicine. Electronic questionnaires were sent out in September, October and November 2023. Descriptive statistics were used to analyze the overall results, as well as to compare the answers between emergency physicians and emergency nurses about certain topics. A total of 114 emergency physicians and 78 nurses responded to the survey. The mean age was 38 years with a mean working experience of 10 years in prehospital healthcare. Nursing home staff were perceived as understaffed and lacking in competence, with an impact on patient care especially during nights and weekends. General practitioners were perceived as insufficiently involved in the patient's care, as well as often unavailable in times of need, leading to activation of Emergency Medical Services (EMS) and transfers of nursing home residents to the Emergency Department (ED). Advance directives were almost never available at EMS interventions and transfers were often not in accordance with the patient's wishes. Palliative care and pain treatment were perceived as insufficient. Emergency physicians and nurses felt mostly disappointed and frustrated. Additionally, differences in perception were noted between emergency physicians and nurses regarding certain topics. Emergency nurses were more convinced that the nursing home physician should be available 24/7 and that transfers could be avoided if nursing home staff had more authority regarding medical interventions. Emergency nurses were also more under the impression that pain management was inadequate, and emergency physicians were more afraid of the medical implications of doing too little during interventions than emergency nurses. Suggestions to reduce the number of EMS interventions were more general practitioner involvement (82%), better nursing home staff education/competences (77%), more nursing home staff (67%), mobile palliative care support teams (65%) and mobile geriatric nursing intervention teams (52%). EMS interventions in nursing homes were almost never seen as necessary or indicated by emergency physicians and nurses, with the appropriate EMS level almost never being activated. The following key issues were found: shortages in numbers and competence of nursing home staff, insufficient primary care due to the unavailability of the general practitioner as well as a lack of involvement in patient care, and an absence of readily available advance directives. General practitioners should be more involved in the decision to call the Emergency Medical Services (EMS) and to transfer nursing home residents to the Emergency Department. Healthcare workers should strive for vigilance regarding the patients' wishes. The emotional burden of deciding on an avoidable hospital admission of nursing home residents, perhaps out of fear for medico-legal consequences if doing too little, leaves the emergency physicians and nurses frustrated and disappointed. Improvements in nursing home staffing, more acute and chronic general practitioner consultations, and mobile geriatric and palliative care support teams are potential solutions. Further research should focus on the structural improvement of the above-mentioned shortcomings.

The identification and treatment of alcohol problems in primary care (iTAPP) study: protocol for a stepped wedge cluster randomized control trial testing the 15-method in a primary care setting

BackgroundThe 15-method is a targeted screening and treatment approach for alcohol problems in primary care. The 15-method used in primary care has proven as effective as specialized treatment for mild to moderate alcohol dependence in Sweden. A feasibility study of the 15-method in Danish primary care found the method acceptable and feasible.AimsTo evaluate the effectiveness of the 15-method in a Danish primary care setting in (1) lowering the proportion of patients exceeding the Danish low-risk alcohol consumption limit of ten standard units per week and a maximum of four standard units on a single day for men and women, and (2) increasing the likelihood of alcohol use being addressed during a consultation in general practice. Further, the rate of prescribed pharmacological treatment for alcohol problems (Disulfiram, Naltrexone, Acamprosate, and Nalmefene) will be measured along with the use of the biomarkers Alanine Transaminase and Gamma-Glutamyl Transferase.MethodsStepped wedge cluster randomized controlled trial in sixteen general practices in the Region of Southern Denmark. Following a three-month baseline, the practices are randomly assigned to launch dates in one of four clusters. General practitioners and nurses receive three hours of training in the 15-method before launch. Patient questionnaires will collect data on alcohol consumption levels among patients affiliated with the practices. The healthcare professionals will register consultations in which alcohol is addressed in their patient filing system. Pharmacological treatment rates and the use of biomarkers will be collected through Danish national registries. The study follows the Medical Research Council’s guidelines for developing and evaluating complex interventions.DiscussionFrom the patient’s perspective, the 15-method may help identify alcohol-related problems at an earlier stage with flexible treatment offers in a familiar setting. For healthcare professionals, it addresses a traditionally challenging topic by equipping them with concrete tools, communication training, and clear treatment directives. From a societal perspective, primary care holds a unique position to identify hazardous and harmful alcohol use across different age groups, with potential public health and economic benefits through early identification and intervention.Trial registrationClinicaltrials.gov NCT05916027. Retrospectively registered 22 June 2023.

Patient perspectives of general practice consultation for musculoskeletal disorders: A qualitative study.

Musculoskeletal disorders (MSKDs) are a significant reason for general practice consultations in the United Kingdom. Current models of care include consultation with a General Practitioner (GP) or a First Contact Physiotherapy Practitioner (FCPP). Evidence suggests that FCPP led care is safe, yet it is unknown whether patients share this belief. To explore patients' perspectives of general practice consultation for MSKDs, including views on safety, satisfaction and recommendations for future practice. A secondary data analysis utilising qualitative data from the Patient Reported Experiences and Outcomes of Safety in Primary Care (PREOS-PC) questionnaire completed by 426 general practice patients who consulted with a MSKD between December 2019 and October 2022. Responses to the question 'What changes, if any, would you suggest to your GP surgery to make sure that health care is provided safely?' were analysed using content analysis. 606 responses across three timepoints were analysed. Two themes and six subthemes were identified; views on safety and satisfaction (inherent trust in the system, provision of face-to-face appointments, prompt access to care, person-centred care) and recommendations for future practice (appointment system: prompt access to face-to-face appointments, delivery of care: co-ordinated and collaborative person-centred care). Patients commented that FCPP consultations provided quick and accurate diagnoses and targeted advice. Recommendations for future practice included prompt access to face-to-face appointments, phone calls to be answered more quickly, improved communication for test results and follow ups, patients to feel listened to with a more individualised approach, and better continuity of care.

Giving patients a voice for healthcare reform in Austria: the qualitative voice-study.

Inclusion of patients in healthcare service and system planning is an increasingly important tool to improve healthcare systems worldwide. In 2012, a focused healthcare reform was initiated in Austria to strengthen the primary care sector which is still underway in 2023. The aim of this study was to assess the perceptions, desires, and needs of patients in terms of primary care as a necessary building block of the Austrian healthcare reform. This study was designed as an exploratory qualitative study using semi-structured interviews between the years 2013 and 2018. Interviews with patients focused on positive and negative experiences with regard to general practice (GP) consultations and perceptions of the primary care system in general, as well as desires for improvement. Qualitative content analysis was used to analyse the material using the software atlas.ti. Altogether, 41 interviews were conducted with seven categories identified. These categories include organization and time management around consultation, access, and availability including opening hours, human and professional aspects of consultation, infrastructure and hygiene of the waiting room, healthcare system factors, as well as non-clinical/administrative staff. Appreciating and responding to patients' perceptions and needs, healthcare reform in Austria should include improvements regarding consultation/waiting time, coordination, and navigation in Primary Care. Successful healthcare reform has to include the patient voice.

Evaluating video and hybrid group consultations in general practice: mixed-methods, participatory study protocol (TOGETHER 2)

Background General practice is facing an unprecedented challenge in managing the consequences of the pandemic. In the midst of a policy drive to balance remote and in-person service provision, substantial workload pressures remain, together with increasing prevalence of long-term conditions, and declining staff numbers and morale. To address these challenges, some practices in the UK have been delivering video and hybrid group consultations (VHGCs). Despite positive initial findings and enthusiasm, there are still gaps in our understanding of the influence VHGCs have on patient experience, healthcare utilisation, quality, safety, equity and affordability. Objectives To generate an in-depth understanding of VHGCs for chronic conditions in general practice, surface assumptions and sociotechnical dynamics, inform practice and extend theorisation. Methods Mixed-methods, multi-site research study using co-design and participatory methods, from qualitative, quantitative and cost-related perspectives. WP1 includes a national, cross-sectional survey on VHGC provision across the UK. In WP2 we will engage patients and general practice staff in co-design workshops to develop VHGC models with emphasis on digital inclusion and equity. In WP3 we will carry out a mixed-methods process evaluation in up to 10 GP practices across England (5 sites already running VHGCs and 5 comparison sites). Qualitative methods will include interviews, focus groups and ethnographic observation to examine the experiences of patients, carers, clinical and non-clinical NHS staff, commissioners and policy-makers. Quantitative methods will examine the impact of VHGCs on healthcare utilisation in primary and secondary care, patient satisfaction, engagement and activation. We will also assess value for money of group and individual care models from a health economics perspective. Conclusions We aim to develop transferable learning on sociotechnical change in healthcare delivery, using VHGCs as an exemplar of technology-supported innovation. Findings will also inform the design of a future study.

Extravertebral low back pain: a scoping review

BackgroundLow back pain (LBP) is one of the most common reasons for consultation in general practice. Currently, LBP is categorised into specific and non-specific causes. However, extravertebral causes, such as abdominal aortic aneurysm or pancreatitis, are not being considered.MethodsA systematic literature search was performed across MEDLINE, Embase, and the Cochrane library, complemented by a handsearch. Studies conducted between 1 January 2001 and 31 December 2020, where LBP was the main symptom, were included.ResultsThe literature search identified 6040 studies, from which duplicates were removed, leaving 4105 studies for title and abstract screening. Subsequently, 265 publications were selected for inclusion, with an additional 197 publications identified through the handsearch. The majority of the studies were case reports and case series, predominantly originating from specialised care settings. A clear distinction between vertebral or rare causes of LBP was not always possible. A range of diseases were identified as potential extravertebral causes of LBP, encompassing gynaecological, urological, vascular, systemic, and gastrointestinal diseases. Notably, guidelines exhibited inconsistencies in addressing extravertebral causes.DiscussionPrior to this review, there has been no systematic investigation into extravertebral causes of LBP. Although these causes are rare, the absence of robust and reliable epidemiological data hinders a comprehensive understanding, as well as the lack of standardised protocols, which contributes to a lack of accurate description of indicative symptoms. While there are certain disease-specific characteristics, such as non-mechanical or cyclical LBP, and atypical accompanying symptoms like fever, abdominal pain, or leg swelling, that may suggest extravertebral causes, it is important to recognise that these features are not universally present in every patient.ConclusionThe differential diagnosis of extravertebral LBP is extensive with relatively low prevalence rates dependent on the clinical setting. Clinicians should maintain a high index of suspicion for extravertebral aetiologies, especially in patients presenting with atypical accompanying symptoms.

What is current care for people with Long COVID in England? A qualitative interview study

ObjectiveTo investigate current care for people with Long COVID in England.DesignIn-depth, semistructured interviews with people living with Long COVID and Long COVID healthcare professionals; data analysed using thematic analysis.SettingNational Health...

Health and lifestyle advice in community pharmacy for musculoskeletal conditions: a focused ethnography

Abstract Introduction Musculoskeletal health conditions are common, painful, and disabling, and often occur alongside other long-term conditions. Around a third of the UK population live with a musculoskeletal condition placing a huge burden on health and social care resources, accounting for 1 in 7 general practitioner consultations.[1] Primary care often focuses on using safe but less effective pharmacological approaches (e.g., paracetamol) despite evidence-based recommendations for self-management and lifestyle support being more effective, particularly in the context of pain management. However, access to such support is not always available or adequate. Community pharmacy is recognised for its important and well positioned setting for the delivery of public health promotion, supporting people to improve their health and live well through the Healthy Living Pharmacy Framework. Despite policy recommendations for an extended role in supporting people to self-manage long-term conditions and to adopt healthier behaviours, we currently do not know how community pharmacy manages and supports lifestyle advice in practice, particularly in relation to musculoskeletal health. Aim To gain an in-depth insight into community pharmacy daily practice in relation to the delivery of health and lifestyle advice, in order to examine community pharmacy’s current and future potential for supporting musculoskeletal health conditions. Methods An in-depth multi-site ethnographic approach was used across four community pharmacies differing in geographical and socioeconomic areas in England (April 2023 – October 2023). Data included 92 hours of observations within community pharmacies observing everyday practice and customer interactions, and 19 in-person semi-structured interviews (participants included counter assistants, dispensers, technicians and pharmacists). Results were analysed iteratively using analytic induction.[2] Results The provision of lifestyle advice was seen as awkward by staff members and problematic in consultations where advice was deemed unsolicited by customers, particularly in relation to sensitive topics such as weight or alcohol use. Pharmacists were generally more confident including lifestyle advice within appointments in the consultation room, and embedding behaviour change messages within an overall health check. Nevertheless, they lacked knowledge and training with regards to support and lifestyle advice specific for musculoskeletal health conditions. Observed over-the-counter interactions with customers were often complicated in terms of opportunities for staff to offer lifestyle advice, with encounters concerning pain relief medication at times resulting in tense and arduous consultations. Staff often found the experience of trying to offer lifestyle advice uncomfortable and challenging, leaving many feeling demotivated and lacking in confidence and as a result avoid introducing lifestyle advice into conversations. Conclusion Community pharmacy staff recognised the importance of the provision of lifestyle advice but experienced many barriers to its delivery. Increasing demands on community pharmacy with new services have implications with regards to capacity, time and skills development to effectively imbed lifestyle advice into everyday practice. Pharmacy staff may benefit from enhanced support and training to increase confidence and motivation in providing lifestyle advice, particularly relating to understanding musculoskeletal health and effective self-management strategies.

Associations between healthcare use and migration background in persons with dementia: A cohort study in the Netherlands

Background: Qualitative research shows barriers in access to healthcare for persons with a migration background, possibly leading to healthcare inequalities. We aimed to compare healthcare use between older community-dwelling persons with a migration background and native Dutch persons with dementia. Methods: Observational cohort study using electronic health records of NIVEL Primary Care Database (2013–2014) linked to nationwide administrative registries managed by Statistics Netherlands. We included all community-dwelling persons with dementia in the Netherlands aged 65 years and older. Negative binomial and logistic regression analyses were conducted to assess differences in healthcare use outcomes. The largest migrant groups (persons born in Surinam, Turkey and Morocco) were studied separately. Results: 138,864 persons with dementia were included in the study, whereof 3,991 persons with a migration background and 132,477 native Dutch persons. Moroccan-born persons showed 1.46 higher odds of having an unplanned hospital admission compared to native Dutch persons (95 % Confidence Interval [CI] 1.22–1.74). Persons with a migration background used less professional home care (Odds Ratio [OR] 0.55, 95 %CI 0.51–0.59), and received less home visits from their general practitioner (OR 0.50, 95 %CI 0.43–0.57) than native Dutch persons. Moroccan-born persons had more often an out-of-hours general practitioner consultation compared to native Dutch persons (Incidence Rate Ratio 1.36, 95 %CI 1.18–1.57). Conclusions: We found significant quantitative differences in healthcare use between persons with a migration background and native Dutch persons with dementia. Further research is needed to gain insight into the reasons of these differences, with consideration of specific migration background.