Diagnosis In General Practice Research Articles

Symptomatic cancer diagnosis in general practice: a critical perspective of current guidelines and risk assessment tools.

Symptomatic cancer diagnosis in general practice: a critical perspective of current guidelines and risk assessment tools.

Prospective diagnostic accuracy study of history taking and physical examination for adults with vertigo in general practice: study protocol

IntroductionVertigo is a prevalent and burdensome symptom. More than 80% of patients with vertigo are primarily treated by their general practitioner (GP) and are never referred to a medical specialist....

Prevalence and factors associated with a prescription of a Lyme borreliosis serology for erythema migrans diagnosis in general practice: a study from the French sentinel network, 2009–2020

BackgroundSerological testing of patients consulting for typical erythema migrans (EM) is not recommended in European recommendations for diagnosis of Lyme borreliosis (LB). Little is known on the level of adherence of French general practitioners to these recommendations. The objectives were to estimate the proportion of Lyme borreliosis serological test prescription in patients with erythema migrans seen in general practice consultations in France, and to study the factors associated with this prescription.MethodsLB cases with an EM reported by the French general practitioners (GPs) of the Sentinelles network between January 2009 and December 2020 were included. To assess the associations with a prescription of a serological test, multilevel logistic regression models were used.ResultsAmong the 1,831 EM cases included, a prescription for a LB serological test was requested in 24.0% of cases. This proportion decreased significantly over the study period, from 46.8% in 2009 to 15.8% in 2020. A LB serological prescription was associated with patients with no reported tick bite (Odds Ratio (OR): 1.95; 95% confidence interval [1.23–3.09]), multiple EM (OR: 3.82 [1.63–8.92]), EM of five centimeters or more (OR: 4.34 [2.33–8.08]), and GPs having diagnosed less than one EM case per year during the study period (OR: 5.28 [1.73–16.11]).ConclusionsSerological testing of patients consulting for EM is not recommended in European recommendations for diagnosis of Lyme borreliosis. Therefore, the significant decrease in the rate of LB serological test for EM over the study period is encouraging. The factors identified in this study can be used to improve messaging to GPs and patients. Further efforts are needed to continue to disseminate diagnostic recommendations for LB to GPs, especially those who rarely see patients with EM.

Results from the PRIMA Trial: Comparison of the STHLM3 Test and Prostate-specific Antigen in General Practice for Detection of Prostate Cancer in a Biopsy-naïve Population

BackgroundCurrent management of prostate cancer (PC) lacks biomarker tests and diagnostic procedures that can accurately distinguish clinically significant and clinically insignificant PCs at an early stage of the disease. ObjectiveTo compare the Stockholm 3 (STHLM3) test and prostate-specific antigen (PSA) as entry tests for magnetic resonance imaging (MRI) in a prospective study of PC diagnosis in general practice. Design, setting, and participantsParticipants were biopsy-naïve men aged 50–69 yr who had a PSA test in general practice. Participants with PSA 1–10 ng/ml also had an STHLM3 test and were referred for MRI if the STHLM311 test was positive (risk ≥11%) and/or PSA ≥3 ng/ml, and to targeted MRI-guided biopsy (MRGB) if their Prostate Imaging-Reporting and Data System (PI-RADS) score was ≥3. Outcome measurements and statistical analysisThe primary outcome was the number of International Society of Urological Pathology grade group ≥2 (GG ≥2) cases detected with a positive STHLM311 test versus PSA ≥3 ng/ml. Post hoc analysis was performed using a higher STHLM3 test cutoff (risk ≥15%; positive STHLM315 test). Results and limitationsBetween January 2018 and December 2021, we recruited 1905 men. The STHLM3 test was performed in 1134 participants. Of these, 437 underwent MRI and 117 underwent MRGB, which detected 38 (32.5%) GG ≥2 and 52 (44.4%) with GG 1 cases. In comparison to PSA ≥3 ng/ml, a positive STHLM311 test increased detection of GG ≥2 from 30 to 37 cases (23.3%, 95% confidence interval [CI] 5.6–52.2%) and detection of GG 1 from 37 to 50 cases (35.1%, 95%CI 11.6–66.7%). STHLM315 positivity did not differ from PSA ≥3 ng/ml regarding detection of GG ≥2 PC (30 vs 32; 6.6%, 95% CI −8.1% to 25.9%), GG 1 PC (37 vs 37; 0.0%, 95% CI −19.6% to 25.0%), or MRGB use (88 vs 83; −5.7%, 95% CI −17.9% to 7.4%), but reduced MRI scans from 320 to 236 (−26.2%, 95% CI −33.1% to −18.9%). ConclusionsThe STHLM311 test improved sensitivity but not specificity for detection of GG ≥2 PC in the clinical setting of nonsystematic PC testing in general practice. Further studies are needed to validate a possible benefit of using a higher cutoff for STHLM3 positivity as an entry test for MRI. Patient summaryWe used a test called STHLM3 for detection of prostate cancer in general practice and compared its performance to the conventional PSA (prostate-specific antigen) test. We found that STHLM3 test results of 11% or above were not better at selecting men for MRI (magnetic resonance imaging) scans than the PSA test with a cutoff of 3 ng/ml or above. Analysis suggested that a higher cutoff for a positive STHLM3 test may improve selection of men for MRI scans, but further validation is needed.

PREVALENCE OF HELICOBACTER PYLORI INFECTION IN ENDOSCOPIC BIOPSY SPECIMEN AMONG ACID PEPTIC DISORDER PATIENTS ATTENDING GASTRO-OUTPATIENT DEPARTMENT OF A TERTIARY CARE CENTER IN CENTRAL NEPAL

Background: Acid peptic disorder (APD) is the most frequently encountered provisional diagnosis in general practice with Helicobacter pylori being the major causal agent. In the present study we aim to report the incidence of H. pylori infection among patients undergoing upper gastrointestinal endoscopy at a tertiary care center in central Nepal. Methods: A hospital-based cross-sectional study was conducted among 101 patients with diagnosis of APD. An Upper gastrointestinal (UGI) Endoscopy was performed on all the participants and biopsy specimen was obtained from various parts depending on the endoscopic findings. Reports of H&E stain H. pylori status was recorded using a pre-formed proforma. Data analysis was done using SPSS-20. Results: H. pylori infection was found in 41.6% (42/101) patients with female predominance (25/60) (59.5%). Both married men and women had higher prevalence of HP infection than their unmarried counterparts. Patients with blood group O were found to be the most affected. Conclusions: A higher prevalence of H. pylori was found among APD patients who had undergone upper gastrointestinal endoscopy.

Pattern of Heart Rate Variability in Somatoform Disorder and Its Association with Anxiety level: An Analytical Study

Background: Somatoform disorder (SD), nowadays considered as the most frequent psychiatric diagnosis in general practice has strong association with anxiety. Though there are a handful of studies showing heart Rate variability (HRV) in SD patients, as such no studies according to author’s knowledge had been addressed to the anxiety component hidden in the SD patients applying HRV tests so far. Aims: Aim of the current study was assess the presence and extent of Heart rate variability in SD patients and to find out it’s possible relationship with their anxiety level. Materials and Methods: An analytical observational cross-sectional study was done among fifty newly diagnosed somatoform disorder patients of eighteen to forty years age attending Psychiatry OPD and fifty age and sex matched healthy control. After assessing their anxiety level using State Trait Anxiety Inventory, Short term Heart rate Variability tests were performed. Appropriate Statistical tests were applied using SPSS 20 version. Results: The SD patients showed reduced heart rate variability as SDNN and RMSDD were less, LF and LF/HF ratio were more in them than controls and significant differences were there. Both SAS and TAS scores were more in cases and there was positive correlation of TAS score with LF and LF/HF ratios. Conclusions: The results of this study actually set an alarm for controlling their symptoms as well as their hidden anxiety underneath, as reduced HRV poses the risk of developing cardiovascular disease and hidden anxiety has influence on heart rate variability.

EASI™ 12‑lead ECG with a handheld computer refines cardiovascular diagnosis in general practice

BackgroundElectrocardiogram (ECG) is used to a small extent in general medicine, because of general practitioner (GP) apprehension about interpretation and time consumption. AimThis study tested the hypothesis that user-friendly EASI ECG improves GP diagnosis of cardiovascular symptoms. MethodPatients over 18 years with recent cardiovascular symptoms or auscultation rhythm abnormalities were included in this prospective, multicentric study (10 practices, 17 GPs). ECG recordings were made with Cardiosecur® (4‑lead ECG connected to a handheld computer for EASI™ processing). Besides clinical data, diagnosis/patient referral were noted before and after ECG and interpretation. GP diagnosis and ECG interpretation were compared with a reference diagnosis made by ECG specialist. ResultsThere were 338 patients; 66% had cardiovascular risk factors. ECGs were performed for chest pain (41%), auscultation rhythm abnormalities (33%) or palpitations (19%). Average time to perform ECG was 4.7 ± 2.1 min, with possible home recordings. Compared with standard ECG, improvement provided by Cardiosecur® was scored 9/10 (range 7–10) by GPs. GPs correctly interpreted ECG normality/abnormality in 77% of patients. Diagnosis was correctly changed for 14% of patients thanks to the ECG, and wrongly changed for 2%. One new appropriate final diagnosis was achieved for 9 ECG recordings (p < 0.001). Diagnostic certainty increased 1.9 ± 2.1/10 (p < 0.001). ECG brought about changes in GP decision making: referral or treatment changed for 82 patients (24%) and complementary test for 69 patients (20%). ConclusionThe EASI™ algorithm coupled with a handheld computer facilitates ECG recordings in the primary care setting, providing improved diagnosis.

‘We're happy as we are’: the experience of living with possible undiagnosed dementia

AbstractIt is estimated that a third of people in the United Kingdom with signs of dementia are living without a formal diagnosis. In Wales, the proportion is nearly half. Some explanations for the gap between prevalence of dementia and number of diagnoses include living with a long-term partner/spouse and systemic barriers to diagnosis. This study recruited participants from the Cognitive Function and Ageing Studies-Wales (CFAS-Wales) cohort, randomly selected from people aged over 65 living in two areas of Wales, who met study criteria for a diagnosis of dementia and did not have a record of a formal diagnosis in general practice records. We aimed to understand more about the contexts and circumstances of people who live with and cope with cognitive difficulties without having a formal diagnosis of dementia. We conducted qualitative interviews with six participants and their spouses, and additionally with four family members of three invited people who were unable to take part. Themes were generated using thematic analysis. We present the argument that there is an adaptive response to low service levels and a complex interaction between the expectations of levels of service, perceptions of the legitimacy of cognitive problems and the right to make demands on services. This paper concludes that more could be done to address barriers to diagnosis and treatment services for those living with symptoms of dementia, but that the value placed on diagnosis by some individuals might be lower than anticipated by government policy.

Somatic symptoms and associations with common psychological diagnoses: a retrospective cohort study from Norwegian urban general practice.

Patients with mental health problems often present with somatic symptoms when visiting their general practitioner (GP). Somatic presentations may challenge correct diagnosing of mental health disorders in general practice, where most of these disorders are treated. Explore the associations between common psychological diagnoses and somatic symptom diagnoses in Norwegian urban general practice. A retrospective cohort study including electronic medical data from 15 750 patients aged 16-65 years from 35 GPs in six GP offices in Oslo, Norway, during 12 months in 2014-2015. We explored prevalences and associations between anxiety-, depression-, and stress-related diagnoses, and somatic symptom diagnoses. Patients with anxiety-, depression- and stress-related diagnoses had a mean number of 2.9±3.6 somatic symptom diagnoses during the 12 months, compared to 1.9±2.5 for patients without any psychological diagnoses (P < 0.001). The mean number of somatic symptoms was significantly higher for the different psychological diagnoses viewed separately, for both sexes and different age groups. There was an increase in probability for anxiety, depression, or stress-related diagnoses with an increasing number of somatic symptom diagnoses during the 12 months. We found a significant increase in somatic symptom diagnoses from ICPC-2 chapters: General and unspecified, digestive, cardiovascular, musculoskeletal, neurological, urological, female genital disorders and social problems. Associated symptom patterns were different for each of the included psychological diagnoses. This study shows that patients with anxiety, depression- and stress-related diagnoses present with increased and characteristic somatic symptoms compared to patients without these diagnoses in general practice.

Testing for coeliac disease rarely leads to a diagnosis: a population-based study

Background Coeliac disease (CD) has an estimated prevalence of ∼1% in Europe with a significant gap between undiagnosed and diagnosed CD. Active case finding may help to bridge this gap yet the diagnostic yield of such active case finding in general practice by serological testing is unknown. Objective The aim of this study was to determine (1) the frequency of diagnosed CD in the general population, and (2) to investigate the yield of active case finding by general practitioners. Methods Electronic medical records of 207.200 patients registered in 49 general practices in The Netherlands in 2016 were analysed. An extensive search strategy, based on International Classification of Primary Care codes, free text and diagnostic test codes was performed to search CD- or gluten-related contacts. Results The incidence of CD diagnosis in general practice in 2016 was 0.01%. The prevalence of diagnosed CD reported in the general practice in the Netherlands was 0.19%, and considerably higher than previously reported in the general population. During the one year course of the study 0.95% of the population had a gluten-related contact with their GP; most of them (72%) were prompted by gastrointestinal complaints. Serological testing was performed in 66% (n = 1296) of these patients and positive in only 1.6% (n = 21). Conclusion The number of diagnosed CD patients in the Netherlands is substantially higher than previously reported. This suggests that the gap between diagnosed and undiagnosed patients is lower than generally assumed. This may explain that despite a high frequency of gluten-related consultations in general practice the diagnostic yield of case finding by serological testing is low. Key points The diagnostic approach of GPs regarding CD and the diagnostic yield is largely unknown Case finding in a primary health care practice has a low yield of 1.6% CD testing was mostly prompted by consultation for gastrointestinal symptoms There is a heterogeneity in types of serological test performed in primary care

Improving the precision of depression diagnosis in general practice: a cluster-randomized trial

BackgroundMethods to enhance the accuracy of the depression diagnosis continues to be of relevance to clinicians. The primary aim of this study was to compare the diagnostic precision of two different diagnostic strategies using the Mini International Neuropsychiatric Interview (MINI) as a reference standard. A secondary aim was to evaluate accordance between depression severity found via MINI and mean Major Depression Inventory (MDI) sum-scores presented at referral.MethodsThis study was a two-armed, cluster-randomized superiority trial embedded in the Collabri trials investigating collaborative care in Danish general practices. GPs performing case-finding were instructed always to use MDI when suspecting depression. GPs performing usual clinical assessment were instructed to detect depression as they would normally do. According to guidelines, GPs would use MDI if they had a clinical suspicion, and patients responded positively to two or three core symptoms of depression. We compared the positive predictive value (PPV) in the two groups.ResultsFifty-one GP clusters were randomized. In total, 244 participants were recruited in the case-finding group from a total of 19 GP clusters, and 256 participants were recruited in the usual clinical assessment group from a total of 19 GP clusters. The PPV of the GP diagnosis, when based on case-finding, was 0.83 (95% CI 0.78–0.88) and 0.93 (95% CI 0.89–0.96) when based on usual clinical assessment. The mean MDI sum-scores for each depression severity group indicated higher scores than suggested cut-offs.ConclusionsIn this trial, systematic use of MDI on clinical suspicion of depression did not improve the diagnostic precision compared with the usual clinical assessment of depression.Trial registrationThe trial was retrospectively registered on 07/02/2016 at ClinicalTrials.gov. No. NCT02678845.

GPs' drug treatment for depression by patients' educational level: registry-based study.

BackgroundAntidepressant drugs are often prescribed in general practice. Evidence is conflicting on how patient education influences antidepressant treatment.AimTo investigate the association between educational attainment and drug treatment in adult patients with a new depression diagnosis, and to what extent sex and age influence the association.Design & settingA nationwide registry-based cohort study was undertaken in Norway from 2014–2016.MethodThe study comprised all residents of Norway born before 1996 and alive in 2015. Information was obtained on all new depression diagnoses in general practice in 2015 (primary care database) and data on all dispensed depression medication (Norwegian Prescription Database [NorPD]) 12 months after the date of diagnosis. Independent variables were education, sex, and age. Associations with drug treatment were estimated using a Cox proportional hazard model and performed separately for sex.ResultsOut of 49 967 patients with new depression (61.6% women), 15 678 were dispensed drugs (30.4% women, 33.0% men). Highly educated women were less likely to receive medication (hazard ratio [HR] = 0.93; 95% confidence interval [CI] = 0.88 to 0.98) than women with low education. No such differences appeared among men. Women aged 20–29 years were more likely to be treated with drugs than those aged 30–59 years, and women aged ≥70 years were more likely to receive drugs (HR = 1.65; 95% CI = 1.54 to 1.77) than those aged 20–29 years. The pattern was similar but less pronounced for men.ConclusionEducational differences in antidepressant therapy among women may reflect different treatment approaches that clinicians should be aware of to avoid unintended variation. Reasons for this variation and consequences for quality of treatment should be explored.

Making a good mental health diagnosis: Science, art and ethics.

There are limitations to psychiatric classification, which affects the utility ofdiagnosis in general practice. The aim of this article is to explore the principles of science, art and ethics tocreate clinically useful psychiatric diagnoses in general practice. Psychiatric classification systems provide useful constructs for clinical practice and research. Evidence-based treatments are based on the classification of mental illnesses. However, while classification isnecessary, it is not sufficient to provide a full understanding of 'what is going on'. A good psychiatric diagnosis will also include a formulation, which provides anunderstanding of the psychosocial factors that provide a context for illness. Experiences such as trauma and marginalisation will change the illness experience but also provide other formsof evidence that shape therapy. Diagnoses also carry ethical implications, including stigma and changes in self‑concept. The science, art and ethics of diagnosis need to be integrated to provide a complete assessment.

General practitioners' drug treatment for depression by patients' educational level: registry-based study.

Antidepressant drugs are often prescribed in general practice. Evidence is conflicting on how patient education influences antidepressant treatment. To investigate the association between educational attainment and drug treatment in adult patients with a new depression diagnosis, and how gender and age influence the association. Nationwide registry-based cohort study, Norway, 2014-2016. The study comprised all residents of Norway born before 1996 and alive in 2015. We obtained information on all new depression diagnoses in general practice in 2015 (Primary Care Database) and data on all dispensed depression medication (Norwegian Prescription Database) 12-months after the date of diagnosis. Independent variables were education, gender, and age. Associations with drug treatment were estimated using a Cox proportional hazard model, for genders separately. Out of 49,967 patients with new depression (61.6% women), 15,678 were dispensed drugs (30.4% women, 33.0% men). Highly educated women were less likely to receive medication (Hazard Ratio (HR) =0.93, 95% CI (0.88 - 0.98)) than women with low education. No such differences appeared among men. Women aged 20-29 were more likely to be treated with drugs than those aged 30-59, and women aged 70+ were more likely to receive drugs (HR=1.65, (1.54 - 1.77)) than those aged 20-29. The pattern was similar but less pronounced for men. Educational differences in antidepressant therapy among women may reflect different treatment approaches that clinicians should be aware of to avoid unintended variation. Reasons for this variation and consequences for quality of treatment should be.

Variation in general practitioners' depression care following certification of sickness absence: a registry-based cohort study.

BackgroundDepression is more prevalent among women and people with low socio-economic status. Uncertainties exist about how general practitioner (GP) depression care varies with patients’ social position.ObjectiveTo investigate associations between patients’ gender and educational status combined and GP depression care following certification of sickness absence.MethodsNationwide registry-based cohort study, Norway, 2012–14. Reimbursement claims data from all consultations in general practice for depression were linked with information on socio-demographic data, social security benefits and depression medication. The study population comprised all individuals aged 25–66 years with taxable income, sick-listed with a new depression diagnosis in general practice in 2013 (n = 8857). We defined six intersectional groups by combining educational level and gender. The outcome was type of GP depression care during sick leave: follow-up consultation(s), talking therapy, medication and referral to secondary care. Associations between intersectional groups and outcome were estimated using generalized linear models.ResultsAmong long-term absentees (17 days or more), highly educated women were less likely to receive medication compared to all other patient groups [relative risk (RR) ranging from 1.17 (95% confidence interval 1.03–1.33) to 1.49 (1.29–1.72)] and more likely to receive talking therapy than women with medium [RR = 0.90 (0.84–0.98)] or low [RR = 0.91 (0.85–0.98)] education.ConclusionsOur findings suggest that GPs provide equitable depression care regarding consultations and referrals for all intersectional groups but differential drug treatment and talking therapy for highly educated women. GPs need to be aware of these variations to provide personalized care and to prevent reproducing inequity.

Long-term employment, education, and healthcare costs of childhood and adolescent onset of epilepsy

ObjectiveChildhood- and adolescent-onset epilepsy may have a significant impact on long-term educational and vocational status, which in turn has consequences for individuals' socioeconomic status. We estimated the factual long-term socioeconomic consequences and healthcare costs of individuals with diagnosed epilepsy. MethodsThe prospective cohort study included Danish individuals with epilepsy onset before the age of 18 years, diagnosed between 2002 and 2016. Healthcare costs and socioeconomic data were obtained from nationwide administrative and health registers. The prediction was made with a general estimating equation (GEE). A total of 15,329 individuals were found with the diagnosis during this period and were followed until the age of 30 years. These were compared with 31,414 controls. We used 30 years as this represent an age where most has finalized their education, and as such represent the final educational level. Patients and their controls were subdivided into debut age groups of 0–5 and 6–18 years. Individuals were matched for age, gender, and residential location. ResultsCompared with control groups, patients with epilepsy at the age of 30 years tended to have the following: 1) parents with lower educational attainment; 2) a significantly lower educational level when controlling for parental education attainment; 3) lower grade-point averages; 4) a lower probability of being in employment and lower income, even when transfer payments were considered; and 5) elevated healthcare costs, including those for psychiatric care. It was also noted that the long-term educational consequences for patients with epilepsy were associated with parental educational level. Differences were more pronounced for those with early (0–5 years) rather than later (6–18 years) onset epilepsy. ConclusionsEpilepsy is associated with severe long-term socioeconomic consequences: lower educational level, school grades, employment status, and earned income. The presence of epilepsy is associated with parental educational level. Limitations1.Register-based study; epilepsy based on diagnosis within the hospital sector; patients found with diagnosis in general practice were not included.2.Some patients treated in the primary sector may not have been identified.3.Parental education level may have risen after the index date when the patient was first included. Significant outcomes•Childhood and adolescent epilepsy are associated with long-term negative impacts on educational level, employment status, and earned income.•Childhood and adolescent epilepsy are associated with long-term healthcare uses, especially for those with early disease onset.•Childhood and adolescent epilepsy are related to lower levels of parental education.

P0842MANAGEMENT OF RENAL RISK PATIENTS AND THERAPEUTIC CHANGES AFTER DIAGNOSIS OF KIDNEY DISEASE IN PRIMARY CARE

Abstract Background and Aims Screening for chronic kidney disease (CKD) is proposed in high risk groups. Whether a new CKD diagnosis in general practice leads to improved patient management, is largely unknown. Method To answer this question and evaluate the kidney disease specific pharmacological care in renal risk patients, a screening study in patients at high risk for kidney disease was performed in the primary care setting in ten general practices in the state of Vorarlberg, Austria. General practitioners were provided with guidelines for the management of CKD with a focus on blood pressure control, RAS inhibition and use of statins. Results In total, 434 patients between age 35 and 77 were included (61% males, mean age 56±7 years, eGFR 86±15 ml/min, body mass index 31±6 kg/m, blood pressure 135±16/83±10 mmHg), of whom 80% had hypertension, 43% had diabetes and 42% were obese. RAS-blockers were already taken by 64% of patients, statins by 39%. A diagnosis of CKD (stage ≥G3 and/or ≥A2) was established in 73 patients (17%), 60% of them had diabetes. Compared to patients without CKD, CKD patients were already treated more often with RAS-blockers (78% vs 61%, p=0.005), whereas statin usage was comparable (44% vs 38%, p=0.3347). After CKD diagnosis, medical therapy was changed in 13 patients (18%). A RAS-blocker was initiated in two out of the 16 patients without a preexisting RAS-blocker (12.5%), the dosage was increased in one patient. Antihypertensive therapy was intensified adding amlodipine in seven patients (10%), and a statin was begun in six (15%) out of 41 statin-naive patients. In those without CKD after the screening, therapy was changed in 40 patients (11%). Compared to patients with CKD, fewer patients started a statin therapy (5% vs 15%, p=0.012) and were additionally treated with amlodipine (3% vs 10%, p=0.021) to optimize blood pressure control. Conclusion This study shows that in the primary care setting a great proportion of CKD patients are already on RAS-blockers, whereas the prescription rate for statins is low. A diagnosis of CKD led to a moderate increase in statin therapy, which leaves further opportunity for improvement. The reasons for this rather low use of statins in CKD patients need to be determined.

Evaluating the impact of post-trial implementation of RHIVA nurse-led HIV screening on HIV testing, diagnosis and earlier diagnosis in general practice in London, UK

BackgroundUK and European guidelines recommend HIV testing in general practice. We report on the implementation of the Rapid HIV Assessment trial (RHIVA2) promoting HIV screening in general practice into routine care. MethodsInterrupted time-series, difference-in-difference analysis and Pearson-correlation on three cohorts comprising 42 general practices in City & Hackney (London, UK); covering three periods: pre-trial (2009–2010), trial (2010–2012) and implementation (2012–2014). Cohorts comprised practices receiving: “trial intervention” only (n = 19), “implementation intervention” only (n = 13); and neither (“comparator”) (n = 10). Primary outcomes were HIV testing and diagnosis rates per 1000 people and CD4 at diagnosis. FindingsOverall, 55,443 people were tested (including 38,326 among these cohorts), and 101 people were newly diagnosed HIV positive (including 65 among these cohorts) including 74 (73%) heterosexuals and 69 (68%) people of black African/Caribbean background; with mean CD4 count at diagnosis 357 (SD=237). Among implementation intervention practices, testing rate increased by 85% (from 1·798 (95%CI=(1·657,1·938) at baseline to 3·081 (95%CI=(2·865,3·306); p = 0·0000), diagnosis rate increased by 34% (from 0·0026 (95%CI=(0·0004,0·0037)) to 0·0035 (95%CI=(0·0007,0·0062); p = 0·736), and mean CD4 count at diagnosis increased by 55% (from 273 (SD=372) to 425 (SD=274) cells per μL; p = 0·433). Implementation intervention and trial intervention practices achieved similar testing rates (3·764 vs. 3·081; 6% difference; 95% CI=(-5%,18%); p = 0·358), diagnosis rates (0·0035 vs. 0·0081; -13% difference; 95%CI=(-77%,244%; p = 0·837), and mean CD4 count (425 (SD=274) vs. 351 (SD=257); 69% increase; 95% CI=(-61%,249%); p = 0·359). HIV testing was positively correlated with diagnosis (r = 0·114 (95% CI=[0·074,0·163])), and diagnosis with CD4 count at diagnosis (r = 0·011 (95% CI=[-0·177,0·218])). InterpretationImplementation of the RHIVA programme promoting nurse-led HIV screening into routine practice in inner-city practices with high HIV prevalence increased HIV testing, and may be associated with increased and earlier diagnosis. HIV screening in primary care should be considered a key strategy to reduce undiagnosed infection particularly among high risk persons not attending sexual health services. FundingNational Institute for Health Research ARC North Thames, and Barts and The London School of Medicine and Dentistry.

Healthcare utilisation in general practice and hospitals in the year preceding a diagnosis of cancer recurrence or second primary cancer: a population-based register study

BackgroundThe organisation of cancer follow-up is under scrutiny in many countries, and general practice is suggested to become more involved. A central focus is timely detection of recurring previous cancer and new second primary cancer. More knowledge on the patient pathway before cancer recurrence and second primary cancer is warranted to ensure the best possible organisation of follow-up. We aimed to describe the healthcare utilisation in the year preceding a diagnosis of cancer recurrence or second primary cancer.MethodsThis nationwide register study comprises patients diagnosed with bladder, breast, colorectal, endometrial, lung, malignant melanoma and ovarian cancer in Denmark in 2008–2016. The frequency of healthcare contacts during the 12 months preceding a cancer recurrence or second primary cancer was estimated and compared to the frequency of cancer survivors in cancer remission. The main analyses were stratified on sex and healthcare setting. Furthermore, two sub-analyses were stratified on 1) sex, healthcare setting and age group and on 2) sex, healthcare setting and comorbidity status.ResultsThe study population consisted of 7832 patients with recurrence and 2703 patients with second primary cancer. On average, the patients were in contact with general practice one time per month in the 12th month preceding a new cancer diagnosis (recurrence or second primary cancer). Increasing contact rates were seen from 7 months before diagnosis in general practice and from 12 months before diagnosis in hospitals. This pattern was more pronounced in patients with cancer recurrence, younger patients and patients with no comorbidity. For instance, the contact rate ratios for hospital contacts in non-comorbid women with recurrence demonstrated 30% more contacts in the 12th month before recurrence and 127% more contacts in the 2nd month before recurrence.ConclusionsThe results show that cancer survivors are already seen in general practice on a regular basis. The increasing contact rates before a diagnosis of cancer recurrence or second primary cancer indicate that a window of opportunity exists for more timely diagnosis; this is seen in both general practice and in hospitals. Thus, cancer survivors may benefit from improvements in the organisation of cancer follow-up.

Use of Healthcare Services Two Years before Diagnosis in Danish Sarcoma Patients, 2000-2013.

Background Sarcoma is a rare type of cancer with nonspecific symptoms and uncertain aetiology. Thus, timely diagnosis of sarcomas is a clinical challenge. The aim of this study was to investigate the use of healthcare services 24 months preceding a sarcoma diagnosis compared to a matched cohort. Materials and Methods The study was a retrospective, population-based, matched cohort registry-study. Patients with sarcoma in Denmark in 2000–2013 were identified in the Danish Sarcoma Registry (n = 2167) and matched 1 : 10 on gender, age, and listed general practice. Using a binomial regression model, incidence rate ratios were calculated for face-to-face contacts in general practice, inpatient and outpatient visits, surgery, paraclinical examinations, and diagnostic imaging. Analyses were stratified for sarcoma subtypes, grade, stage, gender, and presence of comorbidity. Results The sarcoma patients had significantly increased incidence rate ratios in use of healthcare services compared to the matched cohort a year before their diagnoses. An increase in consultation rates was seen 11 months before diagnosis for inpatient visits, 9 months before diagnosis in general practice and outpatient visits, 8 months before diagnosis for paraclinical examinations, and 4 and 3 months before diagnosis for diagnostic imaging and surgery, respectively. There were no clinical significant differences in length of increased consultation rates between sarcoma type, stage, and grade. Sarcoma patients with comorbidity had persistently higher consultation rates compared to patients without comorbidity. Conclusions The use of healthcare services among sarcoma patients increased several months before diagnosis in all healthcare sectors. The results reveal a diagnostic time window and a potential to refer, diagnose, and treat sarcoma patients in a timelier manner.