English General Practitioners Research Articles

General practitioners’ risk literacy and real-world prescribing of potentially hazardous drugs: a cross-sectional study

BackgroundOveruse of medical care is a pervasive problem. Studies using hypothetical scenarios suggest that physicians’ risk literacy influences medical decisions; real-world correlations, however, are lacking. We sought to determine the...

Risk of unintended consequences from lower antibiotic prescribing for respiratory tract infections in primary care

About 60% of antibiotic prescribing in primary care is for respiratory tract infections (RTIs), some of which is likely unnecessary. There is limited evidence on the association between reduced antibiotic prescribing and adverse events. We aimed to identify associations between practice-level prescribing rates for RTIs in general practice, and patient-level adverse outcomes. We included 1471 English General Practitioner (GP) practices, linked to hospital admissions in England, from the Clinical Practice Research Datalink for 2005 to 2019. Outcomes were hospitalisations, RTI-related re-consultations and additional antibiotic prescriptions, adjusted for practice level case-mix prescribing. Prescribing rates for practices falling within the lowest and highest prescribing quintiles were 52 and 139 prescriptions per 1000 RTI-related consultations. Patients from practices in the lowest prescribing quintile did not have significantly higher risk of hospitalisation, adjusted odds ratio 0·99 (95% CI 0·96 to 1·02). Re-consultations within 30 days were significantly higher for the lowest prescribing practices, adjusted odds ratio 1·209 (1·206 to 1·212). Additional antibiotic prescriptionsand subsequent prescriptions upon re-consultationwere significantly lower for the lowest prescribing practices, adjusted odds ratio 0·317 (0·314 to 0·321) and 0·706 (0·699 to 0·712), respectively. Our results contribute to evidence on the safety of reduced antibiotic prescribing for RTIs in primary care. Results suggest that for the majority of practices, further reductions in RTI-related antibiotic prescribing should be possible without an increase in hospitalisation for pneumonia.

The patient experience of skill mix changes in primary care: an in-depth study of patient 'work' when accessing primary care.

This paper presents insights into patient experiences of changes in workforce composition due to increasing deployment in general practice of practitioners from a number of different professional disciplines (skill mix). We explore these experiences via the concept of 'patient illness work'; how a patient's capacity for action is linked to the work arising from healthcare. We conducted four focus group interviews with Patient Participation Group members across participating English general practitioner practices. Thematic analysis and a theoretical lens of illness work were used to explore patients' attempts to understand and navigate new structures, roles and ways to access healthcare. Participants' lack of knowledge about incoming practitioners constrained their agency in accessing primary care. They reported both increased and burdensome illness work as they were given responsibility for navigating and understanding new systems of access while simultaneously understanding new practitioner roles. While skill mix changes were not resisted by patients, they were keen to improve their agency in capacity to access, by being better informed about newer practitioners to accept and trust them. Some patients require support to navigate change, especially where new systems demand specific capacities such as technological skills and adaptation to unfamiliar practitioners.

Overseas general practitioners (GPs) and prescription behaviour in England

The UK imports many doctors from abroad, where medical training and experience may differ. This study aims to understand how drug prescription behaviour varies in English GP practices with higher shares of foreign-trained GPs. Results indicate that in general prac- tices with a high proportion of GPs trained outside the UK, there are higher prescriptions for antibiotics, mental health medication, analgesics, antacids, and statins, while controlling for patient and practice characteristics. However, we found no significant impact on pa- tient satisfaction or unplanned hospitalisations, suggesting that this behaviour may be due to over-prescribing. Identifying differences in prescribing habits amongst GPs is crucial in deter- mining best policies for ensuring consistent services across GP practices and reducing health inequalities.

Association between continuity of primary care and both prescribing and adherence of common cardiovascular medications: a cohort study among patients in England

ObjectivesTo investigate whether better continuity of care is associated with increased prescribing of clinically relevant medication and improved medication adherence.SettingRandom sample of 300 000 patients aged 30+ in 2017 within...

Physicians under Pressure: Evidence from Antibiotics Prescribing in England.

BackgroundMany physicians are experiencing increasing demands from both their patients and society. Evidence is scarce on the consequences of the pressure on physicians’ decision making. We present a theoretical framework and predict that increasing pressure may make physicians disregard societal welfare when treating patients.SettingWe test our prediction on general practitioners’ antibiotic-prescribing choices. Because prescribing broad-spectrum antibiotics does not require microbiological testing, it can be performed more quickly than prescribing for narrow-spectrum antibiotics and is therefore often preferred by the patient. In contrast, from a societal perspective, inappropriate prescribing of broad-spectrum antibiotics should be minimized as it may contribute to antimicrobial resistance in the general population.MethodsWe combine longitudinal survey data and administrative data from 2010 to 2017 to create a balanced panel of up to 1072 English general practitioners (GPs). Using a series of linear models with GP fixed effects, we estimate the importance of different sources of pressure for GPs’ prescribing.ResultsWe find that the percentage of broad-spectrum antibiotics prescribed increases by 6.4% as pressure increases on English GPs. The link between pressure and prescribing holds for different sources of pressure.ConclusionsOur findings suggest that there may be societal costs of physicians working under pressure. Policy makers need to take these costs into account when evaluating existing policies as well as when introducing new policies affecting physicians’ work pressure. An important avenue for further research is also to determine the underlying mechanisms related to the different sources of pressure.JEL-code: I11, J28, J45HighlightsMany physicians are working under increasing pressure.We test the importance of pressure on physicians’ prescribing of antibiotics.The prescribed rate of broad-spectrum antibiotics increases with pressure.Policy makers should be aware of the societal costs of pressured physicians.

What do doctors understand by spiritual health? A survey of UK general practitioners

BackgroundIn the UK, doctors’ regulatory and professional bodies require general practitioners (GPs) to consider discussing spiritual health as part of the consultation. However, spiritual health is not defined in guidance,...

Climatic factors are associated with asthma prevalence: An ecological study using English quality outcomes framework general practitioner practice data.

Asthma is a complex disease with multiple environmental factors proposed to contribute to aetiology. Geographical analyses can shed light on the determinants of asthma. Ultraviolet radiation has been associated with asthma prevalence in past ecological studies. We have increased the detail of examining the association between asthma and ultraviolet radiation with addition of the variables of temperature, relative humidity and precipitation. An ecological study was designed to investigate meteorological factors associated with asthma prevalence in England. Data from the 2005 quality outcomes framework were used to determine the prevalence of asthma in primary care in England. This information was supplemented with indicators of obesity and smoking of the General Practitioner practice and population (by age and sex), deprivation and ethnicity at lower super output level from the 2001 and 2011 census. Annual mean meteorological data was attained from the Met Office and Joint Research Centre. We used a multiple linear regression to examine individual and multiple climatic factors through a principal components analysis. We tested for an association with asthma prevalence, after taking into account the spatial autocorrelation of the data. Asthma prevalence from general practice surgeries in England was 5.88% (95% CI 5.83 to 5.92). In the highest ultraviolet radiation weighted by the pre-vitamin D action spectrum (UVvitd) quartile (2.12 to 2.50kJ/m2/day), asthma had a 5% reduction in prevalence; compared to the lowest quartile here (0.95 (95% CI 0.92 to 0.98)). Similar reductions were found in the higher temperature 0.93 (95% CI 0.90 to 96). The opposite was found with relative humidity 1.09 (95% CI 1.05 to 1.12). A combination of high temperature and UVvitd highlighted postcode districts in the South East of England with a climate beneficial to low asthma prevalence. The South West of England represented a climate which had both beneficial and detrimental associations with asthma development. Climate is associated with asthma prevalence in England. Understanding the contribution of multiple climatic factors and the relationship with the indoor environment could help to explain the population distribution of asthma.

A cross-sectional survey investigating the care of the primary dentition by general dental practitioners working in Japan and England

To compare treatment decisions about primary dentistry made by Japanese and English general dental practitioners (GDPs). Four clinical scenarios were used to ascertain the clinical opinions of GDPs about what treatment to offer a 6-year-old boy with a carious molar. The first and second scenarios were a single distal and a distalocclusal cavity in a vital tooth without pain. The third was a large distal-occlusal cavity in a non-vital tooth without pain. The fourth was large distal-occlusal cavity in a non-vital tooth with pain. The participants were 234 GDPs in Japan and 322 GDPs in England. In the first scenario, 62.2% of Japanese GDPs preferred traditional restorative care compared with 34.7% of English GDPs. In the second scenario, Japanese participants were less likely to offer atraumatic treatment (16.5% vs. 34.9%). In the third scenario, Japanese dentists displayed a greater tendency to open the pulp chamber (55.2% vs. 7.6%). In the final scenario, 71% of Japanese GDPs would open the pulp chamber, whereas 50.3% of English GDPs favoured extraction. Japanese and English GDPs differed substantially in their views about the best treatment for a young child with a carious molar.

Implausible States: Prevalence of EQ-5D-5L States in the General Population and Its Effect on Health State Valuation.

The EQ-5D is made up of health state dimensions and levels, in which some combinations seem less "plausible" than others. If "implausible" states are used in health state valuation exercises, then respondents may have difficulty imagining them, causing measurement error. There is currently no standard solution: some valuation studies exclude such states, whereas others leave them in. This study aims to address 2 gaps in the literature: 1) to propose an evidence-based set of the least prevalent two-way combinations of EQ-5D-5L dimension levels and 2) to quantify the impact of removing perceived implausible states from valuation designs. For the first aim, we use data from 2 waves of the English General Practitioner Patient Survey (n = 1,639,453). For the second aim, we remodel a secondary data set of a Discrete Choice Experiment (DCE) with duration that valued EQ-5D-5L and compare across models that drop observations involving different health states: 1) implausible states as defined in the literature, 2) the least prevalent states identified in stage 1, and 3) randomly select states, alongside 4) a model that does not drop any observations. The results indicate that two-way combinations previously thought to be implausible actually exist among the general population; there are other combinations that are rarer, and removing implausible states from an experimental design of a DCE with duration leads to value sets with potentially different characteristics depending on the criterion of implausible states. We advise against the routine removal of implausible states from health state valuation studies.

Infectious Disease and Primary Care Research-What English General Practitioners Say They Need.

Background: Infections are one of the most common reasons for patients attending primary care. Antimicrobial resistance (AMR) is perhaps one of the biggest threats to modern medicine; data show that 81% of antibiotics in the UK are prescribed in primary care. Aim: To identify where the perceived gaps in knowledge, skills, guidance and research around infections and antibiotic use lie from the general practitioner (GP) viewpoint. Design and Setting: An online questionnaire survey. Method: The survey, based on questions asked of Royal College of General Practitioners (RCGP) members in 1999, and covering letter were electronically sent to GPs between May and August 2017 via various primary care dissemination routes. Results: Four hundred and twenty-eight GPs responded. Suspected Infection in the elderly, recurrent urinary tract infection (UTI), surveillance of AMR in the community, leg ulcers, persistent cough and cellulitis all fell into the top six conditions ranked in order of importance that require further research, evidence and guidance. Acute sore throat, otitis media and sinusitis were of lower importance than in 1999. Conclusion: This survey will help the NHS, the UK National Institute for Health and Care Excellence (NICE) and researchers to prioritise for the development of guidance and research for chronic conditions highlighted for which there is little evidence base for diagnostic and management guidelines in primary care. In contrast, 20 years of investment into research, guidance and resources for acute respiratory infections have successfully reduced these as priority areas for GPs.

Never events in general practice: a focus group study exploring the views of English and Scottish general practitioners of ‘never events’

ObjectivesTo examine general practitioner (GP) understanding of the never event (NE) concept in general practice, and to identify potential enablers and barriers to implementation in UK general practice.DesignQualitative study using...

Mixed-methods feasibility study of blood pressure self-screening for hypertension detection

ObjectiveTo assess the feasibility of using a blood pressure (BP) self-measurement kiosk—a solid-cuff sphygmomanometer combined with technology to integrate the BP readings into patient electronic medical records— to improve hypertension...

Primary care doctors' understandings of and strategies to tackle health inequalities: a qualitative study.

To examine general practitioners' knowledge of and their role in tackling health inequalities, in relation to their professional responsibilities. Primary care is often seen as being in the frontline of addressing health inequalities and the social determinants of health (SDH). A qualitative study with a maximum variety sample of English General Practitioners (GPs). In-depth, semi-structured interviews were held with 13 GPs in various geographical settings; they lasted between 30 and 70 min. Interviews were audio-recorded and transcribed. The analysis involved a constant comparison process undertaken by both authors to reveal key themes. GPs' understanding of health inequalities reflected numerous perspectives on the SDH and they employ various different strategies in tackling them. This study revealed that GPs' strategies were changing the nature of (medical) professionalism in primary care. We locate these findings in relation to Gruen's model of professional responsibility (comprising a distinction between obligation and aspiration, and between patient advocacy, community participation and political involvement). We conclude that these GPs do not exploit the full potential of their contribution to tackling health inequalities. These findings have implication for policy and practice in other practitioners and in other health systems, as they seek to tackle health inequalities.

Prescribing Variation in General Practices in England Following a Direct Healthcare Professional Communication on Mirabegron.

Introduction: Pharmacovigilance may detect safety issues after marketing of medications, and this can result in regulatory action such as direct healthcare professional communications (DHPC). DHPC can be effective in changing prescribing behaviour, however the extent to which prescribers vary in their response to DHPC is unknown. This study aims to explore changes in prescribing and prescribing variation among general practitioner (GP) practices following a DHPC on the safety of mirabegron, a medication to treat overactive bladder (OAB). Methods: This is an interrupted time series study of English GP practices from 2014–2017. National Health Service (NHS) Digital provided monthly statistics on aggregate practice-level prescribing and practice characteristics (practice staff and registered patient profiles, Quality and Outcomes Framework indicators, and deprivation of the practice area). The primary outcome was monthly mirabegron prescriptions as a percentage of all OAB drug prescriptions and we assessed the change following a DHPC issued by the European Medicines Agency in September 2015. The DHPC stated mirabegron use was contraindicated with severe uncontrolled hypertension and cautioned with hypertension. Variation between practices in mirabegron prescribing before and after the DHPC was assessed using the systematic component of variation (SCV). Multilevel segmented regression with random effects quantified the change in level and trend of prescribing after the DHPC. Practice characteristics were assessed for their association with a reduction in prescribing following the DHPC. Results: This study included 7408 practices. During September 2015, 88.9% of practices prescribed mirabegron and mirabegron comprised a mean of 8.2% (SD 6.8) of OAB prescriptions. Variation between practices was classified as very high and the median SCV did not change significantly (p = 0.11) in the six months after the September 2015 DHPC (12.4) compared to before (11.6). Before the DHPC, the share of mirabegron over all OAB drug prescriptions increased by 0.294 (95% confidence interval (CI), 0.287, 0.301) percentage points per month. There was no significant change in the month immediately after the DHPC (−0.023, 95% CI −0.105 to 0.058), however there was a significant reduction in trend (−0.036, 95% CI −0.049 to −0.023). Higher numbers of registered patients, patients aged ≥65 years, and practice area deprivation were associated with having a significant decrease in level and slope of mirabegron prescribing post-DHPC. Conclusion: Variation in mirabegron prescribing was high over the study period and did not change substantively following the DHPC. There was no immediate prescribing change post-DHPC, although the monthly growth did slow. Knowledge of the degree of variation in and determinants of response to safety communications may allow those that do not change prescribing habits to be provided with additional support.

Development and piloting of a survey to estimate the frequency and nature of potentially harmful preventable problems in primary care from a UK patient’s perspective

ObjectivesTo design and pilot a survey to be used at the population level to estimate the frequency of patient-perceived potentially harmful preventable problems occurring in UK primary care. To explore...

Primary care challenges in diagnosing and referring patients with suspected rheumatoid arthritis: a national cross-sectional GP survey.

ObjectiveNational guidelines advocate referring patients with persistent synovitis to rheumatology within 3 working days of presentation to primary care. This occurs infrequently. We aimed to identify modifiable barriers to early referral of suspected RA patients among English general practitioners (GPs).MethodsWe carried out a national cross-sectional survey of 1388 English GPs (RA Questionnaire for GPs [RA-QUEST] study). Questions addressed GPs’ confidence in diagnosing RA, clinical factors influencing RA diagnosis/referral, timeliness of referrals and secondary care access. Data were captured using 10-point visual analog scales, five-point Likert scales, yes/no questions or free text, and were analysed descriptively.ResultsSmall joint swelling and pain were most influential in diagnosing RA (91 and 84% rated the importance of these as 4 or 5 on a five-point Likert scale, respectively); investigations including RF (61% rating 4 or 5) and anti-CCP antibody (72% rating 4 or 5) were less influential. Patient history had the greatest impact on the decision to refer (92% rating this 4 or 5 on a 5-point Likert scale), with acute phase markers (74% rating 4 or 5) and serology (76% rating 4 or 5) less impactful. Despite the importance placed on history and examination, only 26% referred suspected RA immediately without investigations; 95% of GPs organizing further tests opted to test for RF.ConclusionFor suspected RA patients to be referred within 3 days of presentation to primary care there needs to be a paradigm shift in GPs’ approaches to making referral decisions, with a focus on clinical history and examination findings, and not the use of investigations such as RF.

Quantile regression for overdispersed count data: a hierarchical method

Generalized Poisson regression is commonly applied to overdispersed count data, and focused on modelling the conditional mean of the response. However, conditional mean regression models may be sensitive to response outliers and provide no information on other conditional distribution features of the response. We consider instead a hierarchical approach to quantile regression of overdispersed count data. This approach has the benefits of effective outlier detection and robust estimation in the presence of outliers, and in health applications, that quantile estimates can reflect risk factors. The technique is first illustrated with simulated overdispersed counts subject to contamination, such that estimates from conditional mean regression are adversely affected. A real application involves ambulatory care sensitive emergency admissions across 7518 English patient general practitioner (GP) practices. Predictors are GP practice deprivation, patient satisfaction with care and opening hours, and region. Impacts of deprivation are particularly important in policy terms as indicating effectiveness of efforts to reduce inequalities in care sensitive admissions. Hierarchical quantile count regression is used to develop profiles of central and extreme quantiles according to specified predictor combinations.

Variations in GPs' decisions to investigate suspected lung cancer: a factorial experiment using multimedia vignettes

IntroductionLung cancer survival is low and comparatively poor in the UK. Patients with symptoms suggestive of lung cancer commonly consult primary care, but it is unclear how general practitioners (GPs)...

Variation in Direct Access to Tests to Investigate Cancer: A Survey of English General Practitioners.

BackgroundThe 2015 NICE guidelines for suspected cancer recommend that English General Practitioners have direct access to diagnostic tests to investigate symptoms of cancer that do not meet the criteria for urgent referral. We aimed to identify the proportion of GPs in England with direct access to these tests.MethodsWe recruited 533 English GPs through a national clinical research network to complete an online survey about direct access to laboratory, radiology, and endoscopy tests in the three months leading up to the release of the 2015 NICE guidance. If they had direct access to a diagnostic test, GPs were asked about the time necessary to arrange a test and receive a report. Results are reported by NHS sub-region and, adjusting for sampling, for England as a whole.ResultsAlmost all GPs reported direct access to x-ray and laboratory investigations except faecal occult blood testing (54%, 95% CI 49–59%) and urine protein electrophoresis (89%, 95% CI 84–92%). Fewer GPs had direct access to CT scans (54%, 95% CI 49–59%) or endoscopy (colonoscopy 32%, 95% CI 28–37%; gastroscopy 72%, 95% CI 67–77%). There was significant variation in direct access between NHS regions for the majority of imaging tests—for example, from 20 to 85% to MRI. Apart from x-ray, very few GPs (1–22%) could access radiology and endoscopy within the timescales recommended by NICE. The modal request to test time was 2–4 weeks for routine radiology and 4–6 weeks for routine endoscopy with results taking another 1–2 weeks.ConclusionAt the time that the 2015 NICE guideline was released, local investment was required to not only provide direct access but also reduce the interval between request and test and speed up reporting. Further research using our data as a benchmark is now required to identify whether local improvements in direct access have been achieved in response to the NICE targets. If alternative approaches to test access are to be proposed they must be piloted comprehensively and underpinned by robust effectiveness data.