General Practice Clinics Research Articles

Why patients attend emergency department for primary care type problems: views of healthcare providers working in a remote community.

Emergency department (ED) utilisation continues to increase, particularly for primary care presentations that do not require high level ED services. The reasons for this are complex, and research has focused on patient perspectives in choosing where to seek care rather than those of ED and general practitioner (GP) providers. This study aimed to address this gap by exploring the views of ED and GP providers regarding ED utilisation for primary care type health conditions in a small, remote Australian city with perhaps unique population demographics and service configuration. Service providers from the ED and general practice clinics were invited to participate in focus groups and semi-structured interviews exploring their views on ED utilisation for primary-care-type health presentations. The data were analysed using thematic content analysis. In total, 24 healthcare providers (five GPs, seven ED practitioners, seven community nurse navigators, four Aboriginal and Torres Strait Islander Health Workers and one Indigenous Liaison Officer) participated in focus groups discussion and interviews. The analysis identified three themes: access and logistic barriers, rational decision-making and self-perceived urgency. While there was some overlap in the healthcare providers' perceptions, there were also strong differences between ED and GP groups. In particular, the ED group believed that GP services are less accessible for urgent appointments, whereas GPs believed that such arrangements were in place. Both groups agreed on the need for clear communication between the ED and general practice. ED and GP providers demonstrate similarities and differences in understanding patients' reasons for choosing which service to access. The differences may stem from ED providers' focus on offering a rapid resolution of acute presentations and GP providers' focus on offering comprehensive and continuing care. Effective communication between general practice and the ED services and clearer referral pathways may help in reducing ED utilisation for less urgent primary-care-type problems.

Abstract P2-10-06: Validation of abridged breast cancer risk assessment model for the general population

Abstract The ability to efficiently and accurately risk stratify women can lead to improved risk-reduction measures. Actionable risk thresholds for both screening and risk-reduction guidance exist; however, despite several clinical risk models currently in existence, the utilization of such models is underwhelming. We have developed and validated an abridged clinical risk model, COSMO (Clinical pOlygenic denSity faMily mOdel), incorporating three of the most relevant epidemiological risk factors associated with sporadic and familial breast cancer in a format that is designed for “ease of use”. Polygenic risk is recognized as a promising epidemiological risk factor however, its value is greater when integrated with other phenotypic risk factors including 1st and 2nd family history, breast density menopausal status, BMI and age. We used 200,009 active UK Biobank (UKB) members who were female, genetically Caucasian, had SNP data for 313 breast cancer associated variants and aged 40 to 69 years at baseline assessment date. We used age and date of baseline assessment to calculate censoring age for those who had died before completing 5 years of follow-up and to determine the date at which 5 years of follow-up was completed for the others. We used both self-reported and linked cancer registry data (ICD9 code 174 or ICD10 code C50) to determine the earliest diagnosis of invasive breast cancer for each affected woman. In terms of discrimination, COSMO (AUC=0.651; 95% CI 0.642, 0.661) performed better than the Gail model (AUC=0.567; 95% CI=0.557, 0.567); P value for difference <0.0001. Overall calibration showed the number of breast cancers expected using COSMO was slightly higher than the number observed (SIR=0.94; 95% CI=0.91, 0.97), while for the Gail model, the number of breast cancers was lower than the number observed (SIR=1.07; 95% CI=1.04, 1.11). The modest over estimation may be explained by the “healthy volunteer” selection bias of the UKB. Importantly, COSMO significantly improved predicted risk classification of women compared to the Gail when stratified according to actionable thresholds. (Table) Limitations to the validation include the lack of mammographic breast density data in the UKB—a critical factor in COSMO. To this end, we have an ongoing validation in a Nurses’ Health Study population (1,269 cases and 1,812 controls) that includes breast density data. Ongoing model comparison studies will confirm the equivalence of COSMO to standard clinical models. If performance is equivalent, COSMO has an advantage in clinical implementation because the abridged model can be less time consuming to implement in a general practice or screening clinic setting due to the truncated pedigree. Furthermore, as multiethnic cohort data access continues to improve, the epidemiological components can be recalibrated for application across any ethnicity. COSMO integrates the most impactful epidemiological risk factors, is well calibrated for the general population and provides improved discrimination over a standard risk model. General population risk assessment like COSMO can lead to the identification of more women who would benefit from clinical intervention based on current risk-reduction guidelines. Beyond that, incidental by products of a general population risk assessment include promoting breast cancer awareness, empowering women to understand their own risk, and encouraging all women to consider their lifestyle habits. Citation Format: Erika Spaeth, Gillian Dite, Richard Allman. Validation of abridged breast cancer risk assessment model for the general population [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P2-10-06.

Patient-centred care during the COVID-19 pandemic: Protocol for a qualitative collective case study by high‑performing general practice teams.

The COVID-19 pandemic has changed the way general practice teams interact with patients. This protocol article describes the rationale and design of anexploration of the experiences and perceptions of patient-centred care (PCC) by high-functioning general practice teams in Australia. A qualitative descriptive approach and collective case study method will be used. Potential participants are individuals representing a high-functioning general practice team, who will be asked to participate in a semi-structured interview. Eligible general practice clinics have received a 'Practice of the Year' award or commendation from The Royal Australian College of General Practitioners or Australian General Practice Accreditation Limited. Interview data will be analysed thematically, with constant comparison and meta-synthesis. Collective case study research is valuable because it enables rich exploration of PCC within the context of the pandemic. Rapid research on PCC may highlight new approaches towards the delivery ofPCC.

COVID-19 pandemic: an assessment of risk perception and the implementation of precautionary measures in a group of primary care workers in Nigeria

SummaryIntroductionThe world is currently faced with the challenge of the COVID-19 pandemic, with healthcare workers at high risk of contracting infection. This study assessed the risk perception of COVID-19 and practice of precautionary measures against its spread by primary care workers.MethodsThis was a descriptive cross-sectional study of primary care workers in the General Practice Clinic (GPC) of University of Benin Teaching Hospital (UBTH), Nigeria, sub-Saharan Africa. A pretested self-administered semi-structured questionnaire was employed to obtain data on Socio-demographic characteristics, Risk perception of COVID-19, and Practice of precautionary measures from the respondents. Obtained data were analysed using IBM SPSS Statistics version 22.0 (Chicago, IL, USA). Chi-square test, Ordinal regression analysis and logistic regression analysis were performed. A p-value of less than 0.05 was considered statistically significant. Ethical clearance was obtained from the Health Research Ethics Committee.ResultsMost respondents (39.6%) had moderate risk perception of COVID-19. High risk perception was more frequent in females than males (27.8 vs 11.9%; Chi-square test; p-value = 0.001). Majority (76.0%) of the respondents had good practice of precautionary measures against COVID-19.ConclusionsMost HCWs surveyed in this study had moderate-risk perception of COVID-19 and good practice of precautionary measures. It is recommended that formal training and retraining on Infection Prevention and Control (IPC) of infections, including COVID-19, should be regularly provided for all cadres of healthcare staff.

Bio-psycho-social characteristics and impact of musculoskeletal pain in one hundred children and adolescents consulting general practice

BackgroundEight percent of all child and adolescent general practice consultations are due to musculoskeletal conditions, with pain as the most frequent symptom. Despite the commonality of musculoskeletal pain, limited knowledge exists about care-seeking children and adolescents with musculoskeletal pain.The purpose of this study was to describe characteristics of children and adolescents consulting their general practitioner with musculoskeletal pain.MethodsThis is a cross-sectional study based on baseline data from the child and adolescent musculoskeletal pain cohort study (ChiBPS), carried out in 17 Danish general practice clinics. Patients aged 8–19 years who had musculoskeletal pain when consulting their general practitioner were recruited. Participants completed a questionnaire on demographics, physical activity, pain impact, psychosocial factors, and expectations of their general practitioner. Descriptive statistics were used to summarize data. Normally distributed continuous data were described using mean and standard deviation while non-normally data were described using median and interquartile range (IQR).ResultsWe included 100 participants (54% female, median age 13 [IQR: 12–16.5 years]). Frequent pain sites limiting activity were knee (56%), back (20%), ankle (19%), and neck (13%). Most participants (63%) consulted their general practitioner due to inability to use their body as usual, due to pain. Median pain duration at consultation was 5 months [IQR: 3 weeks-1 year]. More than a third were often/sometimes nervous (34%), worried or anxious (33%), and took pain medication (33%). Pain impeded ability to participate in sport activities at school (79%) and disturbed spare time activities (88%). Pain also made it difficult to concentrate for 58%, and to fall asleep for 38%. Only 38% expected a pain free long-term future.ConclusionThis study demonstrates the bio-psycho-social impact of musculoskeletal pain in care-seeking children and adolescents. Demographics, pain characteristics, psychosocial characteristics, and physical characteristics should be included in addressing children and adolescents with musculoskeletal pain.Trial registrationThe ChiBPS study was pre-registered before participant recruitment (ClinicalTrials.gov Identifier: NCT03678922) date: 09.20.18.

The M-CHooSe pilot: the acceptability and utilisation of the nurse-led, general practice clinic co-located 'Mater CALD Healthcare Coordinator Service' for patients from multicultural backgrounds.

Patients from culturally and linguistically diverse (CALD) backgrounds often have unmet healthcare coordination needs. We aimed to evaluate the acceptability, utilisation and perceived benefits of the Mater CALD Health Coordinator Service (M-CHooSe), a pilot, nurse-led, general practice co-located, healthcare coordination service for patients from CALD backgrounds. M-CHooSe began in March 2020 at five Brisbane (Queensland) sites. Process and service user data were collected over 12months at one site. A survey evaluated primary healthcare professionals' perceived benefits of the service. Another survey of M-CHooSe nurses examined indicators of service complexity. In total, 206 individuals accessed M-CHooSe over the 12-month period. Commonly delivered services included health service advocacy, chart reviews and health system navigation, including addressing social determinants. M-CHooSe nurses reported frequently performing tasks such as following up with external health services and performing health and social care system coordination. M-CHooSe benefits reported by primary healthcare professionals included better patient access to external health services and improved patient understanding of their conditions and treatments. Patients were accepting of referrals to M-CHooSE. Primary healthcare professionals also reported a variety of benefits to themselves and their patients because of M-CHooSe. M-ChooSe highlights the potential of a healthcare coordination service for multicultural patients to improve healthcare equity, accessibility, and system efficiency. This project demonstrates the potential value of coordination services to increase patient access and uptake of existing health and social care services for modern Australian communities, thus improving the efficiency and effectiveness of our health system. Further investigations, including user experience, opinions and cost analyses, will be required to confirm the promising benefits of embedding M-CHooSe into usual care.

Should I stay or should I go? Observation post-vaccination during the COVID-19 pandemic and the law of unintended consequences.

Standard practice after all vaccinations in Australia is to observe patients for 15min. During the coronavirus disease 2019 (COVID-19) pandemic, could the risk of contracting and dying from COVID-19 acquired in the waiting room be greater than the risk of dying from post-vaccine anaphylaxis when leaving immediately? The risks are modelled for a patient aged 70+years attending for annual influenza vaccination in a typical Australian general practice clinic. The risk of death from anaphylaxis is estimated based on known rates of anaphylaxis shortly after influenza vaccination. The risk of acquiring COVID-19 during a 15-min wait and then dying from that infection is estimated using the COVID-19 Aerosol Transmission Estimator and COVID-19 Risk Calculator. Other than at times of extremely low COVID-19 prevalence, the risk of death from anaphylaxis for a patient aged 70+years leaving immediately after influenza vaccine is less than the risk of death from COVID-19 acquired via aerosol transmission during a 15-min wait. The risk of death from COVID-19 is greatest for the unimmunised and when masks are not worn. A more nuanced approach to advice post-vaccination is recommended that considers current COVID-19 prevalence and virulence, the characteristics of the waiting room, the risk of anaphylaxis, and the patient's susceptibility to death from COVID-19. There are many circumstances where it would be safer for a patient to leave immediately after vaccination.

Assessment of the knowledge, practice, and perception of COVID-19 among patients attending the General Practice Clinic of a tertiary hospital in South-South, Nigeria

Assessment of the knowledge, practice, and perception of COVID-19 among patients attending the General Practice Clinic of a tertiary hospital in South-South, Nigeria

Patient‐reported outcome measures (PROMs) to guide clinical care: recommendations and challenges

PROMs collection is encouraged to involve patients in their health care The patient is the most reliable reporter of their symptoms, function and health-related quality of life, and can provide a holistic viewpoint of the benefits and risks of treatments or the severity of their conditions. Including the patient’s voice is critical for shared decision making and patient-centred care. Patient-reported outcomes (PROs) are defined as “any report of the status of a patient’s health condition that comes directly from the patient, without interpretation of the patient’s response by a clinician or anyone else”.1 Patient-reported outcome measures (PROMs) are validated tools or questionnaires used to collect PROs. PROMs can complement traditional methods of clinical assessment, such as medical history and physical examination. The use of systematically collected PROMs to inform the delivery of care has been researched for many years,2, 3 with patient and health service impacts including reduced symptom burden, improved quality of life and increased survival of patients with advanced cancer,4 and reduced emergency department presentations in a broad population of patients with cancer.5 As research suggests, the collection of PROMs in the clinical setting could better measure differences in the effects of health care interventions.6 PROMs collection is encouraged in the 2020–25 National Health Reform Agreement to empower patients to be involved in their health care, improve care across the health system, and focus on outcomes that matter to patients.7 This article outlines recommendations from the Health Services Research Association of Australia and New Zealand (HSRAANZ) for implementing PROMs to guide clinical care. It also describes the challenges that may arise and future research that may assist in the effective implementation of PROMs. The recommendations presented in this article have been developed by members of the HSRAANZ PROMs Special Interest Group. Health systems are encouraged to provide incentives to clinicians and practices (eg, funding through the National Health Reform Agreement) to implement these measures effectively. This will motivate clinicians to routinely incorporate their patients’ perspective into their busy schedules. They will be more likely to implement PROMs if there is a benefit to patient care and their clinical practice, by making care easier and more timely and reducing the administrative burden. There are several challenges to consider when integrating PROMs into clinical care. As patients are recruited to PROMs collection, challenges can arise at different time points through the journey of their care (Box). It is important to note that while these exist, they are not insurmountable and can be overcome with further research on implementation in general practice and hospital clinics. Already, research into the integration of PROMs in clinical care in Australia has shown that implementation is feasible and effective. The New South Wales Agency for Clinical Innovation Patient Reported Measures program completed a pilot study8 and demonstrated the feasibility of implementing PROMs in local health districts, community services and general practice. Principles to support the analysis and use of PROMs have been developed.9 CALD = culturally and linguistically diverse population. CALD = culturally and linguistically diverse population. There is increased focus by health care systems to improve the value of care in terms of both value for investment and outcomes that patients value. Embedding patient-reported measures into the clinical setting is a key component towards achieving this. Further research is underway to evaluate the applicability and benefits and harms of collecting PROMs in routine clinical care.10 Future research should focus on investigating the feasibility of prompt feedback of patient-reported data to clinicians and incorporating the results of patient-reported measures into clinical practice. With advances in technology and increased engagement by clinicians and health systems, the implementation of PROMs will be a routine part of health care provision in the future. Rachael Morton receives salary support from a University of Sydney Robinson Fellowship and a National Health and Medical Research Council Investigator Award (APP1194703). The funding source has no role in the planning, writing or publication of this work. No relevant disclosures. Not commissioned; externally peer reviewed.

Rates of diabetic retinopathy screening in pregnant patients with type 1 and type 2 diabetes in a predominantly Indigenous Central Australian population

Pregnancy is a risk factor for the progression of diabetic retinopathy (DR) in women with pre-gestational diabetes. Australian screening guidelines recommend DR screening in the first trimester of pregnancy. The rates of DR screening in pregnant patients with pre-gestational diabetes are unknown in Australia. To determine the rates of DR screening in pregnant women with pre-gestational diabetes at Alice Springs Hospital Diabetes Antenatal Care and Education (DANCE) clinic. Retrospective review of women with pre-gestational diabetes who attended the DANCE clinic between July 2016 and June 2020. There were 146 pregnancies in 144 individual women included in this review. There were 93% (n=134) who identified as Aboriginal but not Torres Strait Islander. DR screening was performed in 23 (16%) pregnancies, in which DR was present in six (26%) and no retinal abnormality was found in 17 (74%). Of seven (5%) women who had a history of DR, only three had a screen during the pregnancy period. The location of the DR screen included Alice Springs Hospital (17%, n=4), Alice Springs general practice clinics (35%, n=8) and remote NT community clinics outside of Alice Springs (39%, n=9). The trimesters in which women received their DR screens were: trimester 1, 45%, n=10; trimester 2, 39%, n=9; trimester 3, 17%, n=4. The minority of pregnant women who attend the DANCE clinic at Alice Springs Hospital received DR screening in adherence with national guidelines.

Guidance for Implementing Video Consultations in Danish General Practice: Rapid Cycle Coproduction Study.

BackgroundThe COVID-19 pandemic has changed various spheres of health care. General practitioners (GPs) have widely replaced face-to-face consultations with telephone or video consultations (VCs) to reduce the risk of COVID-19 transmission. Using VCs for health service delivery is an entirely new way of practicing for many GPs. However, this transition process has largely been conducted with no formal guidelines, which may have caused implementation barriers. This study presents a rapid cycle coproduction approach for developing a guide to assist VC implementation in general practice.ObjectiveThe aim of this paper is to describe the developmental phases of the VC guide to assist general practices in implementing VCs and summarize the evaluation made by general practice users.MethodsThe development of a guide for VC in general practice was structured as a stepped process based on the coproduction and prototyping processes. We used an iterative framework based on rapid qualitative analyses and interdisciplinary collaborations. Thus, the guide was developed in small, repeated cycles of development, implementation, evaluation, and adaptation, with a continuous exchange between research and practice. The data collection process was structured in 3 main phases. First, we conducted a literature review, recorded observations, and held informal and semistructured interviews. Second, we facilitated coproduction with stakeholders through 4 workshops with GPs, a group interview with patient representatives, and individual revisions by GPs. Third, nationwide testing was conducted in 5 general practice clinics and was followed by an evaluation of the guide through interviews with GPs.ResultsA rapid cycle coproduction approach was used to explore the needs of general practice in connection with the implementation of VC and to develop useful, relevant, and easily understandable guiding materials. Our findings suggest that a guide for VCs should include advice and recommendations regarding the organization of VCs, the technical setup, the appropriate target groups, patients’ use of VCs, the performance of VCs, and the arrangements for booking a VC.ConclusionsThe combination of coproduction, prototyping, small iterations, and rapid data analysis is a suitable approach when contextually rich, hands-on guide materials are urgently needed. Moreover, this method could provide an efficient way of developing relevant guide materials for general practice to aid the implementation of new technology beyond the pandemic period.

Feasibility Study for a Randomised Controlled Trial for the Topical Treatment of Impetigo in Australian General Practice.

Impetigo affects millions of children worldwide. Most guidelines recommend antibiotics as first-line treatment; however, topical antiseptics present a potentially valuable, understudied, antibiotic-sparing treatment for mild impetigo. We aimed to determine the feasibility of a randomised controlled trial (RCT) comparing efficacy of soft white paraffin (SWP), hydrogen peroxide (H2O2) and mupirocin for mild impetigo. Participants were recruited from general practices and randomly assigned one of three treatments. Size and number of lesions were measured at the initial consultation and day six. Post-recruitment, interviews with general practitioners were transcribed and themes identified to determine protocol acceptability, recruitment barriers and avenues to improve delivery. Two participants received SWP (n = 1) and mupirocin (n = 1). Both commenced oral antibiotics following failure of assigned topical treatment in which lesions increased in size or number. Recruitment barriers included reduced presentation of impetigo due to COVID-19, pre-treatment with existing at-home medications and moderate/severe infection. Childcare centers and pharmacies were identified as alternative venues to improve the recruitment rate. Valuable insight was gained into the practicality of conducting a RCT of impetigo treatments in general practice. Future trials should consider recruiting outside of general practice clinics to capture patients at earlier, more mild stages of infection. Further investigation into the prevalence and impact of use of at-home expired antibiotics may be beneficial.

Patients' assessment of care for type 2 diabetes: Results of the Patient Assessment of Chronic Illness Care scale in a Danish population

BackgroundThe Patient Assessment of Chronic Illness Care (PACIC) scale is the most appropriate for assessing self-reported experience in chronic care. We aimed to validate the PACIC questionnaire by (1) assess patients’ perception of the quality of care for Danish patients with type 2 diabetes, (2) identify which factors are most important to the quality of care designated by the five subscales in PACIC, and (3) the validity of the questionnaire.MethodsA survey of 7,745 individuals randomly selected from the National Diabetes Registry. Descriptive statistics inter-item and item-rest correlations and factor analysis assessed the PACIC properties. Quality of care was analysed with descriptive statistics; linear and multiple regression assessed the effect of forty-nine covariates on total and subscale scores.ResultsIn total, 2,696 individuals with type 2 diabetes completed ≥ 50 % of items. The floor effect for individual items was 8.5–74.5 %; the ceiling effect was 4.1–47.8 %. Cronbach’s alpha was 0.73–0.86 for the five subscales. The comparative fit index (CFI) and the Tucker–Lewis index (TLI) were 0,87, and 0,84, respectively. Mean PACIC score was 2.44 (± 0.04). Respondents, who receive diabetes care primarily at general practice and outpatient clinics had higher scores compared to those receiving care at a private specialist. Receiving rehabilitation was followed by higher scores in all subscales. Those 70 years or older had lower mean total and subscale scores compared to younger patient groups.A higher number of diabetes visits were associated with higher total scores; a higher number of emergency department visits were associated with lower total scores. The effects of healthcare utilisation on subscale scores varied.ConclusionsThese results provide insight into variations in the quality of provided care and can be used for targeting initiatives towards improving diabetes care. Factors important to the quality of perceived care are having a GP or hospital outpatient clinic as the primary organization. Also having a higher number of visits to the two organizations are perceived as higher quality of care as well as participating in a rehabilitation program. Floor and ceiling effects were comparable to an evaluation of the PACIC questionnaire in a Danish population. Yet, floor effects suggest a need for further evaluation and possible improvement of the PACIC questionnaire in a Danish setting. Total PACIC scores were lower than in other healthcare systems, possible being a result of different contexts and cultures, and of a need for improving diabetes care in Denmark.

Antimicrobial stewardship in Australia: the role of qualitative research in programme development.

Antimicrobial stewardship (AMS) in Australia is supported by a number of factors, including enabling national policies, sectoral clinical governance frameworks and surveillance programmes, clinician-led educational initiatives and health services research. A One Health research programme undertaken by the National Centre for Antimicrobial Stewardship (NCAS) in Australia has combined antimicrobial prescribing surveillance with qualitative research focused on developing antimicrobial use-related situational analyses and scoping AMS implementation options across healthcare settings, including metropolitan hospitals, regional and rural hospitals, aged care homes, general practice clinics and companion animal and agricultural veterinary practices. Qualitative research involving clinicians across these diverse settings in Australia has contributed to improved understanding of contextual factors that influence antimicrobial prescribing, and barriers and facilitators of AMS implementation. This body of research has been underpinned by a commitment to supplementing ‘big data’ on antimicrobial prescribing practices, where available, with knowledge of the sociocultural, technical, environmental and other factors that shape prescribing behaviours. NCAS provided a unique opportunity for exchange and cross-pollination across the human and animal health programme domains. It has facilitated synergistic approaches to AMS research and education, and implementation of resources and stewardship activities. The NCAS programme aimed to synergistically combine quantitative and qualitative approaches to AMS research. In this article, we describe the qualitative findings of the first 5 years.

Identifying adults at high-risk for change in weight and BMI in England: a longitudinal, large-scale, population-based cohort study using electronic health records

SummaryBackgroundTargeted obesity prevention policies would benefit from the identification of population groups with the highest risk of weight gain. The relative importance of adult age, sex, ethnicity, geographical region, and degree of social deprivation on weight gain is not known. We aimed to identify high-risk groups for changes in weight and BMI using electronic health records (EHR).MethodsIn this longitudinal, population-based cohort study we used linked EHR data from 400 primary care practices (via the Clinical Practice Research Datalink) in England, accessed via the CALIBER programme. Eligible participants were aged 18–74 years, were registered at a general practice clinic, and had BMI and weight measurements recorded between Jan 1, 1998, and June 30, 2016, during the period when they had eligible linked data with at least 1 year of follow-up time. We calculated longitudinal changes in BMI over 1, 5, and 10 years, and investigated the absolute risk and odds ratios (ORs) of transitioning between BMI categories (underweight, normal weight, overweight, obesity class 1 and 2, and severe obesity [class 3]), as defined by WHO. The associations of demographic factors with BMI transitions were estimated by use of logistic regression analysis, adjusting for baseline BMI, family history of cardiovascular disease, use of diuretics, and prevalent chronic conditions.FindingsWe included 2 092 260 eligible individuals with more than 9 million BMI measurements in our study. Young adult age was the strongest risk factor for weight gain at 1, 5, and 10 years of follow-up. Compared with the oldest age group (65–74 years), adults in the youngest age group (18–24 years) had the highest OR (4·22 [95% CI 3·86–4·62]) and greatest absolute risk (37% vs 24%) of transitioning from normal weight to overweight or obesity at 10 years. Likewise, adults in the youngest age group with overweight or obesity at baseline were also at highest risk to transition to a higher BMI category; OR 4·60 (4·06–5·22) and absolute risk (42% vs 18%) of transitioning from overweight to class 1 and 2 obesity, and OR 5·87 (5·23–6·59) and absolute risk (22% vs 5%) of transitioning from class 1 and 2 obesity to class 3 obesity. Other demographic factors were consistently less strongly associated with these transitions; for example, the OR of transitioning from normal weight to overweight or obesity in people living in the most socially deprived versus least deprived areas was 1·23 (1·18–1·27), for men versus women was 1·12 (1·08–1·16), and for Black individuals versus White individuals was 1·13 (1·04–1·24). We provide an open access online risk calculator, and present high-resolution obesity risk charts over a 1-year, 5-year, and 10-year follow-up period.InterpretationA radical shift in policy is required to focus on individuals at the highest risk of weight gain (ie, young adults aged 18–24 years) for individual-level and population-level prevention of obesity and its long-term consequences for health and health care.FundingThe British Hearth Foundation, Health Data Research UK, the UK Medical Research Council, and the National Institute for Health Research.

Diagnostic coding of chronic physical conditions in Irish general practice

BackgroundChronic conditions are responsible for significant mortality and morbidity among the population in Ireland. It is estimated that almost one million people are affected by one of the four main categories of chronic disease (cardiovascular disease, chronic obstructive pulmonary disease, asthma, and diabetes). Primary healthcare is an essential cornerstone for individuals, families, and the community and, as such, should play a central role in all aspects of chronic disease management.AimThe aim of the project was to examine the extent of chronic disease coding of four chronic physical conditions in the general practice setting.MethodsThe design was a descriptive cross-sectional study with anonymous retrospective data extracted from practices.ResultsOverall, 8.8% of the adult population in the six participating practices were coded with at least one chronic condition. Only 0.7% of adult patients were coded with asthma, 0.3% with COPD, 3% with diabetes, and 3.3% with CVD. Male patients who visited their GP in the last year were more likely to be coded with any of the four chronic diseases in comparison with female patients. A significant relationship between gender and being coded with diabetes and CVD was found.ConclusionsFor a likely multitude of reasons, diagnostic coding in Irish general practice clinics in this study is low and insufficient for an accurate estimation of chronic disease prevalence. Monitoring of information provided through diagnostic coding is important for patients’ care and safety, and therefore appropriate training and reimbursement for these services is essential.

The survey visit as a key evaluative event in accreditation\u2013a qualitative study of survey visit experiences among surveyors and general practice professionals

BackgroundAccreditation is a widely employed quality assurance concept in health care and the survey visit is the central method for assessing participating organisations’ compliance with accreditation standards. Despite this, research on the survey visit as a method for assessing compliance is scarce. In Denmark a mandatory accreditation programme was introduced for general practice clinics in 2016. We performed a qualitative, explorative study of the reflections and actions of surveyors and general practice professionals (GPs and staff) concerning the production of information about compliance with the accreditation standards in relation to the survey visit.MethodsWe conducted qualitative interviews with GPs and staff from general practices in two Danish regions before and after their survey visit. We also interviewed the surveyors. We observed survey visits to qualify the interviews and analysis. All interviews were audio recorded, transcribed, and analysed using an integrative approach.ResultsThe surveyors combined documents, questioning of the professionals, and visual impressions of the clinic to assess compliance. They sought to de-dramatise the survey visit and to generate a natural conversation with attention to workflows. Trust in the professionals’ statements was fundamental to the surveyors’ approach, and they were confident in their ability to assess compliance. Their level of scrutiny was influenced by their observations and the quality of documents. The general practice professionals had generally sought to comply with the standards and to give an authentic portrait of the clinic. The few cases of misrepresention concerned standards that the professionals found too excessive.ConclusionThe validity of the survey visit as a method to assess compliance was highly dependent on the professionals’ willingness to convey a realistic picture of their practice. Since they were generally willing to do so, the trust-based approach seemed suitable for identifying cases of non-compliance caused by insufficient understanding of the standards. However, it can be difficult for the surveyors to detect when the professionals engage in misrepresentation due to disagreements with the standards. Thus, when adopting a trust-based approach to the survey visit, it seems particularly important to ensure that the professionals view the standards as meaningful and manageable.

Cisgenderism and transphobia in sexual health care and associations with testing for HIV and other sexually transmitted infections: Findings from the Australian Trans & Gender Diverse Sexual Health Survey.

Transgender and gender diverse people have unique risks and needs in the context of sexual health, but little is known about sexual health care for this population. In 2018, a national, online survey of sexual health and well-being was conducted with trans and gender diverse people in Australia (n = 1,613). Data from this survey were analysed to describe uptake of sexual health care and experiences of interpersonal and structural cisgenderism and transphobia. Experiences of cisgenderism and transphobia in sexual health care were assessed using a new, four-item scale of 'gender insensitivity', which produced scores ranging from 0 (highly gender sensitive) to 4 (highly gender insensitive). Logistic and linear regression analyses were conducted to determine if experiences of gender insensitivity in sexual health care were associated with uptake and frequency of HIV/STI testing in the 12 months prior to participation. Trans and gender diverse participants primarily accessed sexual health care from general practice clinics (86.8%), followed by publicly funded sexual health clinics (45.6%), community-based services (22.3%), and general hospitals (14.9%). Experiences of gender insensitivity were common overall (73.2% of participants reported ≥2 negative experiences) but most common in hospitals (M = 2.9, SD = 1.3) and least common in community-based services (M = 1.3, SD = 1.4; p<0.001). When controlling for sociodemographic factors, social networks, general access to health care, and sexual practices, higher levels of gender insensitivity in previous sexual health care encounters were associated with a lower likelihood of recent HIV/STI testing (adjusted prevalence ratio = 0.92, 95% confidence interval [CI]:091,0.96, p<0.001) and less-frequent HIV/STI testing (B = -0.07, 95%CI:-0.10,-0.03, p = 0.007). Given the high rates of HIV and other STIs among trans and gender diverse people in Australia and overseas, eliminating cisgenderism and transphobia in sexual health care may help improve access to diagnostic testing to reduce infection rates and support the overall sexual health and well-being of these populations.

Patients' attitudes and intentions towards taking medical advice for type 2 diabetes mellitus: a theory of planned behaviour analysis.

A key component of effective diabetes care is understanding patients' perceptions about diabetes management. Patients' attitudes and intentions towards taking medical advice may predict the outcomes for effective diabetes care. This study aims to measure participants' attitudes, beliefs and intentions towards following medical advice to manage their diabetes using the Theory of Planned Behaviour (TPB). The domains of the TPB are correlated with clinical measures of diabetes to determine if these attitudes and intentions are predictive of better diabetes control. A pilot study was conducted. A 34-item survey was designed using the Theory of Planned Behaviour (TPB) framework and administered via mail by four general practice clinics. Included participants (N = 104; response rate 29.5%) had a diagnosis of type 2 diabetes and were taking medication for glycaemic control. Scores for each domain of the TPB survey were correlated with participants' clinical indicators for diabetes: HbA1c, blood pressure, lipid profile, cholesterol, and kidney health (eGFR and albumin: creatinine ratio) and BMI. Participants surveyed generally reported positive attitudes and intention to follow medical advice. Medical advice was perceived to be beneficial and useful by the majority. However, in general, there was no correlation between positive intentions and improved clinical indicators of disease. Clinical indicators did not improve with duration of illness. The burden of illness is likely a mitigating factor for positive intention as participants perceive medical advice as difficult and inconvenient to follow. Patients' individual capacity to implement medical advice should be addressed in shared-decision making models to potentially improve patient outcomes towards therapeutic targets.

Epidemiology of healthcare harm in New Zealand general practice: a retrospective records review study

ObjectivesTo determine the epidemiology of healthcare harm observable in general practice records.DesignRetrospective cohort records review study.Setting72 general practice clinics were randomly selected from all 988 New Zealand clinics stratified by...