General Practice Setting Research Articles

Frequency of arrhythmias detected in 9440 feline electrocardiograms by breed, age, and sex

ObjectivesThe purpose of this study was to describe the frequency of arrhythmias detected in unsedated feline patients from general practice settings. AnimalsA total 10,638 feline electrocardiograms (ECGs) were retrospectively collected of which 9440 met the inclusion criteria. MethodsRecordings were evaluated by a board-certified cardiologist. If an arrhythmia was present in the ECG tracing, the cardiologist categorized the arrhythmia using pre-established keywords. ResultsAt least one arrhythmia was observed in 249 cases (2.64%, 95% confidence interval (CI): 2.34–2.98, 249/9440), with the most common arrhythmia encountered being ventricular premature complexes (1.63%, 95% CI: 1.39%–1.91%, 154/9440). Ragdoll cats had the highest odds of arrhythmia (odds ratio (OR): 3.17, 95% CI: 1.43–6.17, P=0.036). Both geriatric (Age: 13+ years, OR: 1.70, 95% CI: 1.24–2.34, P=0.013) and senior (Age: 10–13 years, OR: 1.68, 95% CI: 1.19–2.37, P=0.003) cats had higher odds of having an arrhythmia than adult cats. The odds of male cats having an arrhythmia were slightly higher than female (OR: 1.36, 95% CI: 1.06–1.76, P=0.018). Conclusions and relevanceOf the 9440 ECGs included in this study, at least one arrhythmia was detected in 249 distinct cases. Arrhythmias were more common in older cats, male cats and the Ragdoll cat breed. While it is important to note that the presence of an arrhythmia alone does not always indicate the presence of heart disease, further research on the association between breed cardiac health is needed.

Abstract 16694: Impact of Frailty in Non-Valvular Atrial Fibrillation Elderly Patients on Anticoagulation Therapy

Background: As the number of elderly people increases, we see more chances to consider anticoagulant therapy for elderly people with frailty. Research Question: Does frailty affect the outcome of anticoagulation therapy? Goals: To show the impact of frailty to the effectiveness and safety of anticoagulant therapy with rivaroxaban in elderly Japanese non-valvular atrial fibrillation (NVAF) patients. Methods: The GENERAL (GENeral practitioners and Embolism pRevention in NVAF patients treated with RivAroxaban: real-Life evidence) study was an observational study of elderly NVAF patients with rivaroxaban at general practice settings in Japan. We employed multiple imputation for missing baseline characteristics, and propensity score (PS) matching to estimate the treatment effect of frailty accounting for the patients’ imbalance. In each imputed and PS matched data set, the treatment effects of frailty were assessed with Cox proportional hazard models for each outcome. Results: A total of 5,717 (mean 79.3 years old, male 64.8%) were observed for a mean of 2.0 years and up to 3 years. Of these, 485 (8.5%) were classified frailty. Variable missing rates ranged from 0% to 35%. After the imputation and matching, the patients' backgrounds were well matched and balanced between two groups. Frailty was not associated with the primary endpoint: stroke/systemic embolism (Hazard Ratio [HR] 1.128, 95% Confidence Interval [CI]: 0.500 - 2.547, p=0.767). Also, frailty was not associated with all-secondary endpoints (Figure 1). In the sensitivity analyses with the complete cases, the cases with any missing variables were deleted, frailty was significantly related with outcome events except for the bleeding events (Figure 2). Conclusion: In our study results, frailty did not affect the effectiveness or safety of anticoagulant therapy with rivaroxaban for this population. However, we should consider the necessity and benefit for this population to start anticoagulant therapy.

Acceptability of using the Raising Awareness Tool for Endometriosis (RATE) in general practice: a mixed methods pilot study.

The Raising Awareness Tool for Endometriosis (RATE) was developed to facilitate discussions with health providers regarding endometriosis-associated symptoms. We aim to evaluate the acceptability of the RATE by general practitioners (GP), including determining the prevalence of symptoms of women presenting to general practice and immediate management of symptoms. A mixed-methods study was undertaken using a combination of quantitative and qualitative data in Western Australian General Practices from 2021 to 2022. A purposive sample of 12 GPs were included, who recruited women (18-50 years) on attendance for consultation over a one- to two-week period, followed by qualitative interviews exploring GPs' experiences with the tool. The quantitative and qualitative components were integrated during analysis of results. A total of 111 women completed the RATE (mean: 33, standard deviation: 8.6 years) prior to routine consultation. The tool was considered to be acceptable for use in general practice and aided discussions on symptoms and management. Overall, 68.5% of patients experienced pelvic pain or discomfort, with 22.4% rating that this interfered with quality of life. Of those with pelvic pain, 75% had associated chronic pain conditions, and 42.1% reported allodynia. The chronic pain questions provoked GP uncertainty. After symptoms were identified, GPs arranged individualised investigations and follow-up. The RATE was considered to be acceptable for use in the general practice setting. It identified symptoms and initiated discussions on possible diagnosis as well as management of endometriosis. Further GP education on identifying those women at most risk of developing chronic pain syndromes is needed.

Diagnosis, assessment and management of atopic dermatitis in children with skin of colour.

It is important to be able to manage patients regardless of ethnicities. The understanding of skin diseases, including atopic dermatitis, in patients with skin of colour (SOC) is lagging compared with that in patients with lighter skin and has been identified as an educational gap among medical practitioners. This paper synthesises the latest literature on the diagnosis, assessment, treatment outcomes and cultural considerations for managing atopic dermatitis in children with SOC in the general practice setting. Atopic dermatitis in children with SOC can vary from traditional descriptions andappear psoriasiform, lichenoid, scaly, papular, hypopigmented or violaceous. Itcan be misdiagnosed and its severity underestimated. Complications from atopic dermatitis, as well as the treatments provided, might result in inadequate treatment unless the treating doctor is aware of specific nuances in children with SOC.

Factors affecting the experience of joined-up, continuous primary care in the absence of relational continuity: an observational study.

There is an international trend towards the at-scale provision of primary care services, with such services often provided in different settings by a clinician unfamiliar to the patient. It is often assumed that, in the absence of relational continuity, any competent clinician can deliver joined-up, continuous care if they have access to clinical notes. To explore the factors that affect the potential for providing joined-up, continuous care in a system where care is delivered away from a patient's regular practice, by a different organisation and set of staff. Case studies of two extended-access providers in the north of England. Case studies were carried out between September 2021 and January 2022 in two sites. Data collected included observations of patient-healthcare professional interactions, interviews with staff and patients, and documentation. Analysis took place using a constant comparison approach. Data were coded. A model of the factors affecting continuity was constructed. The potential for joined-up, continuous care appears dependent on staff, patient, and system factors. This includes diverse elements such as the attitude of clinicians to care coordination and the ability of an organisation to retain staff. Healthcare systems increasingly rely on the assumption that any competent clinician can deliver joined-up, continuous care if they have access to clinical notes. This appears not to be the case. This study presents a model of factors affecting the patient's experience of continuity. The model needs validating in in-hours general practice and other settings.

The SOFIA pilot study: assessing feasibility and fidelity of coordinated care to reduce excess mortality and increase quality of life in patients with severe mental illness in a general practice setting; a cluster-randomised pilot trial

ObjectiveTo evaluate the feasibility and fidelity of implementing and assessing the SOFIA coordinated care program aimed at lowering mortality and increasing quality of life in patients with severe mental illness by improving somatic health care in general practice.DesignA cluster-randomised, non-blinded controlled pilot trial.SettingGeneral Practice in Denmark.InterventionThe SOFIA coordinated care program comprised extended structured consultations carried out by the GP, group-based training of GPs and staff, and a handbook with information on signposting patients to relevant municipal, health, and social initiatives.PatientsPersons aged 18 years or older with a diagnosis of psychotic, bipolar, or severe depressive disorder.Main outcome measuresWe collected quantitative data on the delivery, recruitment and retention rates of practices and patients, and response rates of questionnaires MMQ and EQ-5D-5 L.ResultsFrom November 2020 to March 2021, nine practices were enrolled and assigned in a 2:1 ratio to the intervention group (n = 6) or control group (n = 3). Intervention group practices included 64 patients and Control practices included 23. The extended consultations were delivered with a high level of fidelity in the general practices; however, thresholds for collecting outcome measures, and recruitment of practices and patients were not reached.ConclusionOur findings suggest that delivering the coordinated care program in a fully powered trial in primary care is likely feasible. However, the recruitment methodology requires improvement to ensure sufficient recruitment and minimize selective inclusion.Trial registrationThe date of pilot trial protocol registration was 05/11/2020, and the registration number is NCT04618250.

‘Really putting a different slant on my use of a glass of wine’: patient perspectives on integrating alcohol into Structured Medication Reviews in general practice

Background Alcohol is often overlooked in primary care even though it has wide-ranging impacts. The Structured Medication Review (SMR) in England is a new ‘holistic’ service designed to tackle problematic polypharmacy, delivered by clinical pharmacists in a general practice setting. Implementation has been protracted owing to the COVID-19 pandemic. This study explores early patient experiences of the SMR and views on the acceptability of integrating clinical attention to alcohol as another drug linked to their conditions and medicines, rather than as a standalone ‘healthy living’ or ‘lifestyle’ question. Method Semi-structured interviews with a sample of 10 patients who drank alcohol twice or more each week, recruited to the study by five clinical pharmacists during routine SMR delivery. Results SMRs received were remote, brief, and paid scant attention to alcohol. Interviewees were interested in the possibility of receiving integrated attention to alcohol within a SMR that was similar to the service specification. They saw alcohol inclusion as congruent with the aims of a holistic medicines review linked to their medical history. For some, considering alcohol as a drug impacting on their medications and the conditions for which they were prescribed, introduced a new frame for thinking about their own drinking. Conclusions Including alcohol in SMRs and changing the framing of alcohol away from a brief check with little meaningful scope for discussion, toward being fully integrated within the consultation, was welcomed as a concept by participants in this study. This was not their current medication review experience.

Integration of social determinants of health information within the primary care electronic health record: a systematic review of patient perspectives and experiences.

Social determinants of health (SDOH) are the non-medical factors that impact health. Although geographical measures of deprivation are used, individual measures of social risk could identify those most at risk and generate more personalised care and targeted referrals to community resources. We know SDOH are important to health care, but it is not yet known whether their collection via the electronic health record (EHR) is acceptable and useful from the patient perspective. To synthesise relevant literature to explore patient perspectives on integrating information about SDOH into primary care EHRs, and the opportunities and challenges of its implementation in a general practice setting. Systematic review of primary care-based qualitative and mixed-method studies using thematic framework analysis. Key databases were searched for articles reporting patient perspectives of SDOH collection within the primary care EHR. Qualitative and mixed-methods studies written in English were included. A framework analysis was conducted to identify themes. From 14 included studies, the following five main themes were identified: rationale for SDOH screening and the anticipated outcomes; impact of the provider-patient relationship on patient perceptions; data, which included privacy concerns; screening process and referral; and recommendations for future research. Integration of information on SDOH into the EHR appears acceptable to patients. This review has added to the discussion of whether and how to implement SDOH screening and referral programmes into UK primary care systems.

Supporting primary care through symptom checking artificial intelligence: a study of patient and physician attitudes in Italian general practice

BackgroundRapid advancements in artificial intelligence (AI) have led to the adoption of AI-driven symptom checkers in primary care. This study aimed to evaluate both patients' and physicians' attitudes towards these tools in Italian general practice settings, focusing on their perceived utility, user satisfaction, and potential challenges.MethodsThis feasibility study involved ten general practitioners (GPs) and patients visiting GP offices. The patients used a chatbot-based symptom checker before their medical visit and conducted anamnestic screening for COVID-19 and a medical history algorithm concerning the current medical problem. The entered data were forwarded to the GP as medical history aid. After the medical visit, both physicians and patients evaluated their respective symptoms. Additionally, physicians performed a final overall evaluation of the symptom checker after the conclusion of the practice phase.ResultsMost patients did not use symptom checkers. Overall, 49% of patients and 27% of physicians reported being rather or very satisfied with the symptom checker. The most frequent patient-reported reasons for satisfaction were ease of use, precise and comprehensive questions, perceived time-saving potential, and encouragement of self-reflection. Every other patient would consider at-home use of the symptom checker for the first appraisal of health problems to save time, reduce unnecessary visits, and/or as an aid for the physician. Patients’ attitudes towards the symptom checker were not significantly associated with age, sex, or level of education. Most patients (75%) and physicians (84%) indicated that the symptom checker had no effect on the duration of the medical visit. Only a few participants found the use of the symptom checker to be disruptive to the medical visit or its quality.ConclusionsThe findings suggest a positive reception of the symptom checker, albeit with differing focus between patients and physicians. With the potential to be integrated further into primary care, these tools require meticulous clinical guidance to maximize their benefits.Trial registrationThe study was not registered, as it did not include direct medical intervention on human participants.

Knowledge, attitudes and practices of general practitioners and paediatricians towards Group A beta-haemolytic streptococcal tonsillopharyngitis: A cross-sectional study from Türkiye.

General practitioners (GPs) and paediatricians are very important in the management of sore throat in terms of providing correct diagnosis and treatment. The aim of this study was to evaluate the knowledge, attitudes and practices of GPs and paediatricians towards Group A beta-haemolytic streptococcal (GABHS) tonsillopharyngitis. Three vignettes/case studies, in which the causative agents were GABHS, Epstein-Barr virus (EBV) and non-EBV viral infection, were presented as part of a questionnaire sent to paediatricians and GPs to elicit information regarding their diagnosis and treatment of tonsillopharyngitis. In all, 236 physicians responded to the questionnaire (126 paediatricians, 106 GPs). GPs registered more accurate diagnoses of GABHS tonsillopharyngitis and tended to administer more symptomatic treatment in the case of non-EBV tonsillopharyngitis than paediatricians. Paediatricians requested more tests in the diagnosis of GABHS tonsillopharyngitis than GPs. Most GPs and paediatricians possess adequate knowledge regarding GABHS diagnosis and the differential diagnosis of patients. Differences between the hospital and general practice settings may have affected the approach to symptomatic treatment and requesting tests.

Developing consensus on the principles and key actions for collaborative working between general practices and community pharmacies: a modified eDelphi study

ObjectivesTo develop consensus on the principles and key actions for collaborative working in practice between general practice, community pharmacy and patients and their carers.DesignThree-round modified eDelphi study, starting from an...

Classification of the implant-ridge relationship utilizing the MobileNet architecture

Background/purposeProper implant-ridge classification is crucial for developing a dental implant treatment plan. This study aimed to verify the ability of MobileNet, an advanced deep learning model characterized by a lightweight architecture that allows for efficient model deployment on resource-constrained devices, to identify the implant-ridge relationship. Materials and methodsA total of 630 cone-beam computerized tomography (CBCT) slices from 412 patients were collected and manually classified according to Terheyden's definition, preprocessed, and fed to MobileNet for training under the conditions of limited datasets (219 slices, condition A) and full datasets (630 cases) without and with automatic gap filling (conditions B and C). ResultsThe overall model accuracy was 84.00% in condition A and 95.28% in conditions B and C. In condition C, the accuracy rates ranged from 94.00 to 99.21%, with F1 scores of 89.36–100.00%, and errors due to unidentifiable bone-implant contact and miscellaneous reasons were eliminated. ConclusionThe MobileNet architecture was able to identify the implant-ridge classification on CBCT slices and can assist clinicians in establishing a reliable preoperative diagnosis and treatment plan for dental implants. These results also suggest that artificial intelligence-assisted implant-ridge classification can be performed in the setting of general dental practice.

Understanding primary care perspectives on supporting women's health needs: a qualitative study.

A consultation for the Women's Health Strategy for England in 2022 highlighted a need to understand and develop how general practice can support women's health needs. To understand the perspectives and experiences of primary care practitioners (PCPs) about supporting women's healthcare needs. Interpretive qualitative research set in general practice in England. PCPs working in general practice settings were recruited through research and professional networks. Semi-structured interviews were conducted via telephone or Microsoft Teams, audiorecorded, transcribed verbatim, and analysed through reflexive thematic analysis. In total, 46 PCPs were interviewed. Participants had a range of roles and worked in a variety of primary care settings. Results are presented within six themes: 1) being alongside a person from cradle to grave; 2) maintaining the balance between general and specialist skills; 3) generalists and specialists combined make more than the sum of their parts; 4) striving for equity in a collapsing system; 5) firefighting with limited resources; and 6) the GP is being cast as the villain. The findings show that relationships and advocacy are valued as fundamental for women's health in general practice, and highlight the adverse impact of threats to these on staff and services. Developing specialist roles and bespoke services can foster staff wellbeing and could support retention. However, care is needed to ensure that service configuration changes do not result in clinician deskilling or rendering services inaccessible. Care is needed when services evolve to ensure that core aspects of general practice are not diminished or devalued. GP teams are well placed to advocate for their patients, including commitment to seeking equitable care, and these skills and specialist knowledge should be actively recognised, valued, and nurtured.

Glycaemic monitoring and control among high-risk patients with type 2 diabetes in Australian general practice during COVID-19

BackgroundThe COVID-19 pandemic disrupted general practice worldwide, primarily due to public health measures that restricted access to care for chronic diseases, such as type 2 diabetes. These measures disproportionately affected...

A review of pharmacy‐led interventions: identification of facilitators and barriers for the design of a new model of care for asthma

AbstractThe objective of this narrative review was to determine the facilitators and barriers identified in pharmacy‐led interventions that improve outcomes in patients with asthma and support the implementation of interventions in practice. EMBASE, Web of Science, Google Scholar, and PubMed were used to identify 17 relevant articles. Seven studies were randomised controlled studies and 10 were one‐arm, pre‐post evaluations of all participants enrolled. Questionnaires assessing asthma control, medicine adherence, and knowledge about asthma were used, while checklists were used to assess inhaler technique. Studies with planned interventions in a clinic or general practice setting and lasting for 6 months (compared to longer interventions of 48 weeks) were more successful in retaining participation in the program. Education was the key intervention in which inhaler technique training was the most common. Knowledge about the disease, its aetiology, trigger factors, and medication used were covered in 10 of the studies. Fifteen of the articles reported an improvement in the asthma of patients receiving intervention by the pharmacist, measured by their asthma control test scores, emergency department visits, or reduced emergency steroid prescriptions. This review highlights five key requirements for the success of pharmacy‐based interventions for asthma management: (a) developing and maintaining a skilled workforce; (b) close proximation of a general practitioner practice or clinic to the pharmacy; (c) patient education on the disease and medicine; (d) structured and standardised intervention and assessment; and (e) length of the intervention suitable to the pharmacist and the patient.

Risk factors and incidence rate of complications originated as a consequence of the acute SARS-CoV-2 infection or the treatments performed. A longitudinal study in general medicine from March 15, 2020 to October 31, 2022 in Toledo, Spain

Background: The epidemiological data on complications originated as a consequence of the acute infection of COVID-19 or the treatments performed are not well known. Objectives: To estimate the incidence rate and the risk factors of complications originating as a consequence of the acute infection of COVID-19 or the treatments performed in general practitioner consultation. Methodology: A prospective study of patients with COVID-19 in a general practice setting in Toledo, Spain, from March 15, 2020, to October 31, 2022. Results: 687 positive cases of acute COVID-19 were diagnosed. Of these, 36 (36% were women and 39% had >=65 years old) presented complications, which represents a gross incidence rate of 5%. In >=65 years old, the incidence rate was 23%. The incidence rate of complications was much higher in 2020 vs. 2021 and 2022 (21%, 5%, and 1% cases, respectively). The only statistically significant risk factors were aged > = 65 years (RR = 2.46), having presented moderate-severe severity of primary infection (RR = 14.54) having chronic diseases (RR = 3.11), and specifically of the circulatory system (RR = 1.98). Conclusion: In the context of general medicine in Toledo (Spain) incidence rate of complications originated as a consequence of acute infection of COVID-19 or the treatments performed, was higher in cases with acute infection in 2020, and in >=65 years old, and are risk factors having presented moderate-severe severity of primary infection, having chronic diseases, and specifically of circulatory system, and being >= 65 years old.

Implementation of a group-based lifestyle intervention programme (Healthy Heart) in general practices in The Netherlands: a mixed-methods study.

Lifestyle intervention programmes target behavioural risk factors that contribute to cardiovascular diseases (CVDs). Unfortunately, sustainable implementation of these programmes can be challenging. Gaining insights into the barriers and facilitators for successful implementation is important for maximising public health impact of these interventions. The Healthy Heart (HH) programme is an example of a combined lifestyle intervention programme. To analyse the reach, adoption, and implementation of the HH programme. A mixed-methods study conducted in a general practice setting in The Netherlands. Quantitative data were collected from the Healthy Heart study (HH study), a non-randomised cluster stepped-wedge trial to assess the effect of the HH programme on patients at high risk of developing CVDs at practice level. Qualitative data were obtained through focus groups. Out of 73 approached general practices, 55 implemented the HH programme. A total of 1082 patients agreed to participate in the HH study, of whom 64 patients were referred to the HH programme and 41 patients participated. Several barriers for participation were identified such as time investment, lack of risk perception, and being confident in changing lifestyle on their own. Important barriers for healthcare providers (HCPs) to refer a patient were time investment, lack of information to sufficiently inform patients, and preconceived notions regarding which patients the programme was suitable for. This study has offered insights from a patient and HCP perspective regarding barriers and facilitators for implementation of the group-based lifestyle intervention programme. The identified barriers and facilitators, and the suggested improvements, can be used by others who wish to implement a similar programme.

Review of adult gender transition medications: mechanisms, efficacy measures, and pharmacogenomic considerations.

Gender dysphoria is the imparity between a person's experienced gender and their birth-assigned gender. Gender transition is the process of adapting a person's sexual characteristics to match their experienced gender. The number of adults receiving sex hormone therapy for gender dysphoria is increasingly and these pharmacotherapies are increasing being prescribed in a general practice setting. The role of hormone therapy is to reverse or reduce physical sexual characteristics of the birth-assigned gender and enhance and build characteristics aligning to the expressed gender and these therapies apply to both transgender and gender nonconforming patients. Recognizing the options and interpreting the effects of gender transition therapies are fundamental to the discussion and treatment of gender dysphoria. This review summarizes pharmacodynamics, comparative dosing, adverse effects, monitoring, and potential pharmacogenetic influence of current pharmacotherapy. These include the use of 17-beta-estradiol, spironolactone, testosterone, GnRH agonists as well as adjunctive phosphodiesterase-5 inhibitors. The article also addresses gaps within the published literature including optimal routes of administration for individual patients, risks of malignancy and dosing reductions as transgender patients age.

Streptococcal infections (Strep A) in primary care settings

In December 2022, there was a reported increase in the number of infections in the UK, resulting in deaths of young children, occurring as a result of invasive Strep A infections. Margaret Perry explains how these infections can be managed in a general practice setting. Group A streptococcal infections (GAS) are reported to be common and are often carried on the skin or in the throat and are harmless. However, in some cases they cause infection which may be mild, or in some cases the problem becomes invasive (iGAS) resulting in a more serious infection requiring hospital admission and treatment. This article will give an overview of the commonest infections arising as a result of GAS and will look at signs and symptoms, treatment, and complications, with the aim of increasing confidence among practice nurses and non-medical prescribers in the recognition and management of these conditions.

Can extended duties dental nurses (EDDNs) as oral health educators (OHEs) be beneficial for the practice and morale?

Jo Dawson explores what it is like to use the Oral Health Education qualification in a general dental practice setting and the empowering opportunities it can offer patients and staff. Aim To have a better understanding of the advantages of using EDDN OHEs in general dental practice. Objectives To have an increased awareness of the role of an oral health educator. To understand what benefits offering an OHE service could bring to a dental practice. To look at examples using EDDN OHEs and the impact they have had on Dental Nurse's self-esteem and their standing within the practice team.