Participation Of General Practitioners Research Articles

Supporting GPs and people with hypertension to maximise medication use to control blood pressure: a pilot cluster RCT of the MIAMI intervention

BackgroundHypertension, or high blood pressure, is a key modifiable risk factor for heart disease and stroke. International guidelines have highlighted ‘poor adherence to treatment’ and ‘physician inertia’ as major barriers to effective blood pressure management. The Maximising Adherence, Minimising Inertia (MIAMI) intervention, a theory-based complex intervention, supports General Practitioners (GPs) and people with hypertension in maximising medication use to manage blood pressure. This pilot cluster randomised control trial (RCT) aimed to collect and analyse feasibility data to refine the MIAMI intervention and assess the feasibility of a definitive RCT.MethodA pilot cluster RCT with a MIAMI intervention arm and usual care control arm was conducted. Quantitative data collection consisting of clinical measures and a self-report questionnaire took place at baseline and twelve week follow up. Semi-structured interviews with GP and patient participants were conducted. Fidelity (as measured by a protocol checklist and through qualitative interviews) and health economics costings were assessed.ResultsSix GP practices (intervention arm n = 3, control arm n = 3) and 52 patients (intervention arm n = 25, control arm n = 27) took part. All six GP practices and 92% of patients were retained. Fidelity, as measured by a checklist and through qualitative interviews, was good but three deviations from protocol were identified. Outcomes and measures used were acceptable. The implementation cost of the MIAMI intervention was estimated at €490 per participant. The qualitative data demonstrated that the intervention was considered acceptable and feasible by both GP and patient participants, except for the urine test component, which GPs found difficult to incorporate into practice due to logistical challenges.ConclusionsThe MIAMI intervention was considered largely acceptable and feasible. Some changes to both intervention components and trial processes are required but with these in place a definitive RCT could be considered worthwhile.Trial registrationISRCTN registry, ISRCTN85009436, registered 17/1/23.

International survey of people living with chronic conditions (PaRIS survey): effects of general practitioner non-participation on the representativeness of the Norwegian patient data

BackgroundThe International Survey of People living with Chronic Conditions (OECD-PaRIS survey), aims to systematically gather patient-reported experiences (PREMs) and - outcomes (PROMs) and potential predictors for these outcomes for persons with chronic conditions as well as information from professionals about health care provided. In such patient surveys, the advantages of a multilevel (nested) approach in which patients are sampled ‘within providers’ need to be balanced against the potential for bias if patient populations from participating GPs significantly differ from those of non-participating GPs. The objective was to assess the effects of general practitioner (GP) non-participation on the representativeness of the Norwegian patient data of the International Survey of People living with Chronic Conditions (OECD-PaRIS survey).MethodsTo test all aspects of the first main PaRIS survey, it was preceded by a field trial which this paper reports on the Norwegian part of. For the Norwegian part of the field trial in 2022, we randomly sampled and surveyed 75 GPs and 125 patients 45 years and older for each GP, regardless of whether their GP were also participating in the study. GPs were sampled from a national register that included all GPs. The surveys were primarily digital, but we sent postal questionnaires to non-digital patients and non-responding digital patients. We compared GP and patient characteristics as well as patient-reported experiences and outcomes according to GP participation status in bivariate analysis, supplemented with multiple linear regressions with PREMs/PROMs as dependent variables and participation status as independent adjusting for significant patient factors.Results17 of 75 sampled GPs participated (22.7%), of which 993 of 2,015 patients responded (49.3%). 3,347 of 7,080 patients of non-responding GPs answered (47.3%). Persons with chronic conditions from participating GPs reported significantly better patient-centred coordinated care (p = 0.017), overall experiences with the GP office the last 12 months (p = 0.004), mental well-being (p = 0.039) and mental health (p = 0.013) than patients from non-participating GPs. The raw differences between participating and non-participating GPs on patient-reported experiences and – outcomes varied from 1.5 to 2.9 points on a 0-100 scale, and from 2.2 to 3.0 after adjustment for case-mix.ConclusionsThe Norwegian field trial indicates that estimates based on participants in the PaRIS survey may modestly overestimate patient-reported experiences and -outcomes at the aggregated level and the need for more research within and across countries to identify and address this potential bias.

Effectiveness of Community-Based Multidisciplinary Integrated Care for Older Adults with General Practitioner Involvement: A Systematic Review and Meta-Analysis

Abstract Background Changing demographics has led to healthcare systems reorientating healthcare delivery towards the community setting and implementing integrated models of care worldwide. A knowledge gap exists with regards to what elements of integrated care facilitate effective age-attuned healthcare delivery. This systematic review examines the effectiveness of community-based multidisciplinary integrated care strategies with General Practitioner (GP) participation for community-dwelling older adults and describes the level of care integration in each study. Methods PUBMED, EMBASE, CINAHL, Central Register of Controlled Trials in the Cochrane Library and MEDLINE were systematically searched in April 2023. Randomised controlled trials (RCTs) or cluster RCTs that focused on interventions for community-dwelling older adults delivered by health and social care professionals with GPs were included. Two reviewers independently conducted the risk of bias assessment, applied the GRADE tool to quantify the certainty of evidence and used the Rainbow Model of Integrated Care taxonomy to describe the elements of integrated care used within studies. The primary outcome was functional status. Meta-analyses were performed using Review Manager 5.4. Results Twelve trials (14 reports) recruiting 8069 participants across 8 countries were included. Community-based multidisciplinary team (MDT) integrated care demonstrated significant improvements in functional status (standardised mean difference (SMD) 0.21, 95% confidence interval (CI) 0.05-0.37; low certainty evidence), hospitalisation (risk ratio (RR) 0.77, 95% CI 0.63-0.95; very low certainty evidence) and participant satisfaction with care (SMD 0.46, 95%c CI 0.15-0.76; low certainty evidence) from 12-36 months. No statistically significant effects favouring community-based MDT interventions for functional status at 6-month follow-up, Emergency Department presentation, mortality, health-related quality of life, or nursing home admission were established. Conclusion Community-based MDT integrated care with GP participation improves clinical and process outcomes for community-dwelling older adults. Future research should focus on models of integrated care that respond to the needs and preferences of older adults.

How Were European GPs/FPs Involved in the COVID-19 Vaccination Campaign? A European Questionnaire Study about the Experiences of the Vaccinations in 2021.

The SARS-CoV-2 pandemic has become the greatest public health challenge worldwide. Soon after the appearance of the virus in 2019, intensive efforts to develop vaccines were initiated, and by late 2020, delivery of vaccines for the targeted population as a campaign had started. Collect information from European Union countries regarding how and to what extent were family physicians (FPs)/general practitioners (GPs) involved in the vaccination campaigns in 2021 and how these were organized at the national level. A short questionnaire was distributed through the secretariats of WONCA (World Organization of Family Doctors) Europe and the European Forum for Primary Care (EFPC). In most of the countries, participation of FPs/GPs was compulsory. The vaccination was usually centrally organized by governmental authorities. In the beginning, registration (web-based) of patients was required, mainly at the national level. By the middle of 2021, vaccination on a walk-in basis became available in almost every country for the first immunization as well as for the booster injections. The remunerations of GPs/FPs differed; in some countries, no extra payments were offered. The Pfizer vaccine was used in all countries, while in nine countries, non-European Medicines Agency (EMA)-approved vaccines were also given in primary care settings and at vaccination centers. In some countries, professional homepages helped the GPs. The involvement of primary health care (PHC) providers did not correlate to the vaccination coverage of the entire population of the respective countries. It was the highest in the more developed countries with higher living standards, where participation of GPs was voluntary and appropriate financial incentives were offered to them. The vaccination campaign was a professional and logistic challenge and an excellent performance of PCH providers. Experiences gained could be used in the future to manage similar pandemic challenges.

"What script am I meant to use?": a qualitative study in chronic primary pain.

Chronic primary pain (CPP) as a diagnosis has been introduced in the recent International Classification of Diseases, 11th Revision (ICD-11). CPP captures the experience of pain as the primary problem, without an underlying attributable cause. Dissemination of UK guidance regarding CPP represents the first time it has been recognised as a condition in its own right. Little is known regarding General Practitioner (GP) views concerning caring for patients with CPP and how related guidance is viewed and applied in practice. To explore GP perspectives in relation to caring for people with CPP, including challenges encountered and use of related guidelines in practice. A UK-wide qualitative interview study in primary care. Purposive and snowball sampling were used to recruit 15 GP participants from England, Northern Ireland, Wales and Scotland. Semi-structured interviews were undertaken and analysed using reflexive thematic analysis. Three main themes were generated: (1) "How to start? Problematic beginnings" referred to difficulties regarding diagnosis; (2) "Where to go? Mapping the management challenge" and (3) "How to get there? Navigating strategies and response", explored GP awareness and acceptability of UK guidelines for chronic pain. Areas identified for potential improvement included increased access to NPM and secondary care services, support with de-prescribing and an expanded multidisciplinary team input. CPP is complex to both diagnose and manage. Although guidelines provide a useful framework, they pose challenges when translating into day-to-day practice.

Strategies for General Practitioners to Enhance Cancer Care: Insights from a Patient-Centered Questionnaire Survey in Southern China.

The incidence of cancer is increasing, and cancer survivors are also growing exponentially. Cancer is defined as a new chronic disease. Nevertheless, the management of cancer in the form of chronic diseases in China is still in its infancy, without a standardized care model. This study aimed to explore the current status of management of cancer care from the patient's perspective. This cross-sectional study was a questionnaire survey of patients diagnosed with cancer, including information of the current situation of daily medical consultation, status of comorbidity, and expectations of seeking cancer care in future. Chi-square test and logistic regression analysis were used to explore the factors influencing patients' choice of cancer management mode. A total of 200 cancer patients were included in the study. The majority (n = 150) of cancer patients chose an oncologist in a tertiary hospital for cancer care. Difficulty in registration (45%), time-consuming (34.5%), repeated examinations (34.5%) and different treatment opinions (12.0%) were the main difficulties they encountered currently during tertiary hospital visits. In community hospital, lack of trust in general practitioners (n = 33) and the necessary drugs or testing items in community hospitals (n = 47) were the main difficulties during their visits. Logistic regression analysis showed that male (OR = 2.737, 95% CI, 1.332-5.627, p = 0.006) and elderly patients (OR = 3.186, 95% CI, 1.172-8.661, p = 0.023) were more likely to choose general practitioners (GPs) in community hospitals. Twenty-nine (14.5%) patients hope to have an integrated multidisciplinary management in tertiary and community hospitals with the active participation of GPs for cancer care. Improving drug availability, equipment and quality of cancer care services can help to increase cancer patients' recognition of community hospital. In addition, the multidisciplinary management integrated tertiary hospitals and communities with the participation of GPs is a worth exploring mode that improves the management of cancer care.

Effectiveness of a School- and Primary Care–Based HPV Vaccination Intervention

The human papillomavirus (HPV) vaccine is safe and effective, yet vaccination coverage remains below public health objectives in many countries. To examine the effectiveness of a 3-component intervention on HPV vaccination coverage among adolescents aged 11 to 14 years 2 months after the intervention ended, each component being applied alone or in combination. A cluster randomized trial with incomplete factorial design (PrevHPV) was conducted between July 1, 2021, and April 30, 2022, in French municipalities receiving 0, 1, 2, or 3 components of the intervention. Randomization was stratified by school district and municipalities' socioeconomic level. Analyses were carried out on 11- to 14-year-old adolescents living in all participating municipalities, regardless of what had been implemented. The PrevHPV intervention had 3 components: (1) educating and motivating 11- to 14-year-old adolescents in middle schools, along with their parents; (2) training general practitioners (GPs) on up-to-date HPV information and motivational interviewing techniques; and (3) free HPV vaccination at school. The primary outcome was HPV vaccination coverage (≥1 dose) 2 months after the intervention ended among 11- to 14-year-old adolescents living in participating municipalities, based on the French national reimbursement database and data collected during the trial in groups randomized to implement at-school vaccination. A total of 91 municipalities comprising 30 739 adolescents aged 11 to 14 years (15 876 boys and 14 863 girls) were included and analyzed. Half the municipalities were in the 2 lowest socioeconomic quintiles and access to GPs was poor in more than two-thirds of the municipalities. Thirty-eight of 61 schools (62.3%) implemented actions and 26 of 45 municipalities (57.8%) had at least 1 trained GP. The median vaccination coverage increased by 4.0 percentage points (IQR, 2.0-7.3 percentage points) to 14.2 percentage points (IQR, 9.1-17.3 percentage points) at 2 months. At-school vaccination significantly increased vaccination coverage (5.50 percentage points [95% CI, 3.13-7.88 percentage points]) while no effect was observed for adolescents' education and motivation (-0.08 percentage points [95% CI, -2.54 to 2.39 percentage points]) and GPs' training (-1.46 percentage points [95% CI, -3.44 to 0.53 percentage points]). Subgroup analyses found a significant interaction between at-school vaccination and access to GPs, with a higher effect when access was poor (8.62 percentage points [95% CI, 5.37-11.86 percentage points] vs 2.13 percentage points [95% CI, -1.25 to 5.50 percentage points]; P = .007 for interaction). In this cluster randomized trial, within the context of the late COVID-19 pandemic period and limited school and GP participation, at-school HPV vaccination significantly increased vaccination coverage. The trial did not show a significant effect for training GPs and education and motivation, although it may be observed after more time has elapsed after the intervention. ClinicalTrials.gov Identifier: NCT04945655.

Effectiveness of Community‐Based Multidisciplinary Integrated Care for Older Adults with General Practitioner Involvement: A Systematic Review and Meta‐Analysis

Background. Changing demographics has led to healthcare systems reorientating healthcare delivery towards the community setting and implementing integrated models of care worldwide. This systematic review examines the effectiveness of community‐based multidisciplinary integrated care strategies with general practitioner (GP) participation for community‐dwelling older adults and describes the level of care integration in each study. Methods. PubMed, Embase, CINAHL, Central Register of Controlled Trials in the Cochrane Library, and MEDLINE were systematically searched in February 2024. Randomised controlled trials (RCTs) or cluster RCTs that focused on interventions for community‐dwelling older adults delivered by health and social care professionals with GPs were included. Two reviewers independently conducted the risk of bias assessment, applied the GRADE tool to quantify the certainty of evidence, and used the rainbow model of integrated care taxonomy to describe the elements of integrated care. Outcomes included functional status, healthcare utilisation, participant satisfaction with care, health‐related quality of life, mortality, nursing home admission, and adverse outcomes. Meta‐analyses were performed using Review Manager 5.4. Results. Twelve trials recruiting 8069 participants across 8 countries were included. Community‐based multidisciplinary team (MDT) integrated care demonstrated significant improvements in functional status (standardised mean difference (SMD): 0.21; 95% confidence interval (CI): 0.05–0.37; low certainty evidence), hospitalisation (risk ratio (RR): 0.77; 95% CI: 0.63–0.95; very low certainty evidence), and participant satisfaction with care (SMD: 0.46; 95% CI: 0.15–0.76; low certainty evidence) from 12 to 36 months. No statistically significant effects favouring community‐based MDT interventions for functional status at 6‐month follow‐up, emergency department presentation, mortality, health‐related quality of life, or nursing home admission were established. Conclusion. Community‐based MDT integrated care with GP participation improves functional status, reduces hospitalisations, and increases patient satisfaction among community‐dwelling older adults in the long term. Future research should focus on models of integrated care that respond to the needs and preferences of older adults. This trial is registered with CRD42022309744.

Knowledge of the patient's bio-psycho-social context as a predictive tool for outcomes in palliative care.

The General Practitioner (GP), thanks to his knowledge of the patient's bio-psycho-social context, has a fundamental role in the definition of a personalized care planning (Pcp). The HexCom model can be a valid tool for standardizing the level of complexity of the patient in palliative care and for evidentiate critical care issues. The GP participants retrospectively assessed, using HexCom model, the complexity of the biopsycho-social context of 53 patients taken care by the Palliative Care Unit and who died in the years 2019-2021. For each patient, age, sex, treating doctor, main diagnosis, data and place of death (home/hospice/hospital) were collected. Subjects who died in hospital or hospice had similar HexCom complexity scores, higher than those who died at home (p=0.04). The HexCom score was inversely related to the subject's age (p=0.01). The ROC curve suggested a cut-off for HexCom equal to 209, whereby subjects with HexCom ≥209 would be associated with death in hospital/hospice while subjects with HexCom <209 would be associated with death at home. The present study confirms the importance of evaluating the complexity of a patient in palliative care and proposes the use of the HexCom model for the evaluation of the biopsycho-social context, a predictor of the outcome of a patient in palliative care. bio-psycho-social, complexity, GP, HexCom, palliative care, Pcp.

Medication optimization in nursing homes: the impact of education and interdisciplinary case conferencing

Introduction: Potentially inappropriate prescribing has shown to be highly prevalent in older adults, especially in nursing home residents. Previous research, such as the Come-On study, proved that a complex intervention, containing an educational component and interdisciplinary case conferencing, is effective in reducing this phenomenon. &#x0D; Policy context and objective: Awaiting the structural implementation supported by the government, an initiative was set up in West-Flanders to locally implement such an intervention and explore its impact.&#x0D; Target population: This study targeted nursing home residents and nursing home staff.&#x0D; Innovation, impact, outcomes: The intervention included three components: 1) education of nursing home staff by the pharmacist with regard to medication use in nursing home residents, 2) interdisciplinary case conferencing during which medication plans of residents were discussed (i.e. medication review) by the resident’s general practitioner (or the nursing home’s coordinating physician), a nurse, and the pharmacist, and 3) intervision across nursing homes to discuss experiences. Nursing homes were encouraged to involve residents and family members as much as possible (e.g. to invite them to the interdisciplinary case conference). For each case conference, nursing homes were instructed to report the duration, the identified (potential) drug-related problems, and the proposed medication changes. Throughout the study, financial incentives were provided for pharmacists and nursing homes.&#x0D; Quantitative data were analyzed descriptively, while qualitative data were analyzed inductively. Furthermore, an economic evaluation was performed.&#x0D; Eight nursing homes participated in the study. Nursing home staff indicated to have better medication-related knowledge and to be more aware of potential drug-related problems thanks to their participation in the project. They also experienced better communication between all involved healthcare professionals and with residents and their families.&#x0D; So far, data with regard to the interdisciplinary case conferences has been collected from five nursing homes, encompassing 266 nursing home residents. An interdisciplinary case conference lasted on average about 30 minutes per resident. For 60% of these nursing home residents, at least one medication change was implemented (e.g. stopping of a drug, change of administration time or route, change of dosage form). The five most frequently stopped drugs included 1) vitamins and supplements, 2) psychotropic drugs, 3) pain killers, 4) PPIs, and 5) antihypertensive drugs. On average, this resulted in a saving of €105 per year per resident.&#x0D; It was noted that general practitioners only participated in the case conferences in one nursing home. Likewise, residents nor family members were present during the interdisciplinary meetings. Nevertheless, residents (and families) were interviewed regarding their medication use in preparation of the conference and were informed about medication changes afterwards. &#x0D; Transferability and conclusion: The intervention was shown to be effective in optimizing the medication use of nursing home residents. Following steps will focus on the implementation of the intervention in a higher number of nursing homes, as well as in other home replacing settings. Additionally, opportunities for involvement of residents and their families, as well the participation of general practitioners will be further investigated.&#x0D; Key words: Residential care, interdisciplinary case conferences, inappropriate prescribing, medication review

Multidisciplinary care of older adults in the emergency department to influence deprescribing in older adults: a cohort study

AbstractBackgroundInappropriate polypharmacy in older adults is a major health problem associated with poor clinical and health service outcomes.AimWe aimed to evaluate the effectiveness of a geriatric pharmacist service in the emergency department (ED) identifying potentially inappropriate prescribing (PIP).MethodBetween 1 June 2018–31 May 2019, adults ≥70 years of age presenting to ED were reviewed by the Geriatric Emergency Department Intervention (GEDI) pharmacist. The intervention consisted of pharmacist‐led medication review using Screening Tool of Older Person’s Prescriptions (STOPP) and Screening Tool to Alert doctors to Right Treatment (START) criteria, patient education on recommendations, an updated medication list, and a letter sent to their general practitioner (GP) electronically. For eligible consenting older adults, telephone calls were made at least 28 days post‐discharge to assess the effectiveness of the intervention. A survey with GPs after 6 months determined how recommendations were perceived. Ethics approval was granted by the Metro North Health B Human Research Ethics Committee (reference no: HREC/18QCH/69–1245) and research governance approval was granted by the study site (Cairns Hinterland Hospital and Health Service, reference no: SSA/Q12345/40673). Informed consent was obtained from all participants via a project information sheet and either the completion of a written consent form (patient participants), verbal consent before interview (GP participants), or implied consent via email responses (GP participants). Routinely collected health data obtained for this study were de‐identified and data included in the follow‐up study was de‐identified.ResultsThe GEDI pharmacist reviewed 1214 older adults with an average age of 81 years. The median number of prescribed medications was 10 and 36.8% of older adults had STOPP recommendations. When contacted (n = 35), of those enrolled in the follow‐up study, 71% had stated their medications changed, 40% reported all STOPP medications had ceased, and 69% had START medications commenced, suggesting the recommendations provided were clinically appropriate and readily accepted by their GPs.ConclusionIntegration of a geriatric pharmacist demonstrated ample opportunities to address PIP in targeted older adults presenting to ED. This study shows that the pharmacist was able to promote appropriate prescribing through patient education and recommendations communicated to the GP on discharge.

Mistrust in government and National Health Insurance: A qualitative study of solo private practitioners in Cape Town.

The participation of independent private general practitioners (GPs) is of fundamental importance to the successful implementation of key elements of the proposed National Health Insurance (NHI) reform, notably the contracting units for primary health care (CUPS). This study explored knowledge and perceptions of the NHI reforms of private GPs following the tabling of the NHI Bill in parliament in 2019. An explorative qualitative research methodology was adopted. Using a semi-structured guide, nine solo private GPs, purposefully selected to represent the range of practices in the southern peninsula of Cape Town were interviewed in depth by B.L.P. over the period from January 2021 to March 2022. The GPs indicated support for the values of greater equity outlined in the NHI proposals. However, they had little engagement on or knowledge of their potential future roles in NHI. Concerns over financial viability and design were underpinned by an overall mistrust in the public sector to implement and manage NHI. The study concurs with previous research that private GPs are broadly in support of the principles of, and are potential allies, in advancing NHI. General practitioners need a platform to share their concerns and contribute as co-designers of NHI reforms. In the interim, steps to increase collaboration between private and public sectors at local and provincial level through, for example, referral processes may help to build the trust that is necessary between the sectors.Contribution:This study foregrounds the role of trust relationships in advancing NHI.

Assessing the fidelity of a behavioural intervention involving academic detailing in general practice: a sub-study of the ‘Implementing work-related Mental health guidelines in general PRacticE’ (IMPRovE) trial

BackgroundAssessing the fidelity of intervention components enables researchers to make informed judgements about the influence of those components on the observed outcome. The ‘Implementing work-related Mental health guidelines in general PRacticE’ (IMPRovE) trial is a hybrid III trial aiming to increase adherence to the ‘Clinical Guidelines for the diagnosis and management of work-related mental health conditions in general practice’. IMPRovE is a multifaceted intervention, with one of the central components being academic detailing (AD). This study describes the fidelity to the protocol for the AD component of the IMPRovE intervention.MethodAll AD sessions for the trial were audio-recorded and a sample of 22% were randomly selected for fidelity assessment. Fidelity was assessed using a tailored proforma based on the Modified Conceptual Framework for fidelity assessment, measuring duration, coverage, frequency and content. A descriptive analysis was used to quantify fidelity to the protocol and a content analysis was used to elucidate qualitative aspects of fidelity.ResultsA total of eight AD sessions were included in the fidelity assessment. The average fidelity score was 89.2%, ranging from 80 to 100% across the eight sessions. The sessions were on average 47 min long and addressed all of the ten chapters in the guideline. Of the guideline chapters, 9 were frequently discussed. The least frequently discussed chapter related to management of comorbid conditions. Most general practitioner (GP) participants used the AD sessions to discuss challenges with managing secondary mental conditions. In line with the protocol, opinion leaders who delivered the AD sessions largely offered evidence-based strategies aligning with the clinical guideline recommendations.Conclusions/implicationsThe IMPRovE AD intervention component was delivered to high fidelity. The sessions adhered to the intended duration, coverage, frequency, and content allowing participating GPs to comprehend the implementation of the guideline in their own practice. This study also demonstrates that the Modified Conceptual Fidelity Framework with a mixed methods approach can support the assessment of implementation fidelity of a behavioural intervention in general practice. The findings enhance the trustworthiness of reported outcomes from IMPRovE and show that assessing fidelity is amenable for AD and should be incorporated in other studies using AD.Trial registrationAustralian New Zealand Clinical Trials Registry ACTRN 12620001163998, November 2020.

General practitioners’ decision-making process to prescribe pain medicines for low back pain: a qualitative study

BackgroundPain medicines are widely prescribed by general practitioners (GPs) when managing people with low back pain (LBP), but little is known about what drives decisions to prescribe these medicines.ObjectivesThe aim...

Gatekeepers in the health financing scheme: Assessment of knowledge, attitude, practices, and participation of Malaysian private general practitioners in the PeKa B40 scheme.

This is cross-sectional research done to assess the readiness of the private Malaysian general practitioners (GPs) for the implementation of the national health financing scheme. The study focused on their levels of knowledge and attitudes towards the types of health financing scheme, gatekeeper roles in the health financing scheme, and their participation in the PeKa B40 scheme. Their acceptance and level of participation in the national health financing scheme (NHFS) were also assessed. A set of self-designed and pre-tested questionnaires focusing on the aforementioned objectives were mailed to the respondents. The selection of respondents was done by stratified random sampling of the GPs in all 14 Malaysian states at both urban and rural levels. Out of a calculated number of 362 GPs targeted, 296 responses were received which represented a response rate of 81.7%. The respondents had a mean age of 50.7 years 165 (55.75%) were males and 131 (44.3%) were females. The rural respondents totalled 158 (53.4%) as compared to those from urban 138 (46.6%) areas. The outcomes observed were that GPs with PeKa B40 provider status, positive attitude towards health financing schemes, gatekeeper roles, and PeKa B40, were strongly associated with their acceptance and level of participation in the NHFS. The GPs possessed a positive attitude and were generally ready to participate in the NHFS, but the lower scores in knowledge levels would require definite education and training plans to further enhance their readiness. More incentives should be given to GPs to enrol as PeKa B40 providers. The results of this study should be strongly considered by the government in the efforts to engage the Malaysian private GPs in the forthcoming NHFS. Most importantly, the role of GPs as gatekeepers needed to be implemented, and the PeKa B40 scheme be greatly improved.

"We're trained to trust our patients": a qualitative study on the general practitioners' trust in patients for colorectal cancer shared care.

In a therapeutic partnership, physicians rely on patients to describe their health conditions, join in shared decision-making, and engage with supported self-management activities. In shared care, the patient, primary care, and specialist services partner together using agreed processes and outputs for the patient to be placed at the centre of their care. However, few empirical studies have explored physicians' trust in patients and its implications for shared care models. To explore trust in patients amongst general practitioners (GPs), and the impacts of trust on GPs' willingness to engage in new models of care, such as colorectal cancer shared care. GP participants were recruited through professional networks for semi-structured interviews. Transcripts were integrity checked, coded inductively, and themes developed iteratively. Twenty-five interviews were analysed. Some GPs view trust as a responsibility of the physician and have a high propensity for trusting patients. For other GPs, trust in patients is developed over successive consultations based on patient characteristics such as honesty, reliability, and proactivity in self-care. GPs were more willing to engage in colorectal cancer shared care with patients with whom they have a developed, trusting relationship. Trust plays a significant role in the patient's access to shared care. The implementation of shared care should consider the relational dynamics between the patient and health care providers.

Statins for extension of disability-free survival and primary prevention of cardiovascular events among older people: protocol for a randomised controlled trial in primary care (STAREE trial)

IntroductionThe world is undergoing a demographic transition to an older population. Preventive healthcare has reduced the burden of chronic illness at younger ages but there is limited evidence that these...

Effectiveness of community-based multidisciplinary integrated care for older people: a protocol for a systematic review

IntroductionThe increasing number of older adults with multiple complex care needs has placed increased pressure on healthcare systems internationally to reorientate healthcare delivery. For many older adults, their first point...

General practitioner perspectives on factors that influence implementation of secondary care-initiated treatment in primary care: Exploring implementation beyond the context of a clinical trial.

The Beta-blockers Or Placebo for Primary Prophylaxis of oesophageal varices (BOPPP) trial is a 3-year phase IV, multi-centre clinical trial of investigational medicinal product (CTIMP) that aims to determine the effectiveness of carvedilol in the prevention of variceal bleeding for small oesophageal varices in patients with cirrhosis. Early engagement of General Practitioners (GPs) in conversations about delivery of a potentially effective secondary care-initiated treatment in primary care provides insights for future implementation. The aim of this study was to understand the implementation of trial findings by exploring i) GP perspectives on factors that influence implementation beyond the context of the trial and ii) how dose titration and ongoing treatment with carvedilol is best delivered in primary care. This qualitative study was embedded within the BOPPP trial and was conducted alongside site opening. GP participants were purposively sampled and recruited from ten Clinical Commissioning Groups in England and three Health Boards across Wales. Semi-structured telephone individual interviews were conducted with GPs (n = 23) working in England and Wales. Data were analysed using reflexive thematic analysis. Five overarching themes were identified: i) primary care is best placed for oversight, ii) a shared approach led by secondary care, iii) empower the patient to take responsibility, iv) the need to go above and beyond and v) develop practice guidance. The focus on prevention, attention to holistic care, and existing and often long-standing relationships with patients provides an impetus for GP oversight. GPs spoke about the value of partnership working with secondary care and of prioritising patient-centred care and involving patients in taking responsibility for their own health. An agreed pathway of care, clear communication, and specific, accessible guidance on how to implement the proposed treatment strategy safely and effectively are important determinants in the success of implementation. Our findings for implementing secondary care-initiated treatment in primary care are important to the specifics of the BOPPP trial but can also go some way in informing wider learning for other trials where work is shared across the primary-secondary care interface, and where findings will impact the primary care workload. We propose a systems research perspective for addressing implementation of CTIMP findings at the outset of research. The value of early stakeholder involvement is highlighted, and the need to consider complexity in terms of the interaction between the intervention and the context in which it is implemented is acknowledged. ISRCTN10324656.

Work-related, socio-cultural, and personal factors associated with locus of control among Australian general practitioners

BackgroundLocus of control (LoC) is a social cognition, that relates to the level of self-control that people have over their personal environment that influences their life. In this context, LoC is frequently associated with work-related behavioral outcomes, ranging from job attitudes, career behaviors, stress, and burnout. ObjectiveTo investigate the association between LoC, and work-related behavioral factors, socio-cultural factors, and personal factors among Australian General Practitioners (GPs). MethodsThis study utilized data from the 2010 Medicine in Australia: Balancing Employment and Life (MABEL) survey of doctors. Locus of control (LoC) was measured by a 7-point Likert scale based on Pearlin-Schooler Mastery/Self-efficacy 7-item Scale. Higher score indicated lower internal LoC. Multivariate linear regression model was performed to determine the independent predictors of LoC. ResultsOf 3,664 GP participants, LoC did not differ by gender. Poor/fair self-rated health, working in urban location, running a stressful practice, poor balance of professional and personal commitments, poor support network, financial circumstances after retirement, and perception of unrealistic expectation by patients were significant predictors for a lower Internal LoC in a multivariate linear regression model. Adjusted R2 explained 22.4% of variation in predicting the LoC in our models. ConclusionsLoC of Australian GPs is negatively affected by poor work-life balance, inadequate support, and unrealistic patient expectation. These work-place specific factors could be targeted by interventions to improve GPs wellbeing.