GP Consultations Research Articles

Mortality in patients with Dupuytren's disease in the first 5 years after diagnosis: a population-based survival analysis.

Previous studies suggest that Dupuytren's disease is associated with increased mortality, but most studies failed to account for important confounders. In this population-based cohort study, general practitioners' (GP) data were linked to Statistics Netherlands to register all-cause and disease-specific mortality. Patients with Dupuytren's disease were identified using the corresponding diagnosis code and assessing free-text fields from GP consultations. Multiple imputations were performed to estimate missing values of covariates, followed by 1:7 propensity score matching to balance cases with controls on confounding factors. A frailty proportional hazard model was used to compare mortality between both groups. Out of 209,966 individuals, 2561 patients with Dupuytren's disease were identified and matched to at least four controls. After a median follow-up of 5 years, mortality was found to be actually reduced in patients with Dupuytren's disease. There was no difference in mortality secondary to cancer or cardiovascular disease. Future studies with longer average follow-up using longitudinal data should clarify these associations in the longer term.Level of evidence: III.

First contact physiotherapy: an evaluation of clinical effectiveness and costs.

First contact physiotherapy practitioners (FCPPs) are embedded within general practice, providing expert assessment, diagnosis, and management plans for patients with musculoskeletal disorders (MSKDs), without the prior need for GP consultation. To determine the clinical effectiveness and costs of FCPP models compared with GP-led models of care. Multiple site case-study design of general practices in the UK. General practice sites were recruited representing the following three models: 1) GP-led care; 2) FCPPs who could not prescribe or inject (FCPPs-standard [St]); and 3) FCPPs who could prescribe and/or inject (FCPPs-additional qualifications [AQ]). Patient participants from each site completed outcome data at baseline, 3 months, and 6 months. The primary outcome was the SF-36 Physical Component Summary (PCS) score. Healthcare usage was collected for 6 months. In total, 426 adults were recruited from 46 practices across the UK. Non-inferiority analysis showed no significant difference in physical function (SF-36 PCS) across all three arms at 6 months (P = 0.667). At 3 months, a significant difference in numbers improving was seen between arms: 54.7% (n = 47) GP consultees, 72.4% (n = 71) FCPP-St, and 66.4% (n = 101) FCPP-AQ (P = 0.037). No safety issues were identified. Following initial consultation, a greater proportion of patients received medication (including opioids) in the GP-led arm (44.7%, n = 42), compared with FCPP-St (18.4%, n = 21) and FCPP-AQ (24.7%, n = 40) (P<0.001). NHS costs (initial consultation and over 6-month follow-up) were significantly higher in the GP-led model (median £105.5 per patient) versus FCPP-St (£41.0 per patient) and FCPP-AQ (£44.0 per patient) (P<0.001). FCPP-led models of care provide safe, clinically effective patient management, with cost-benefits and reduced opioid use in this cohort.

What makes a good general practice consultation? An exploratory pilot study with people from a low socioeconomic background.

While patients from low socioeconomic (SES) backgrounds are at increased risk of developing chronic health conditions, typically managed within general practice, they report fewer positive consultation experiences with GPs than patients from higher SES groups. To our knowledge, existing research does not provide an in-depth understanding of the GP conducts that contribute to positive consultations. To identify the factors that patients from low SES backgrounds perceive as essential for creating good consultation experiences. This exploratory pilot study was performed in GP clinics in Melbourne, Australia. We used an appreciative inquiry approach, focused on positive consultation experiences, previously shown to be helpful for researching sensitive topics. Nine patients from low SES backgrounds, who reported positive consultation experiences, undertook a semi-structured qualitative interview while watching the video recording of their GP consultation. Four different GPs were captured in the recordings. Inductive thematic coding was performed by two researchers. The following four categories were developed: 1) the doctor's demeanour and how the patient was made to feel during the consultation drove their engagement; 2) an established and collaborative therapeutic relationship was of high importance to patients; 3) a doctor's therapeutic skillset was integral to patient confidence and comfort; and 4) patients appreciated verbal and non-verbal communication techniques. In each interview, the discussion about the video-recorded consultation often triggered reflections about previous consultations with the respective GP. For patients from low SES groups, positive consultation experiences were underpinned by perceived continuity of care with a specific GP who consistently showed good communication skills and key interpersonal characteristics. This research is a small step towards increasing our understanding of the experience of individuals from low SES backgrounds in primary care and the existing health inequities within this area.

1715 A Hospital at Home service working with care homes to triage acutely unwell patients

Abstract Introduction The Acute clinical team (ACT) is a Hospital at Home (H@H) service and supports care homes to look after residents who are acutely unwell but residents were being inappropriately admitted instead of being referred to ACT. This was due to the lack of awareness among staff about ACT and GPs advising homes to call 999 due to their inability to see patients. Method ACT would phone all the care homes three times a week to ascertain if the care home had residents who were acutely unwell or not responding to treatment initiated by the GP. Residents who were identified would be triaged and either advice would be given or patient would be seen within 24 hours. Results The intervention took place from 20/03/23 to 30/04/23. Total number of referrals- 33. Average age- 87 years. 5/33 (15%) were given advice and 28/33 (85%) had face to face assessment. 29/33 remained at home. 4/33 were admitted 2 died. The 28/33 who received face to face assessments had received 106 GP consultations (most were virtual) within one month of referral equating to 3.7 consultations per patient. 8/28 patients had been discharged from hospital within 28 days of referral to ACT. ACT administered parenteral fluids 11/28 patients, Intravenous antibiotics 5/28, medication review with changes 14/28. Conclusion

Primary care transformation in Scotland: a qualitative evaluation of the views of patients.

The new Scottish GP contract introduced in April 2018 aims to improve quality of care through expansion of the multidisciplinary team (MDT) to enable GPs to spend more time as expert medical generalists with patients with complex needs. To explore patients' views on the changes in general practice in Scotland since the inception of the new contract. Qualitative study with 30 patients (10 living in urban deprived areas, 10 living in urban affluent/mixed urban areas, and 10 living in remote and rural areas). In-depth semi-structured interviews with thematic analysis. Patients were generally unaware of the new GP contract, attributing recent changes in general practice to the COVID-19 pandemic. Ongoing concerns included access to GP consultations (especially face-to-face ones), short consultation length with GPs, and damage to continuity of care and the GP-patient relationship. Most patients spoke positively about consultations with MDT staff but still wanted to see a known GP for health concerns that they considered potentially serious. These issues were especially concerning for patients with multiple complex problems, particularly those from deprived areas. Following the introduction of the new Scottish GP contract, patients in this study's sample were accepting of first contact care from the MDT but still wanted continuity of care and longer face-to-face consultations with GPs. These findings suggest that the expert generalist role of the GP is not being adequately supported by the new contract, especially in deprived areas, though further quantitative research is required to confirm this.

ECG of the month

In this issue’s ECG of the month, Charles Bloe presents the case of a 62-year-old man who mentioned experiencing heart palpitations while attending a GP consultation for urinary symptoms.

Association between travel distance and face-to-face consultations with general practitioners before an incident acute myocardial infarction: a nationwide register-based spatial epidemiological study

ObjectivesThis study examined the association between travel distance to the general practitioner’s (GP) office and no face-to-face GP consultation within 1 year before an incident acute myocardial infarction (AMI).DesignA prospective...

Patients' experiences of GP consultations following the introduction of the new GP contract in Scotland: a cross-sectional survey.

The new Scottish GP contract commenced in April 2018 with a stated aim of mitigating health inequalities. To determine the health characteristics and experiences of patients consulting GPs in deprived urban (DU), affluent urban (AU), and remote and rural (RR) areas of Scotland. In 2022, a postal survey of a random sample of adult patients from 12 practices who had consulted a GP within the previous 30 days was undertaken. Patient characteristics and consultation experiences in the three areas (DU, AU, RR) were evaluated using validated measures including the Consultation and Relational Empathy (CARE) Measure and Patient Enablement Instrument (PEI). In total, 1053 responses were received. In DU areas, multimorbidity was more common (78% versus 58% AU versus 68% RR, P<0.01), complex presentations (where the consultation addressed both psychosocial and physical problems) were more likely (16% versus 10% AU versus 11% RR, P<0.05), and more consultations were conducted by telephone (42% versus 31% AU versus 31% RR, P<0.01). Patients in DU areas reported lower satisfaction (82% DU completely, very, or fairly satisfied versus 90% AU versus 86% RR, P<0.01), lower perceived GP empathy (mean CARE score 38.9 versus 42.1 AU versus 40.1 RR, P<0.05), lower enablement (mean PEI score 2.6 versus 3.2 AU versus 2.8 RR, P<0.01), and less symptom improvement (P<0.01) than those in AU or RR areas. Face-to-face consultations were associated with significantly higher satisfaction, enablement, and perceived GP empathy than telephone consultations in RR areas (all P<0.05). Four years after the start of the new GP contract in Scotland, patients' experiences of GP consultations suggest that the inverse care law persists.

Engagement with emotional concerns in general practice: a thematic analysis of GP consultations.

Emotional concerns (defined as any expression of low mood, anxiety, or psychosocial stress) are an important part of the biopsychosocial care model used in modern medical practice. Previous work has demonstrated variable engagement with emotional concerns and that improved communication has been associated with reductions in emotional distress. To examine how emotional concerns are engaged with during routine GP consultations. Secondary study using the Harnessing Resources from the Internet (HaRI) database. The available dataset contains 231 recordings from 10 GPs across eight urban and suburban practices recorded in 2017 and 2018. The dataset was reviewed to identify any consultations containing emotional concerns (as defined as any expression of low mood, anxiety, or psychosocial stress) before being imported into NVivo (version 12) to facilitate thematic analysis and coding. Reflexive inductive thematic analysis resulted in two major themes. The two main themes were as follows: engagement with emotional concerns as dynamic throughout consultations; and GPs engage with emotional concerns both diagnostically and therapeutically. In theme 1, this dynamism relates to competing areas of focus, immediate versus delayed engagement and reiteration of concerns throughout consultations. Emotional concerns can be engaged with in a similar way to physical concerns (theme 2) using a diagnostic and treatment-based approach; however, in addition to this, therapeutic listening and conversation is utilised. Awareness of the dynamic nature of emotional concerns within consultations and encouraging engagement with concerns in a flexible and patient-oriented manner may help improve doctor-patient communication. In addition, investigating how GPs and patients build shared understanding around emotional concerns may identify methods to reduce patients' emotional distress.

Asthma and incident coronary heart disease: an observational and Mendelian randomisation study.

Observational studies suggest asthma is a risk factor for coronary heart disease (CHD) and sex modifies the risk, but they may suffer from methodological limitations. To overcome these, we applied a "triangulation approach", where different methodologies, with different potential biases, were leveraged to enhance confidence in findings. First, we conducted an observational study using UK medical records to match asthma patients 1:1, by age, sex and general practitioner (GP) practice, to the general population. We measured the association between asthma and incident CHD (myocardial infarction: hospitalisation/death) by applying minimal sufficient adjustment: model 1, smoking, body mass index, oral corticosteroids, atopy and deprivation; model 2, additionally adjusting for healthcare behaviour (GP consultation frequency). Second, we conducted a Mendelian randomisation (MR) study using data from the UK Biobank, Trans-National Asthma Genetic Consortium (TAGC) and Coronary Artery Disease Genome-wide Replication and Meta-analysis consortium (CARDIoGRAM). Using 64 asthma single nucleotide polymorphisms, the effect of asthma on CHD was estimated with inverse variance-weighted meta-analysis and methods that adjust for pleiotropy. In our observational study (n=1 522 910), we found asthma was associated with 6% increased risk of CHD (model 1: HR 1.06, 95% CI 1.01-1.13); after accounting for healthcare behaviour, we found no association (model 2: HR 0.99, 95% CI 0.94-1.05). Asthma severity did not modify the association, but sex did (females: HR 1.11, 95% CI 1.01-1.21; males: HR 0.91, 95% CI 0.84-0.98). Our MR study (n=589 875) found no association between asthma and CHD (OR 1.01, 95% CI 0.98-1.04) and no modification by sex. Our findings suggest that asthma is not a risk factor for CHD. Previous studies may have suffered from detection bias or residual confounding.

A73Using simulated general practice consultation circuits to develop medical students’ skills in managing uncertainty

Uncertainty is a prevalent concept within medicine, intrinsic to clinical decision-making. Managing uncertainty can be challenging, especially in specialties (i.e. General Practice) where unclear diagnoses are common. This has resulted in curriculums for such specialities introducing teaching on managing uncertainty [1]. With poor tolerance of uncertainty associated with negative outcomes in medical students [2], there is a strong argument that medical schools need to prepare students to manage uncertainty. Uncertainty simulation cases have been utilized to achieve immersive teaching on uncertainty [3], however this is limited by the resources made available by simulation departments, restricting the potential reach of this transformative learning. Aim: To deliver an immersive teaching programme for medical students that develops skills in managing uncertainty within a minimal resource environment. 8 teaching sessions with 46 students were facilitated, which involved students rotating through a circuit of 5 simulated General Practice consultation stations. Students firstly performed the station and then acted as the patient for the next candidate in a continuous cycle ( Circuit Rotation Design – Students started the circuit acting as either the doctor or patient for stations 1-5. After each 10-minute station, there were two minutes for feedback. Students then rotated in a clockwise direction becoming the patient for the station they had previously performed or performing a new station. The students continued to rotate according to this carousel circuit design until they had performed and examined all five stations Students responded positively to the teaching programme, rating its provision of confidence in managing uncertainty and managing GP scenarios (real and OSCE) as &gt;95%. Enjoyment of the sessions was rated at 97% with main aspects being: variety of stations and interactivity. Usefulness of the sessions was rated at 98% with main aspects being: chance to practice, range of cases, receiving feedback. Simulations of GP consultations were rated as highly representative; this was achieved with minimal resources. This teaching programme developed medical students’ confidence and skills in managing uncertainty. They also felt better prepared for managing patients in a GP setting. Critical to the success of this programme was the enjoyment and perceived usefulness of the teaching, as this improved engagement with the learning outcomes. With the cohort being final year students that were integrating knowledge from previous clinical years, we hypothesize that the usefulness was due to students wanting to focus more on revision and opportunities to develop skills in managing less commonly taught but clinically important abstract concepts, such as managing uncertainty. Further programmes should expand on the simulated environments (ED, medical/surgical on-calls) and managing other clinically important abstract concepts (confrontations, prioritization, errors). Authors confirm that all relevant ethical standards for research conduct and dissemination have been met. The submitting author confirms that relevant ethical approval was granted, if applicable.

Impact of COVID-19 pandemic on care for chronic diseases in deprived and non-deprived neighbourhoods

Abstract Background Due to stringent lock-down measures imposed during COVID-19 pandemic the access to the primary care dropped significantly. This study aims to investigate the impact on GP consultations for diabetes mellitus (DM) and COPD during the pandemic. Methods In an observational study from January 2018-June 2022, anonymized medical records of 379.567 patients in Rotterdam, were analyzed for the impact on DM and COPD consultations during the lockdown (March-May 2020) and after the lockdown (June 2020-June 2022) compared to pre-pandemic levels. Results The study included 34.270 DM and 11.570 COPD patients. Until the COVID-19 pandemic, the patients living in deprived neighborhoods had comparisonly on average a higher number of consultations for DM (RR = 1.81, 95%CI=1.76-1.86) and COPD (RR = 1.48 95%CI=1.39-1.58). During the stringent lock-down there was almost same significant drop in both neighbourhoods in consultations for DM (RR = 0.85, 95%CI=0.79-0.92) and COPD (RR = 0.72, 95%CI=0.61-0.86). After the lockdown, the consultations for DM were higher and the HbA1c measurements were normalized compared to pre-pandemic levels in both neighbourhoods, (RR = 1.11, 95%CI=1.05-1.17) and (RR = 0.96, 95%CI=0.91-1.01) respectively. Conversely, the consultations for COPD and spirometry measurements remained significantly lower after the lockdown compared to pre-pandemic levels, (RR = 0.72, 95%CI=0.65-0.80) and (RR = 0.26, 95%CI=0.20-0.34) respectively. Surprisingly, the mean HbA1c value in the study population was significantly lower in the months after the lock-down (RR = 0.96, 95%CI=0.94-0.98) turning back to higher normal value at the end of 2021. Conclusions The recovery of primary care for chronic diseases after the lockdown phase was much faster for DM than for the COPD patients. The positive effect of lockdown on HbA1c was unfortunately temporary. More research is needed to know whether the decrease in chronic care has led to extra morbidity or mortality after 2 years of pandemic. Key messages • Diabetes mellitus’ care recovered soon for both deprived and non-deprived neighbourhoods after a significant drop during the lockdown. Lockdown seems to have a positive effect on disease management. • The significant delay in chronic care for COPD patients in both deprived and non-deprived neighbourhoods for almost two years, raises questions about the adverse health effects due to this delay.

Learning from the universal, proactive outreach of the Brazilian Community Health Worker model: impact of a Community Health and Wellbeing Worker initiative on vaccination, cancer screening and NHS health check uptake in a deprived community in the UK

BackgroundDelays in preventative service uptake are increasing in the UK. Universal, comprehensive monthly outreach by Community Health and Wellbeing Workers (CHW), who are integrated at the GP practice and local authority, offer a promising alternative to general public health campaigns as it personalises health promotion and prevention of disease holistically at the household level. We sought to test the ability of this model, which is based on the Brazilian Family Health Strategy, to increase prevention uptake in the UK.MethodsAnalysis of primary care patient records for 662 households that were allocated to five CHWWs from July 2021. Primary outcome was the Composite Referral Completion Indicator (CRCI), a measure of how many health promotion activities were received by members of a household relative to the ones that they were eligible for during the period July 2021-April 2022. The CRCI was compared between the intervention group (those who had received at least one visit) and the control group (allocated households that were yet to receive a visit). A secondary outcome was the number of GP visits in the intervention and control groups during the study period and compared to a year prior.ResultsIntervention and control groups were largely comparable in terms of household occupancy and service eligibilities. A total of 2251 patients in 662 corresponding households were allocated to 5 CHWs and 160 households had received at least one visit during the intervention period. The remaining households were included in the control group. Overall service uptake was 40% higher in the intervention group compared to control group (CRCI: 0.21 ± 0.15 and 0.15 ± 0.19 respectively). Likelihood of immunisation uptake specifically was 47% higher and cancer screening and NHS Health Checks was 82% higher. The average number of GP consultations per household decreased by 7.4% in the intervention group over the first 10 months of the pilot compared to the 10 months preceding its start, compared with a 0.6% decrease in the control group.ConclusionsDespite the short study period these are promising findings in this deprived, traditionally hard to reach community and demonstrates potential for the Brazilian community health worker model to be impactful in the UK. Further analysis is needed to examine if this approach can reduce health inequalities and increase cost effectiveness of health promotion approaches.

Demographic, health, and prognostic characteristics of Australians with liver cancer: a cohort study of linked data in New South Wales for informing cancer control

BackgroundAustralian age-standardized incidence and death rates for liver cancer are lower than world averages, but increasing as in other economically advanced western countries. World Health Organization emphasizes the need to address sociodemographic disparities in cancer risk. A more detailed sociodemographic risk profiling was undertaken for liver cancer in New South Wales (NSW) by diagnostic stage, than possible with NSW Cancer Registry (NSWCR) alone, by incorporating linked data from the Australian Bureau of Statistics (ABS). The purpose was to inform targeting and monitoring of cancer services.MethodsThe ABS manages the Multi-Agency Data Integration Project (MADIP) which includes a wide range of health, educational, welfare, census, and employment data. These data were linked at person level to NSWCR liver cancer registrations for the period post 2016 census to December 2018. De-identified data were analyzed. Sex-specific age-adjusted odds ratios (95%CIs) of liver cancer were derived using logistic regression by age, country of birth, residential remoteness, proficiency in spoken English, household income, employment status, occupation type, educational attainment, sole person household, joblessness, socioeconomic status, disability status, multimorbidity, and other health-related factors, including GP consultations. These data complement the less detailed sociodemographic data available from the NSWCR, with alignment of numerators and population denominators for accurate risk assessment.ResultsResults indicate liver cancer disproportionately affects population members already experiencing excess social and health disadvantage. Examples where 95% confidence intervals of odds ratios of liver cancer were elevated included having poor English-speaking proficiency, limited education, housing authority tenancy, living in sole-person households, having disabilities, multiple medicated conditions, and being carers of people with a disability. Also, odds of liver cancer were higher in more remote regions outside major cities, and in males, with higher odds of more advanced cancer stages (degrees of spread) at diagnosis in more remote regions.ConclusionsLinked data enabled more detailed risk profiling than previously possible. This will support the targeting of cancer services and benchmarking.

Satisfaction with remote consultations in primary care during COVID-19: a population survey of UK adults.

Mode of access to primary care changed during the COVID-19 pandemic; remote consultations became more widespread. With remote consultations likely to continue in UK primary care, it is important to understand people's perceptions of remote consultations and identify potential resulting inequalities. To assess satisfaction with remote GP consultations in the UK during the COVID-19 pandemic and identify demographic variation in satisfaction levels. A cross-sectional survey from the second phase of a large UK-based study, which was conducted during the COVID-19 pandemic. In total, 1426 adults who self-reported having sought help from their doctor in the past 6 months completed an online questionnaire (February to March 2021). Items included satisfaction with remote consultations and demographic variables. Associations were analysed using multivariable regression. A novel six-item scale of satisfaction with remote GP consultations had good psychometric properties. Participants with higher levels of education had significantly greater satisfaction with remote consultations than participants with mid-level qualifications (B = -0.82, 95% confidence interval [CI] = -1.41 to -0.23) or those with low or no qualifications (B = -1.65, 95% CI = -2.29 to -1.02). People living in Wales reported significantly higher satisfaction compared with those living in Scotland (B = -1.94, 95% CI = -3.11 to -0.78), although caution is warranted due to small group numbers. These findings can inform the use and adaptation of remote consultations in primary care. Adults with lower educational levels may need additional support to improve their experience and ensure equitable care via remote consultations.

Are chronic condition management visits translatable to telehealth? Analysis of in-person consultations in primary care

BackgroundTelehealth was rapidly adopted in primary care during COVID-19. However, there is a lack of research assessing how translatable in-person consultations are to telehealth. ObjectiveTo examine insights from in-person GP-Patient consultations for patients with chronic conditions, including 1/frequency, duration, conditions of physical examinations, and when they occur during consultations, 2/types of physical artefacts used, 3/clinical tasks performed, and 4/translatability of clinical tasks to telehealth. MethodsEligible consultations were extracted from a dataset archive named HaRI, which contains 281 in-person GP consultations in de-identified transcript and video format. 38 consultations were included for analysis meeting eligibility criteria in this study. A multi-method approach (using content analysis, visualisation, video and time analysis) was applied to eligible consultations, extracting clinical tasks that involve physical interactions. Finally, an evidence-based scoring system was used on each clinical task, determining the likelihood of whether each task could be translated into telehealth. ResultsNine chronic conditions were observed across 38 GP-Patient consultations, predominately diabetes (39 %, 15/38). Out of these 38 consultations, 76 % (29/38) featured physical examinations, where 68 % (26/38) were initiated by GPs (e.g., auscultation), and 26 % (10/38) were initiated by patients (e.g., self-palpation). The average percentage of time spent on physical examination(s) during consultations is low (13.6 %, SD = 9.4 %). A total of 24 clinical tasks were observed across these 38 consultations. Out of these 24 tasks, 92 % (22/24) were supported by physical artefacts. The average score of a task being translatable to Telehealth is 7/10 (where Score 1 = Not amenable to being replicated over telehealth at this stage, scoring 10 = Easily translatable over telehealth with almost no additional equipment being required). ConclusionAll tasks observed across chronic condition management visits were deemed translatable/potentially translatable to telehealth. However, physical interactions between GPs and patients are still essential. Future research in telehealth should focus on examining ways to support physical examination, reduce uncertainty, promote safety netting, and facilitate patients’ safety at home with effective technology and support.

The effect of nocebo explanation and empathy on side-effect expectations of medication use following a fictional GP consultation

ABSTRACT The simple act of informing patients about side-effects increases the likelihood they will experience them (i.e. the nocebo effect). Explaining this psychological phenomenon could help to reduce side-effect experience, however, it is yet to be explored if this can be applied to clinical settings where new medication is prescribed. In addition, the degree to which a health-care provider empathetically communicates this to patients may have an impact. To investigate this, we carried out 2 × 2 factorial trial to assess the effect of nocebo explanation and empathy (plus their interaction) on side-effect expectations following a fictional GP consultation prescribing a new medication. Overall, 208 participants were randomised to watch one of the four fictive GP consultations and play the role of the patient. In all videos, participants received information about the reason for the consultation, the recommendation of a new fictive medicine, how to take it, benefits and side-effects. The videos differed in whether the GP provided an explanation of the nocebo effect (yes/no) and whether they communicated in an empathetic style (yes/no). After watching the video, participants were asked about their side-effect expectations and rated the quality of the GP’s communication. Two-way ANOVAs revealed no main effect of nocebo explanation on expectation of side-effects warned or not warned about in the consultation. However, there was a main effect of empathy, with participants watching the empathetic consultations having significantly lower expectations of non-warned-about side-effects. There was no significant interaction. Findings suggest that explaining the nocebo effect and GP empathy did little to allay expectations of side-effects that were specifically mentioned in the consultation. However, GP empathy had an effect by helping to reduce additional side-effect expectations participants still had. Future work should extend these findings to real GP consultations where the full dimensions of empathy can be explored.

The impact of rurality on patient experience and diagnostic pathway intervals in Scotland’s cancer patients: Further results from a national cancer diagnosis audit

BackgroundIn Scotland 17 % of the population reside rurally and previous research has demonstrated worse cancer outcomes in this group. The underlying reason for this is unclear. This study aims to determine whether patient presenting factors, GP consultation factors or the diagnostic pathways differ between urban and rural patients within Scotland. MethodsThis study combined two Scottish National Cancer Diagnosis Audits. Participating GPs collected data on the diagnostic pathway from primary to secondary care for cancer patients diagnosed during the audit period. Using the Scottish Government Urban Rural Classification, patients were designated as rural or urban dwellers and compared in descriptive analyses. Key cancer intervals (primary, diagnostic, secondary and treatment interval) were compared between urban and rural dwellers with an additional adjusted analysis for the main cancer sites. ResultsA total of 4309 cancer diagnoses were included in the study; 22 % were in patients from rural locations. Rural patients had significantly more consultations and investigations prior to referral than their urban counterparts. There was no difference in prolonged cancer pathways between the two groups except in lung cancer patients where rural patients had a significantly increased odds of a diagnostic interval of >90 days. ConclusionOur findings suggest differences in the interaction between patients and GPs prior to referral in urban and rural settings. However, this does not appear to lead to prolonged patient pathways, except in lung cancer. Further research is needed to determine whether this delay is clinically significant and contributing to poorer outcomes in Scottish rural dwellers with lung cancer.

Hospitalizations and severe complications following acute sinusitis in general practice: a registry-based cohort study.

To investigate complication rates of acute sinusitis in general practice, and whether antibiotic prescribing had an impact on complication rate. All adult patients diagnosed with sinusitis in Norwegian general practice between 1 July 2012 and 30 June 2019 were included. GP consultation data from the Norwegian Control and Payment for Health Reimbursements Database were linked with antibiotic prescriptions (Norwegian Prescription Database) and hospital admissions (Norwegian Patient Registry). Main outcomes were sinusitis-related hospitalizations and severe complications within 30 days. Logistic regression was used to estimate associations between antibiotic prescriptions, prespecified risk factors, individual GP prescribing quintile, and outcomes. A total of 711 069 episodes of acute sinusitis in 415 781 patients were identified. During the study period, both annual episode rate (from 30.2 to 21.2 per 1000 inhabitants) and antibiotic prescription rate (63.3% to 46.5%; P < 0.001) decreased. Yearly hospitalization rate was stable at 10.0 cases per 10 000 sinusitis episodes and the corresponding rate of severe complications was 3.2, with no yearly change (P = 0.765). Antibiotic prescribing was associated with increased risk of hospitalization [adjusted OR 1.8 (95% CI 1.5-2.1)] but not with severe complications. Individual GP prescribing quintile was not associated with any of the outcomes, whereas risk factors such as previous drug abuse, or head injury, skull surgery or malformations, and being immunocompromised were significantly associated with increased risk of both outcomes. Severe complications of acute sinusitis were rare and no protective effect of high prescribing practice among GPs was found. Recommendations to further reduce antibiotic prescribing are generally encouraged, except for high-risk groups.

Preparation for cardiac procedures: a cross-sectional study identifying gaps between outpatients' views and experiences of patient-centred care.

To examine and identify gaps in care perceived as essential by patients; this study examined outpatients': (1) views on what characterizes essential care and (2) experiences of care received, in relation to cardiac catheterization and subsequent cardiovascular procedures. Cross-sectional descriptive study. Surveys were posted to outpatients who had undergone elective cardiac catheterization in the prior 6 months at an Australian hospital. Participants completed a 65-item survey to determine: (a) aspects of care they perceive as essential to patients receiving care for a cardiac condition (Important Care Survey); or (b) their actual care received (Actual Care Survey). Numbers and percentages were used to calculate the most frequently identified essential care items; and the experiences of care received. Items rated as either 'Essential'/'Very important' by at least 80% of participants were determined. A gap in patient-centred care was identified as being any item that was endorsed as essential/very important by 80% or more of participants but reported as received by <80% of participants. Of 582 eligible patients, 264 (45%) returned a completed survey. A total of 43/65 items were endorsed by>80% of participants as essential. Of those, for 22 items, <80% reported the care as received. Gaps were identified in relation to general practitionerconsultation (1 item), preparation (1 item) subsequent decision making for treatment (1 item), prognosis (6 items), and post-treatment follow-up (1 item). Areas were identified where actual care fell short of patients' perceptions of essential care.