GP Consultations Research Articles

Managing lower urinary tract symptoms in primary care: qualitative study of GPs’ and patients’ experiences

BackgroundLower urinary tract symptoms (LUTS) are common in males aged ≥40 years and have a considerable impact on quality of life. Management can be complex, and although most LUTS could be treated effectively in primary care, referrals to urology outpatients are increasing.AimTo explore GPs’ experiences of managing LUTS together with patients’ experiences of and preferences for treatment in primary care.Design and settingTelephone interviews were conducted with GPs and male patients presenting to primary care with bothersome LUTS.MethodEleven GPs and 25 male patients were purposively sampled from 20 GP practices in three UK regions: Newcastle upon Tyne, Bristol, and South Wales. Interviews were conducted between May 2018 and January 2019, and were analysed using a framework approach.ResultsDifficulty establishing causes and differentiating between prostate and bladder symptoms were key challenges to the diagnosis of LUTS in primary care, often making treatment a process of trial and error. Pharmacological treatments were commonly ineffective and often caused side effects. Despite this, patients were generally satisfied with GP consultations and expressed a preference for treatment in primary care.ConclusionManaging LUTS in primary care is a more accessible option for patients. Given the challenges of LUTS diagnosis, an effective diagnostic tool for use by GPs would be beneficial. Ensuring bothersome LUTS are not dismissed as a normal part of ageing is essential in improving patients’ quality of life. Greater exploration of the role of non-pharmacological treatments is needed.

Finding meaning in the consultation: working in the hermeneutic window.

In a previous article,1 we proposed a new model of the GP consultation represented as a two-by-two table with four related domains (Figure 1).

Unmet health care need and income-Related horizontal equity in use of health care during the COVID-19 pandemic.

Using monthly data from the Understanding Society (UKHLS) COVID‐19 Survey we analyse the evolution of unmet need and assess how the UK health care system performed against the principle of horizontal equity in health care use during the first wave of COVID‐19 wave. Unmet need was most evident for hospital care, and less pronounced for primary health services (non‐emergency medical helplines, GP consultations, community pharmacist advice, over the counter medications and prescriptions). Despite this, there is no evidence that horizontal equity, with respect to income, was violated for NHS hospital outpatient and inpatient care during the first wave of the pandemic. There is evidence of pro‐rich inequities in use of GP consultations, prescriptions and medical helplines at the peak of the first wave, but these were eliminated as the pandemic progressed. There are persistent pro‐rich inequities for services that may relate to individuals' ability to pay (over the counter medications and advice from community pharmacists).

Re-emerging Historical Clinical Signs: The Psychological and Physical Bystander Victims of COVID-19.

Re-emerging Historical Clinical Signs: The Psychological and Physical Bystander Victims of COVID-19.

Multilevel modeling of geographic variation in general practice consultations.

To test relatively simple and complex models for examining model fit, higher-level variation in, and correlates of, GP consultations, where known nonhierarchical data structures are present. New South Wales (NSW), Australia. Association between socioeconomic circumstances and geographic remoteness with GP consultation frequencies per participant was assessed using single-level, hierarchical, and multiple membership cross-classified (MMCC) models. Models were adjusted for age, gender, and a range of socioeconomic and demographic confounds. A total of 261,930 participants in the Sax Institute's 45 and Up Study were linked to all GP consultation records (Medicare Benefits Schedule; Department of Human Services) within 12months of baseline (2006-2009). Deviance information criterion values indicated the MMCC negative binomial regression was the best fitting model, relative to an MMCC Poisson equivalent and simpler hierarchical and single-level models. Between-area variances were relatively consistent across models, even when between GP variation was estimated. Lower rates of GP consultation outside of major cities were only observed once between-GP variation was assessed simultaneously with between-area variation in the MMCC models. Application of the MMCC model is necessary for estimation of variances and effect sizes in sources of big data on primary care in which complex nonhierarchical clustering by geographical area and GP is present.

Update and practical advice for travel vaccinations and consultations in primary care

Update and practical advice for travel vaccinations and consultations in primary care Abstract. Health issues during travels are common. Infections are amongst the most frequent problem besides accidents and cardiovascular events. Prevention is based on avoiding risks, drug prophylaxis and vaccinations. This article focuses on travel vaccinations and aims to provide a general update and practical advice for travel consultations in primary care. Vaccine-preventable infections are systematically summarized, including a specific risk assessment for children, general vaccination indication, vaccination schedule, and information particularities of specific vaccines. Updating the vaccination status is often neglected in regular GP consultations for adult patients. Appointments for travel advice are therefore an ideal and important means of checking and completing the recommended basic and booster immunizations. Travel immunizations typically aim at providing an individual protection from infection. In contrast, basic vaccinations also consider altruistic aspects such as herd immunity. Since ambivalence or skepticism about vaccination is widespread, this discrepancy may result in discussions. Travel consultations may therefore generate opportunities to clarify general ambivalences towards vaccinations. Based on the concept of "Motivational Interviewing", we show communicative possibilities to reduce ambivalence and resistance and ideally to promote the willingness to vaccinate through shared decision-making.

How many general practice consultations occur in Ireland annually? Cross-sectional data from a survey of general practices

BackgroundGeneral practice plays a central role in the Irish health system. This study aimed to determine a baseline estimate of the number of consultations completed in general practice in Ireland annually to facilitate evidence-based healthcare planning.MethodsA survey was emailed to all 3378 individual members of the Irish College of General Practitioners in February 2020 asking each practice to report on consultations by general practitioners and practice nurses occurring on the previous day of practice.ResultsA total of 507 practices responded to the survey, reporting 34,594 general practitioner consultations and 13,161 nurse consultations on one day. Extrapolating this figure nationally, we estimate 21,353,731 GP consultations and 7,749,615 practice nurse consultations occur in Ireland annually. An Irish person visits their GP an estimated 4.34 times a year and the average consultation time is 13.7 min.ConclusionsThis study shows that over 29.1 million consultations take place in Irish general practice every year. Innovative interventions to increase the capacity of general practice are needed to ensure high-quality care continues to be accessible in Ireland.

Factors associated with potentially missed acute deterioration in primary care: cohort study of UK general practices

BackgroundIn the UK, while most primary care contacts are uncomplicated, safety incidents do occur and result in patient harm, for example, failure to recognise a patient’s deterioration in health.AimTo determine the patient and healthcare factors associated with potentially missed acute deterioration in health.Design and settingCohort of patients registered with English Clinical Practice Research Datalink general practices between 1 April 2014 and 31 December 2017 with linked hospital data.MethodA potentially missed acute deterioration was defined as a patient having a self-referred admission to hospital having been seen in primary care by a GP in the 3 days beforehand. All diagnoses and subsets of commonly-reported missed conditions were analysed..ResultsA total of 116 097 patients contacted a GP 3 days before an emergency admission. Patients with sepsis (adjusted odds ratio [aOR] 1.09, 95% confidence interval [CI] = 1.01 to 1.18) or urinary tract infections (aOR 1.09, 95% CI = 1.04 to 1.14) were more likely to self-refer. The duration of GP appointments was associated with self-referral. On average, a 5-minute increase in appointment time resulted in a 10% decrease in the odds of self-referred admissions (aOR 0.90, 95% CI = 0.89 to 0.91). Patients having a telephone consultation (compared with face-to-face consultation) (aOR 1.14, 95% CI = 1.11 to 1.18) previous health service use, and presence of comorbidities were also associated with self-referred admission.ConclusionDifferentiating acute deterioration from self-limiting conditions can be difficult for clinicians, particularly in patients with sepsis, urinary tract infections, or long-term conditions. The findings of this study support the call for longer GP consultations and caution against reliance on telephone consultations in primary care; however, more research is needed to understand the underlying mechanisms.

The MRCGP Recorded Consultation Assessment: time to drop 10 minutes as standard?

Why do we continue to examine GP trainees at 10 minutes when the RCGP itself has called for longer GP consultations? The recently announced changes to the MRCGP in response to the COVID-19 pandemic has seen the replacement of the Clinical Skills Assessment (CSA) with the Recorded Consultation Assessment (RCA).1 Yet the guidance on the length of the face-to-face consultations to be submitted in the assessment remains at 10 minutes — even for complex cases. Arguments put forward in the past suggest that the 10 minutes examination exists because: 1. The exam only assesses the face-to-face element of the consultation and not those activities that take place either side of the consultation such as preparation and documentation 2. The exam must prepare the candidate to practice …

Incidence, healthcare-seeking behaviours, antibiotic use and natural history of common infection syndromes in England: results from the Bug Watch community cohort study

BackgroundBetter information on the typical course and management of acute common infections in the community could inform antibiotic stewardship campaigns. We aimed to investigate the incidence, management, and natural history of a range of infection syndromes (respiratory, gastrointestinal, mouth/dental, skin/soft tissue, urinary tract, and eye).MethodsBug Watch was an online prospective community cohort study of the general population in England (2018–2019) with weekly symptom reporting for 6 months. We combined symptom reports into infection syndromes, calculated incidence rates, described the proportion leading to healthcare-seeking behaviours and antibiotic use, and estimated duration and severity.ResultsThe cohort comprised 873 individuals with 23,111 person-weeks follow-up. The mean age was 54 years and 528 (60%) were female. We identified 1422 infection syndromes, comprising 40,590 symptom reports. The incidence of respiratory tract infection syndromes was two per person year; for all other categories it was less than one. 194/1422 (14%) syndromes led to GP (or dentist) consultation and 136/1422 (10%) to antibiotic use. Symptoms usually resolved within a week and the third day was the most severe.ConclusionsMost people reported managing their symptoms without medical consultation. Interventions encouraging safe self-management across a range of acute infection syndromes could decrease pressure on primary healthcare services and support targets for reducing antibiotic prescribing.

Cost-effectiveness of high dose versus adjuvanted trivalent influenza vaccines in England and Wales

Aims High dose trivalent influenza vaccine (HD TIV) and adjuvant TIV (aTIV) have been developed specifically for adults aged 65 and older (65+) who are at high risk of life-threatening complications. However, there is a scarcity of evidence comparing the clinical and cost-effectiveness of HD TIV and aTIV. The aim of this study was to determine the cost-effectiveness of HD TIV versus aTIV in the England and Wales 65+ population. Methods A cost-utility analysis was conducted using a decision tree with two influenza related outcomes: Laboratory confirmed cases that could result in GP consultation, and hospitalizations that may result in premature mortality. Due to a lack of comparative evidence, the effectiveness of HD TIV versus aTIV was calculated indirectly, based on relative effectiveness estimates for each vaccine versus a common comparator, standard dose (SD) TIV. The primary analysis included hospitalizations explicitly due to influenza/pneumonia. Cost-effectiveness was established for three scenarios applying differing relative effectiveness estimates for aTIV versus SD TIV. Uncertainty was analysed in one-way deterministic sensitivity analyses. A secondary analysis included hospitalizations due to any respiratory illness. Results The minimum population impact of vaccination with HD TIV rather than aTIV was 13,092 fewer influenza cases, 1,109 fewer influenza related deaths, 4,673 fewer hospitalizations, and 3,245 fewer GP appointments. HD TIV was cost-effective versus aTIV for all three effectiveness scenarios, with incremental cost-effectiveness ratios (ICER) equal to £1,932, £4,181, and £8,767 per quality adjusted life year. Results were consistent across the secondary analysis and deterministic sensitivity analyses. Limitations The analysis was limited by a lack of robust and consistent effectiveness data for aTIV. Conclusion HD TIV is cost-effective versus aTIV in people aged 65+ in England and Wales. Use of HD TIV over aTIV could increase clinical benefits and reduce the public health and economic burden of influenza.

What is learned from an Australian older person health assessment?

Objective To examine what new health information is identified at a patient's most recent 75+HA compared with their standard GP consultations in the prior 24 months. Methods Parameters measured included newly identified chronic conditions, new management for previously diagnosed chronic conditions, medication management, referrals, vaccinations, and positive test results for the monitoring of previously diagnosed chronic conditions. A retrospective patient record study collecting data from two GP clinics in metropolitan and regional Victoria was undertaken. A total of 195 75+HA recipients were included. Results No significant difference was found in the number of new chronic conditions recorded at patients' most recent 75+HA compared with standard GP consultations in the prior 24 months. However, significant differences in the types of conditions were noted, with 75+HAs significantly more likely to record elevated lipids (P<0.001), vitamin D deficiencies (P=0.004), eye/vision-related (P=0.011), diabetes (P=0.019), and hearing conditions (P=0.045) compared with standard GP consultations. Significantly more referrals (P<0.001) and new management for previously diagnosed conditions (P=0.009) occurred at 75+HA than at standard GP consultations. Patients who were receiving their first 75+HA were significantly more likely to receive vaccinations than those receiving a subsequent 75+HA (P=0.022). Conclusion 75+HAs fulfil a role in addressing chronic health problems otherwise overlooked during standard GP consultations. What is known about the topic? Since their introduction in 1999, uptake of 75+HAs has been low. Two studies from 2001 to 2002 have suggested benefits of conducting 75+HAs to identify new health problems. What does this paper add? When compared with standard GP consultations, 75+HAs identify different types of new health problems, including elevated lipids, vitamin D deficiencies, eye/vision-related conditions, diabetes, and hearing conditions. Furthermore, more referrals and new management of previously identified problems occur at 75+HA. What are the implications for practitioners? 75+HAs fulfil a role in identifying and addressing chronic health problems in older patients that may otherwise have been overlooked at standard GP consultations. Suggestions of additions to the 75+HA template are made based on common chronic conditions detected in standard consultations but not included currently within the 75+HA.

Measuring the complexity of general practice consultations: a Delphi and cross-sectional study in English primary care.

BackgroundThe complexity of general practice consultations may be increasing and varies in different settings. A measure of complexity is required to test these hypotheses.AimTo develop a valid measure of general practice consultation complexity applicable to routine medical records.Design and settingDelphi study to select potential indicators of complexity followed by a cross-sectional study in English general practices to develop and validate a complexity measure.MethodThe online Delphi study over two rounds identified potential indicators of consultation complexity. The cross-sectional study used an age–sex stratified random sample of patients and general practice face-to-face consultations from 2013/2014 in the Clinical Practice Research Datalink. The authors explored independent relationships between each indicator and consultation duration using mixed-effects regression models, and revalidated findings using data from 2017/2018. The proportion of complex consultations in different age–sex groups was assessed.ResultsA total of 32 GPs participated in the Delphi study. The Delphi panel endorsed 34 of 45 possible complexity indicators after two rounds. After excluding factors because of low prevalence or confounding, 17 indicators were retained in the cross-sectional study. The study used data from 173 130 patients and 725 616 face-to-face GP consultations. On defining complexity as the presence of any of these 17 factors, 308 370 consultations (42.5%) were found to be complex. Mean duration of complex consultations was 10.49 minutes, compared to 9.64 minutes for non-complex consultations. The proportion of complex consultations was similar in males and females but increased with age.ConclusionThe present consultation complexity measure has face and construct validity. It may be useful for research, management and policy, and for informing decisions about the range of resources needed in different practices.

Two Houses: A new model for the GP consultation

The seemingly freestyle nature of the GP consultation poses a unique challenge for trainees starting out on a career in general practice. Unlike its hospital counterpart, there is no set format for the questions asked when taking a history, and so the structure of consultations is more of a craft to master than a process to be learnt. Consultation models are an attempt to provide a scaffold on which to build communication skills, and this article presents a new model for the consultation based on the metaphor of two houses which the doctor and patient explore together.

Targeted encouragement of GP consultations for possible cancer symptoms: a randomised controlled trial.

BackgroundFor some common cancers, survival is lower in the UK than in comparable high-income countries.AimTo assess the effectiveness of a targeted postal intervention (to promote awareness of cancer symptoms and earlier help seeking) on patient consultation rates.Design and settingA two-arm randomised controlled trial was carried out on patients aged 50–84 years registered at 23 general practices in rural and urban areas of Greater London, Greater Manchester, and the North East of England.MethodPatients who had not had a consultation at their general practice in the previous 12 months and had at least two other risk factors for late presentation with cancer were randomised to intervention and control arms. The intervention consisted of a posted letter and leaflet. Primary outcome was the number of consultations at the practice with patients randomised to each arm in the 6 months subsequent to posting the intervention. All patients with outcome data were included in the intention-to-treat analyses.ResultsIn total, 1513 patients were individually randomised to the intervention (n = 783) and control (n = 730) arms between Nov 2016 — May 2017; outcome data were available for 749 and 705 patients, respectively, with a statistically significantly higher rate of consultation in the intervention arm compared with the control arm: 436 versus 335 consultations (relative risk 1.40, 95% confidence interval = 1.11 to 1.77, P = 0.004). There was, however, no difference in the numbers of patients consulting.ConclusionTargeted interventions of this nature can change behaviour; there is a need to develop interventions that can be more effective at engaging patients with primary care. This study demonstrates that targeted interventions promoting both awareness of possible cancer symptoms and earlier health seeking, can change behaviour. There is a need to develop and test interventions that can be more effective at engaging the most at-risk patients.

Primary care consultation length by deprivation and multimorbidity in England: an observational study using electronic patient records

BackgroundLonger GP consultations are recommended as one way of improving care for people with multimorbidity. In Scotland, patients who are multimorbid and living in deprived areas do not have longer consultations, although their counterparts in the least deprived areas do. This example of the inverse care law has not been examined in England.AimTo assess GP consultation length by socioeconomic deprivation and multimorbidity.Design and settingRandom sample of 1.2 million consultations from 1 April 2014 to 31 March 2016 for 190 036 adults in England drawn from the Clinical Practice Research Datalink.MethodConsultation duration was derived from time of opening and closing the patient’s electronic record. Mean duration was estimated by multimorbidity level and type, adjusted for number of consultations and other patient and staff characteristics and patient and practice random effects.ResultsConsultations lasted 10.9 minutes on average and mean duration increased with number of conditions. Patients with ≥6 conditions had 0.9 (95% confidence interval [CI] = 0.8 to 1.0) minutes longer than those with none. Patients who are multimorbid and with a mental health condition had 0.5 (CI = 0.4 to 0.5) minutes longer than patients who were not multimorbid. However, consultations were 0.5 (CI = 0.4 to 0.5) minutes shorter in the most compared with the least deprived fifth of areas at all levels of multimorbidity.ConclusionGPs in England spend longer with patients who have more conditions, but, at all multimorbidity levels, those in deprived areas have less time per GP consultation. Further research is needed to assess the impact of consultation length on patient and system outcomes for those with multimorbidity.

Changing media depictions of remote consulting in COVID-19: analysis of UK newspapers.

Remote consulting was introduced quickly into UK general practice in March 2020 as an emergency response to COVID-19. In July 2020, 'remote-first' became long-term government policy. To explore how this change was portrayed in national newspapers and how depictions changed over time. Thematic analysis of newspaper articles referring to remote GP consultations from two time periods: 2 March-31 May 2020 (period 1) and 30 July-12 August 2020 (period 2). Articles were identified through, and extracted from, LexisNexis Academic UK. A coding system of themes and narrative devices was developed and applied to the data. The analysis was developed iteratively, amending the coding structure as new data were added. Remote consulting was widely covered in newspapers. Articles in period 1 depicted it positively, equating digital change with progress and linking novel technological solutions with improved efficiency and safety (for example, infection control) in a service that was overdue for modernisation. Articles in period 2 questioned the persistence of a remote-first service now that the pandemic was waning, emphasising, for example, missed diagnoses, challenges to the therapeutic relationship, and digital inequalities. As the first wave of the pandemic came and went, media depictions of remote consulting evolved from an 'efficiency and safety' narrative to a 'risks, inequalities, and lack of choice' narrative. To restore public trust in general practice, public communication should emphasise the wide menu of consulting options now available to patients and measures being taken to assure safety and avoid inequity.

PIN60 Cost-Effectiveness of Quadrivalent Influenza Vaccine High Dose Versus Adjuvanted Standard Dose Trivalent Influenza Vaccine in England

Influenza is recognised as an important cause of morbidity and mortality in human populations, resulting in an average of over 21,000 influenza-associated deaths each year in England alone, with 85% of influenza-associated deaths in those over the age of 65. Quadrivalent Influenza Vaccine High-Dose (QIV-HD) has been specifically developed for the over 65 population, containing 4-times more antigen than current standard dose (SD) vaccines. The objective of this study is to estimate the cost-effectiveness of QIV-HD compared to adjuvant Trivalent Influenza Vaccine (aTIV) using clinically relevant endpoints. A static decision tree model was used to compare influenza cases, GP consultations, hospitalisations, and deaths resulting from influenza complications. Due to a sparsity of trial-based evidence and heterogeneous findings from observational studies for aTIV, three different relative vaccine efficacy scenarios were investigated for QIV-HD versus aTIV. In addition, cost-effectiveness was assessed for QIV-HD versus aTIV for a base case analysis in which hospitalisations were defined as due to influenza/pneumonia. Discounted QALY losses were included for hospitalisations and in-hospital deaths. Analyses were conducted from a UK healthcare system perspective over a one-year time horizon. Base case results, with hospitalisation defined as influenza/pneumonia events, indicate that QIV-HD would be considered a cost-neutral vaccination strategy (ICER: £824/QALY), considerably below the £20,000 willingness to pay threshold, delivering superior health outcomes in the over 65 population compared with the current approach using aTIV. When broader definitions of hospitalisations were considered, QIV-HD was shown to be the dominant vaccination strategy compared to aTIV across most scenarios assuming various vaccine efficacy inputs for aTIV for both lab-confirmed influenza cases and hospitalisations. QIV-HD could be a highly cost-effective, and in some cases dominant, alternative to aTIV in England and could reduce the annual public health burden of influenza-related complications.

Unmet Health Care Need and Income-Related Horizontal Equity in Access During the COVID-19 Pandemic

Using monthly data from the Understanding Society (UKHLS) COVID-19 Survey we analyse the evolution of unmet need and assess how the UK health care system performed against the norm of horizontal equity in health care access during the first wave of COVID-19 wave. Unmet need was most evident for hospital care, and less pronounced for primary health services (medical helplines, GP consultations, local pharmacist advice, over the counter medications and prescriptions). Despite this, there is no evidence that horizontal equity, with respect to income, was violated for NHS hospital outpatient and inpatient care during the first wave of the pandemic. There is evidence of pro-rich inequities in access to GP consultations, prescriptions and medical helplines at the peak of the first wave, but these were eliminated as the pandemic progressed. There are persistent pro-rich inequities for services that relate to individuals’ ability to pay (over the counter medications and advice from the local pharmacist).

The role of local inpatient psychiatric units and general practitioner on continuity of care in Northern Norway: A case-register study.

ObjectivesThe general practitioners' (GP) role in the care of mental health patients has received increased attention. The literature underlines the need for integration of primary and specialist services, but cross‐boundary continuity for patients with severe conditions may be particularly poor. The aim of this study was to analyze the collaboration between primary care and different models of specialized psychiatric services for patients with severe conditions.MethodsWe compared a local and a centralized model of mental health care. Service utilization over a 5‐year period was studied.ResultsFindings suggest that a local institution‐based model of services positively affects the use of both GP and specialist outpatient care, with most inpatients utilizing both GP and specialist outpatient consultations. In the centralized model, a substantial proportion of inpatients only used GP outpatient care. Furthermore, inpatients that used both GP and specialist outpatient services received more of both services compared to those who did not enter specialist outpatient care at all.ConclusionLocal inpatient units may positively affect continuity of care and collaboration between general practitioners and specialist psychiatric services compared to more traditional hospital units, probably because better functional integration of services, better facilitation of clinical alliances/relationships, or a more network‐oriented treatment philosophy.