GP Lists Research Articles

Exploring treatment burden of Oral Nutritional Supplements (ONS) and impact on antibiotics using a data linkage approach

Abstract Introduction Treatment burden associated with thickeners is significant1. Understanding of potential treatment burden associated with ONS is lacking, however wastage due to ONS partial or full nonconsumption, and stock piling are recognised2. Wastage is evidence of over prescribing. Improving fluid intake by increasing variety is evidence based3 - ONS reduces opportunity. Whether thickener or ONS is prescribed, patients can withdraw consent by not drinking (verbally/silently). We investigated a potential correlation between ONS and low intake dehydration, and if detectable using a proxy measure: antibiotic prescribing for urinary tract infection (UTI). We explored using ePACT2 data to investigate co-prescribing of interventions that inter-relate, a type of data linkage study. Improved fluid intake can decrease laxative use, but did not reduce antibiotic use3. We hypothesized that with a large data set, it may be possible to detect associations of treatment burden and antibiotic use. Aim To explore the relationship between prescribing of ONS with antibiotics for UTIs in older adults in Primary Care (England). Methods We investigated co-prescribing of antibiotics prescribed for UTI (nitrofurantoin, trimethoprim) and ONS in older adults (> 65 years) in Primary Care. Data was obtained from the NHS Business Services Authority Data Services Support as bespoke analysis of prescribing ePACT2 data linked by NHS number. Retrospective analysis was performed on anonymised data for 3 years (January 2019 to December 2022). Ethical approval was not required. Data unattributable to a specific region was excluded. Results Initial analysis suggested that prescribing of UTI antibiotics was 3 times more common in older adults prescribed ONS compared with controls (an average 2.86% of the patients on GP list were prescribed an antibiotic for a UTI, increasing to 8.59% for those co-prescribed ONS). This correlation appeared consistent, however, due to high volume and level of detail of UTI antibiotic prescribing, this interpretation is incorrect. On further analysis, the population rate of UTI antibiotic and ONS was plotted to show trend over time, demonstrating no correlation. Prescription of UTI antibiotic over time is consistent, reflecting that acute lower UTI is not very reducible, and antibiotic prophylaxis use is common and repeated monthly. Additionally, from this data set you cannot ascertain if frequency of antibiotic prescription(s) pre-dates initiation of ONS. We did not investigate confounding factors such as co-prescribing of catheter use, gender, frailty and advancing age. Our oldest patients with decreased thirst, reduced appetite cues and ability to eat and drink will also be those most likely to get an UTI. Discussion/Conclusion Future data linkage work in this area should include a wider range of data e.g. detailed demographics, medical and prescribing history over time and all adverse events from low intake dehydration. Exploration of the impact of ONS and thickener prescription on patient experience, perceived treatment burden and the impact on fluid intake would be useful. Audit of shared decision making at initiation and review would also be beneficial in obtaining baseline data on consent at start and throughout duration of prescription.

Implementation of a shared medication list in primary care \u2013 a controlled pre-post study of medication discrepancies

BackgroundAccess to medicines information is important when treating patients, yet discrepancies in medication records are common. Many countries are developing shared medication lists across health care providers. These systems can improve information sharing, but little is known about how they affect the need for medication reconciliation. The aim of this study was to investigate whether an electronically Shared Medication List (eSML) reduced discrepancies between medication lists in primary care.MethodsIn 2018, eSML was tested for patients in home care who received multidose drug dispensing (MDD) in Oslo, Norway. We followed this transition from the current paper-based medication list to an eSML. Medication lists from the GP, home care service and community pharmacy were compared 3 months before the implementation and 18 months after. MDD patients in a neighbouring district in Oslo served as a control group.ResultsOne hundred eighty-nine patients were included (100 intervention; 89 control). Discrepancies were reduced from 389 to 122 (p < 0.001) in the intervention group, and from 521 to 503 in the control group (p = 0.734). After the implementation, the share of mutual prescription items increased from 77 to 94%. Missing prescriptions for psycholeptics, analgesics and dietary supplements was reduced the most.ConclusionsThe eSML greatly decreases discrepancies between the GP, home care and pharmacy medication lists, but does not eliminate the need for medication reconciliation.

Changes in General Practitioners' consultation frequency over time for patients with hypertension or anxiety/depression symptoms: a 10-year follow-up of the Norwegian HUNT study.

General Practitioners' (GPs') workload has been suggested to increase in many countries; how does this impact patient follow-up? To investigate trends in GP consultation patterns for adults according to baseline hypertension and anxiety/depression symptoms and attribution of the GP to trend differences. Prospective cohort study, linking survey data and clinical measurements from the Norwegian HUNT3 study (2006-08) with national administrative data on GP list assignment and consultations with GP services. We grouped participants aged 40-59 years according to sex and their baseline status regarding hypertension and anxiety/depression symptoms. We registered GP consultations in 2007-16 and used general estimation equation models to estimate the level of GP consultations per month per year during follow-up. We used multilevel models with participants nested in their assigned regular GP to calculate GP-level intra-class correlation coefficients, reflecting to what extent patients' consultation patterns could be attributed to the individual GP. In total, 47 550 HUNT3 participants were registered with 102 different GPs in Nord-Trøndelag County, Norway, in 2007. Adjusted for age, we observed an overall increase in GP consultations in 2007-16, particularly in those with a better health status at baseline. About 2% of the variance of patient consultations could be attributed to differences between GPs and 10% to the use of lengthy consultations. Out-of-hours consultations did not change much in the study period 2007-16. Increased use of GP consultations, mainly among the healthiest participants, encourage further research into whether these patients displace patients with heavier and more complex needs.

Informing future research for carriage of multiresistant Gram-negative bacteria: problems with recruiting to an English stool sample community prevalence study

ObjectivesThis study aims to highlight problems with recruiting to an English stool sample community prevalence study. It was part of a larger cross-sectional research to determine the risk factors for...

Diabetes in remission

Diabetes in remission

Concern over plans to remove 'ghost patients' from GP lists.

Nursing leaders have criticised plans to axe patients from GP lists in England if they have not visited their surgery for five years.

P93 Supporting Patient Involvement In Service Development: Eliciting Patient-centred Information To Inform Commissioning Of Copd Services

Introduction Patient involvement in population level health care decisions often involves consultation rather than interactive decision-making. Lack of insight into appropriate methods is a barrier to patient involvement. Working Together for Change (WTfC) is a person-centred process to inform service development. Information from person-centred reviews (PCRs) is themed in a two-day co-production workshop. It is effective in social care and mental health but has not been applied in physical health. We tested its feasibility to improve the quality of person-centred information for COPD commissioners and of patient involvement. Methods Forty COPD patients recruited from GP lists, secondary care and support groups participated in one-to-one PCRs. PCRs identified their priorities for what’s working in their life regarding COPD, what’s not working, what’s important to the future. These patients, health service professionals and third sector organisations involved in COPD support were then invited to attend the two one-day workshops. Patients’ priorities were themed collaboratively. Root cause analysis of what was not working was followed by statements of what success would look like if root causes were addressed. Action plans were created. Qualitative data from workshop observations and participant interviews were analysed using thematic analysis. Results Service priorities included information, holistic care, access, dietary support, access to patient information for HCPs. The improved quality of the person-centred information was evident in the ways in which professionals’ understanding of patient needs was enhanced through close, informal interaction with patients and carers, e.g. witnessing difficulties such as simultaneously eating and breathing and other physical limitations that prevent patients following healthcare advice (Table 1). Participation was positive for patients and professionals (Table 1) experiencing it as engaging and collaborative. Patients felt both heard and empowered and felt all the information they offered was precious. Discussion Patients found it a powerful experience and felt they made a contribution for the future. Professionals gained emotional and practical insights which inspired motivation for change in service delivery. The process tapped into strong motivations for mutual understanding. It is an effective element in developing person-centred COPD services and is transferable to other LTCs. Supported by grant from the Health Foundation

Patient experience and the role of postgraduate GP training: a cross-sectional analysis of national Patient Survey data in England.

Quality indicators for primary care focus predominantly on the public health model and organisational measures. Patient experience is an important dimension of quality. Accreditation for GP training practices requires demonstration of a series of attributes including patient-centred care. The national GP Patient Survey (GPPS) was used to determine the characteristics of general practices scoring highly in responses relating to the professional skills and characteristics of doctors. Specifically, to determine whether active participation in postgraduate GP training was associated with more positive experiences of care. Retrospective cross-sectional study in general practices in England. Data were obtained from the national QOF dataset for England, 2011/12 (8164 general practices); the GPPS in 2012 (2.7 million questionnaires in England; response rate 36%); general practice and demographic characteristics. Sensitivity analyses included local data validated by practice inspections. multilevel regression models adjusted for clustering. GP training practice status (29% of practices) was a significant predictor of positive GPPS responses to all questions in the 'doctor care' (n = 6) and 'overall satisfaction' (n = 2) domains but not to any of the 'nurse care' or 'out-of-hours' domain questions. The findings were supported by the sensitivity analyses. Other positive determinants were: smaller practice and individual GP list sizes, more older patients, lower social deprivation and fewer ethnic minority patients. Based on GPPS responses, doctors in GP training practices appeared to offer more patient-centred care with patients reporting more positively on attributes of doctors such as 'listening' or 'care and concern'.

Diagnosis and management of hereditary haemochromatosis

Hereditary haemochromatosis is an autosomally recessive inherited genetic disorder associated with a defect in the iron regulating hormone hepcidin, causing increased intestinal absorption of iron and subsequent deposition in the liver, pancreas, heart, joints, skin, and gonads. Mutation in the human haemochromatosis protein (HFE) gene is the most common problem and was first described in 1996.1 The majority of patients with HFE haemochromatosis express C282Y homozygosity, which accounts for 80%–85% of individuals with hereditary haemochromatosis. This mutation has a prevalence of 1 in 220–250 in the northern European population in which it is most commonly found.2 The other commonly found mutation is H63D but this is not associated with iron overload unless with C282Y as the compound heterozygote, C282Y/H63D which accounts for approximately 5% of patients with hereditary haemochromatosis.2 There are other mutations of non-HFE genes resulting in iron overload syndromes but these are rare. A GP list of 2000 patients will have approximately four patients with hereditary haemochromatosis. Despite this, many GPs have never seen …

The disappearance of the "revolving door" patient in Scottish general practice: successful policies.

BackgroundWe describe the health of "revolving door" patients in general practice in Scotland, estimate changes in their number over the timescale of the study, and explore reasons for changes, particularly related to NHS and government policy.MethodsA mixed methods predominantly qualitative study, using a grounded theory approach, set in Scottish general practice. Semi-structured interviews were conducted with professional key informants, 6 Practitioner Services staff who administer the GP registration system and 6 GPs with managerial or clinical experience of working with “revolving door” patients. Descriptive statistical analysis and qualitative analysis of patient removal episodes linked with routine hospital admissions, outpatient appointments, drug misuse treatment episodes and deaths were carried out with cohorts of “revolving door” patients identified from 1999 to 2005 in Scotland.ResultsA “revolving door” patient is removed 4 or more times from GP lists in 7 years. Patients had complex health issues including substance misuse, psychiatric and physical health problems and were at high risk of dying. There was a dramatic reduction in the number of “revolving door” patients during the course of the study.Conclusions“Revolving door” patients in general practice had significant health problems. Their numbers have reduced dramatically since 2004 and this probably resulted from improved drug treatment services, pressure from professional bodies to reduce patient removals and the positive ethical regulatory and financial climate of the 2004 GMS GP contract. This is a positive development for the NHS.

Does socioeconomic status of list populations affect GP practice? A register-based study of 2201 Norwegian GPs

Background: Mortality and morbidity rates differ markedly across social strata, resulting in different needs for health services. The utilization of GP services may be higher in groups with lower socioeconomic status (SES), although findings differ when taking health needs into account.Objectives: The aim of this study was to assess the association between the SES of list populations and the characteristics of GP practices, consultation rates, and income per patient in a fee-for-service financing model.Method: A cross-sectional register-based study, including all Norwegian specialist GPs practising in 2008. After grouping GP lists into five levels based on a constructed index of SES, associations between SES and GP practice characteristics were analysed by analysis of variance and linear regression.Results: GP lists with the lowest SES had higher consultation rates (regression coefficient, 0.31; P < 0.001) and a higher total fee-for-service (regression coefficient, 104; P < 0.001) than lists with the highest SES. Laboratory use in consultations was less frequent in the lowest SES group (regression coefficient, –3.1; P < 0.001). No differences were found in the frequency of long consultations or fee-for-service per consultation. The frequency of multidisciplinary meetings was 2.5 times higher in the lowest SES group compared to the highest SES group.Conclusion: The findings indicate a markedly higher utilization of GP services in list populations with a lower SES, compensated by a higher annual GP income per patient. However, consultation characteristics, such as time spent with patients and use of laboratory tests, did not increase with lower SES lists.

Department of Health moves to end “open but full” GP lists

The Department of Health has announced plans to remove incentives for general practices to have “open but full” patient lists, to make the practice list system more transparent to patients. Currently if a practice wants to close its patient list and stop accepting new patients it risks losing the right to provide additional and enhanced services. As a result some practices keep their list open but stop accepting new patients, declaring their list …

Inventing the wheel in general practice

As multiple morbidity becomes more common, budgets tighten and inequalities widen, the fragmentation of health care is increasingly prevalent, expensive, and unacceptable. Fragmentation of care occurs when encounters with patients address only some of a patient's problems, when practitioners are not informed by previous encounters and do not inform the encounters which follow, when the left hand of the service does not know what the right hand is doing and when care is delivered on a partial basis, for example, by responding primarily to demands rather than to needs. Fragmentation of health systems often occurs in conurbations, when some services are delivered on the basis of GP lists, while other services are organised at an area level. Federations of general practices can fragment care within areas when only some practices are involved. A consistent conclusion of Deep End meetings has been that general practices offer a ready solution to the problems of fragmentation, as the natural and sustainable hubs around which local health systems should develop. Although general …

Elective surgical referral guidelines - background educational material or essential shared decision making tool? A survey of GPs' in England

BackgroundTo investigate general practitioners' (GPs') attitudes to guidelines for elective surgical referral in England. To understand their use of guidelines, and attitudes to shared decision making in the referral decision.MethodsA questionnaire was developed which investigated attitudes to and use of guidelines. It was given to a stratified random sample 30% (n = 310) drawn from GP lists of 10 English health districts (primary care trusts (PCTs)). GPs were invited to respond online, by telephone, fax or post. Data were analysed using descriptive statistics and backwards stepwise logistic regression.ResultsResponses were representative of GPs in England, but (despite up to 6 contacts per non-responder) the overall response rate was 41.6% (n = 129; with the range across PCTs of 25-61%). Most responding GPs indicated support for referral guidelines but 18% reported that they had never used them. Less than three per cent reported use for most or all referral decisions. The odds of using guidelines decreased with increasing age, with a ten year increase in age associated with halving odds of use (OR = 0.53, 95%CI = 0.29-0.90). Over 50% of GPs wanted good access to electronic guidelines with expert information and advice on guideline availability. Almost all (>89%) GPs agreed with sharing referral decisions with patients. Female doctors (OR = 5.2, 95%CI: 1.02-26.3) were more likely to agree with this than male GPs as were those working in larger compared to small or single handed practices (OR = 5.3, 95%CI: 1.4-19.9).ConclusionsThis group of responding GPs was supportive of guidelines but used them in different ways. Referral guidelines should have an educational component for background reading; include key messages for internalisation and application; and incorporate mechanisms to facilitate accessibility and appropriate shared decision making with patients.

Consultations with Children

Patients under 15 years of age comprise around 20% of the average GP list and account for one in four GP consultations. School children visit the GP between two and three times a year, but this figure is doubled in the under fives (who visit the GP an average of 6 times per year). The under fives also have more home visits than any other group except the elderly. Children form an important part of a GP's workload and this article aims to give the GP in training a strategy with which to approach their assessment in the community.

‘Breaking up is hard to do’: perspectives of general practitioners and patients towards removals from GP lists

The numbers of removals of patients from General Practitioner lists in Ireland is increasing and is a cause for some concern. To examine the views of both general practitioners and patients toward removals of patients from general practitioner lists. Questionnaire survey to general practitioners in North Inner City Dublin who had removed patients from their list over a 1-year period (n = 45) and to the patients they had removed (n = 86). Follow up semi structured interviews were carried out with five general practitioners and ten patients. For doctors, the decision to remove a problematic patient from their list is generally a positive experience, providing relief and being associated with certainty in both the decision and the process. For the patient, being removed from a GP's list is a negative experience, stressful and confusing. There is a need for the development of a clear responsive, transparent and supportive system for removing patients from a GP list.

Which general practices have higher list inflation? An exploratory study

There is a 7% discrepancy between English population estimates based on census figures and those based on the registered lists of GPs. GP income under the 2004 new contract will be based on registered patient populations but a national 'de-ghosting' exercise will ensue, aiming to eliminate list inflation. To derive an estimate of the variation in list inflation between individual general practices. Letters were sent to all men aged 20-29 years and registered at practices based in three inner city Primary Care Trusts (n = 42 712). Non respondents received one further reminder. Cards were issued to each GP listing non responders. Patients were deducted from the GP list after six months if the GP did not verify the address. 42 712 letters were sent. 33.5% of registered patients were eventually deducted from the GP list (deduction figures only available for 20-24 year old group). Practice level deduction rates ranged from 7-76%. Practices with higher deduction rates achieved lower vaccination rates for 2 year olds (Pearson's r = 20.25; P = 0.005) and cervical smear rates (Pearson's r = 20.18; P = 0.04); they also had cheaper prescribing costs per ASTRO-PU (Pearson's r = 20.20; P = 0.03). If these findings apply to the whole registered population, the national de-ghosting exercise is likely to result in large changes to the list size of some practices. Without correcting for list inflation, primary care research based on patient list size as the denominator may underestimate various measures of GP activity, particularly in deprived inner city areas. Resource allocation is also likely to be distorted by differences in list inflation.

Depression after NICE

Depression is one of the costliest causes of ill health yet evidence suggests it is treated in a hitor-miss style. Depression is a spectrum of experience ranging from severe depression with a high risk of suicide to a prolonged state of mild but functional melancholy. This makes delivering a consistent response is difficult. So too does the fact that about 1 in 15 patients on a GP list experience some level of depression in any year.

Patterns and determinants of alcohol consumption in people aged 75 years and older: results from the MRC trial of assessment and management of older people in the community.

Very little work on alcohol consumption patterns in older people has been undertaken. As a result, knowledge about the prevalence and characteristics of regular drinkers and heavy drinkers in this age group remains limited. To determine the socio-economic and health characteristics associated with different levels of alcohol intake in older people. Detailed screening of patients in one arm of a cluster randomised trial. 53 UK general practices drawn from the Medical Research Council General Practice Research Framework. All patients aged 75 and over on the GP lists (excluding those in nursing homes or other long stay care) were invited to participate in the study. Of the 15358 people who received a detailed assessment in the 'universal' arm, 14962 (97%) of these answered questions on alcohol consumption. Of these, 62% were female and the median age was 80.3 years. Associations between reported alcohol intake and various socio-economic and health variables were investigated, first in univariate analyses and then controlling for other variables in logistic regression models. 5% of men and 2.5% of women exceeded the Royal College of Physicians, Psychiatrists and General Practitioners' recommended drinking limits of 21 and 14 units a week respectively; 17% of subjects had never had a drink. Women and the very elderly were less likely to be drinkers. Those that drank were more likely to be people who still had a fairly active and sociable lifestyle, and with a better self-perceived health status compared with non-drinkers. Moderate drinkers were also less likely to be severely cognitively impaired compared with non-drinkers: adjusted odds ratio 0.69 (95% CI 0.57, 0.85); but more likely to report symptoms of anxiety: 1.31 (1.07, 1.61). Our results suggest that moderate alcohol consumption is associated with relative financial security and good health with the exception of higher levels of anxiety amongst drinkers.

Perceptions of psychological content in the GP consultation--the role of practice, personal and prescribing attributes.

The aim of the present study was to determine the relationship between the characteristics of general practices and the perceptions of the psychological content of consultations by GPs in those practices. A cross-sectional survey was conducted of all GPs (22 GPs based in nine practices) serving a discrete inner city community of 41 000 residents. GPs were asked to complete a log-diary over a period of five working days, rating their perception of the psychological content of each consultation on a 4-point Likert scale, ranging from 0 (no psychological content) to 3 (entirely psychological in content). The influence of GP and practice characteristics on psychological content scores was examined. Data were available for every surgery-based consultation (n = 2206) conducted by all 22 participating GPs over the study period. The mean psychological content score was 0.58 (SD 0.33). Sixty-four percent of consultations were recorded as being without any psychological content; 6% were entirely psychological in content. Higher psychological content scores were significantly associated with younger GPs, training practices (n = 3), group practices (n = 4), the presence of on-site mental health workers (n = 5), higher antidepressant prescribing volumes and the achievement of vaccine and smear targets. Training status had the greatest predictive power, explaining 51% of the variation in psychological content. Neither practice consultation rates, GP list size, annual psychiatric referral rates nor volumes of benzodiazepine prescribing were related to psychological content scores. Increased awareness by GPs of the psychological dimension within a consultation may be a feature of the educational environment of training practices.