GP Patients Research Articles

Short-term symptomatic outcomes of GERD in patients with gastroparesis after gastric per oral endoscopic pyloromyotomy.

Gastroparesis (Gp) patients often have gastroesophageal reflux disease (GERD). Management of GERD in Gp patients is a challenge. Many studies have shown that gastric peroral endoscopic pyloromyotomy (G-POEM or POP) is moderately effective in reducing nausea and vomiting in patients with Gp. This study aims to determine whether G-POEM can improve GERD in Gp Patients. Patients who underwent G-POEM from July 2021 to October 2022 were enrolled in the study. GERD Health-Related Quality of Life (GERD HRQL) and Reflux Symptom Index (RSI) were used to assess patients' GERD before and after G-POEM. The use of proton pump inhibitors (PPIs) before and after G-POEM were also documented. The Gastroparesis Cardinal Symptom Index (GCSI) was used to assess the severity of Gp before and after G-POEM. A 'Welch two-sample t-test' was used to find differences in GERD HRQL (health-related quality of life) and RSI scores before and after the procedure. Pearson's chi-square test was used to find differences for use of PPI before and after G-POEM. Twenty-three consecutive refractory Gp patients with 30% male (average age 63.2) and 70% female patients (average age 53.9) were enrolled. Of these, 14 had diabetes, 3 had a history of surgery, and 6 had idiopathic Gp. The mean follow-up was 41days (range 7-61days). There was a significant decrease in the mean GERD HRQL score from 16.5 to 6.5 after G POEM with a P-value <0.0001 (95% level of significance) and a significant decrease in mean RSI score from 15.3 to 5.2 after G-POEM with P-value <0.0001 (95% level of significance). The proportion of use of PPI before GPOEM was 0.91, and the proportion of PPI use after GPOEM was 0.43 (P = 0.0008). The mean GCSI pre- and post-GPOEM were 3.53 and 1.59, respectively. Eighteen had clinical success in Gp as defined by decreased mean GCSI score greater than 1. In this short-term outcome study, 87% of patients' GERD HRQL scores and RSI scores decreased after G-POEM. These findings indicate that GPOEM not only effectively reduces Gp symptoms but also improves GERD symptoms leading to decreased or more effective use of PPI in these patients. To our knowledge, this is the first study to comprehensively show G-POEM significantly improves GERD. Further studies with a larger patient population and long-term outcomes are needed.

Attention-deficit/hyperactivity disorder and serial missed appointments in general practice

Missingness’ in health care has recently been flagged as a major challenge due to associations between missing multiple appointments and poor long-term outcomes. Patients with a range of mental health diagnoses, for example, can have difficulties maintaining continuity of care and miss appointments with adverse consequences, including increased mortality. This is especially problematic for those with a diagnosis of ADHD because it is relatively common, with an estimated prevalence of 2–5% of the population. This study therefore aimed to a) establish the prevalence of recorded ADHD b) characterise and compare individuals with and without ADHD in terms of health and social variables, and c) assess whether ADHD was associated with an increased risk of missing scheduled appointments in general practice. Using administrative data from 136 Scottish general practices, patients with at least one GP appointment between September 2013–2016 we identified those with ADHD based on diagnoses and prescribing data. Each case was matched (sex and age) to five randomly selected GP attendees. Groups were compared regarding health, social status and missed appointments. All results were stratified by age &lt;18 or ≥18 years. Among 824,374 GP patients we identified 2,452 with a record of ADHD (0.8% among those &lt;18 years; 0.2% age ≥18 years). ADHD was associated with living in socially deprived areas of Scotland, and multimorbidity was more frequent in adults (p&lt;0.01). Adjusting for the number of total appointments made, ADHD was associated missing GP appointments (&lt;18 years: OR = 1.6, 95%CI = 1.4–1.9; ≥18 years: OR = 1.9, 95%CI = 1.7–2.2). Annually 21% in those &lt;18 and 38% of those age ≥18 years missed at least one GP appointment. The prevalence of recorded ADHD in Scottish general practice is low but comparable to other studies using data derived from medical records. More importantly, this is the first study to demonstrate an association between ADHD and missingness in general practice. The findings have important implications for health services concerning the early diagnosis and treatment of ADHD.

Low Vitamin D Levels in Patients with Symptoms of Gastroparesis: Relationships with Nausea and Vomiting, Gastric Emptying and Gastric Myoelectrical Activity

Patients with gastroparesis (Gp) often have diets deficient in calories, electrolytes, and vitamins. Vitamin D levels have been reported to be low in some patients with Gp but has not been systematically studied.AimsTo determine vitamin D levels and relationships among symptoms, gastric emptying and gastric myoelectrical activity (GMA) in patients with symptoms of Gp.Methods25-hydroxy-vitamin D was measured in patients at enrollment in the Gastroparesis Clinical Consortium Registry. Gastroparesis Cardinal Symptoms Index (GCSI), gastric emptying, and GMA before and after water load satiety test (WLST) were measured. GMA, expressed as percentage distribution of activity in normal and dysrhythmic ranges, was recorded using electrogastrography.ResultsOverall, vitamin D levels were low (< 30 ng/ml) in 288 of 513 (56.1%) patients with symptoms of Gp (206 of 376 (54.8%) patients with delayed gastric emptying (Gp) and 82 of 137 (59.9%) patients with symptoms of Gp and normal gastric emptying). Low vitamin D levels were associated with increased nausea and vomiting (P < 0.0001), but not with fullness or bloating subscores. Low vitamin D levels in patients with Gp were associated with greater meal retention at four hours (36% retention) compared with Gp patients with normal vitamin D levels (31% retention; P = 0.05). Low vitamin D in patients with normal gastric emptying was associated with decreased normal 3 cpm GMA before (P = 0.001) and increased tachygastria after WLST (P = 0.01).ConclusionsLow vitamin D levels are present in half the patients with symptoms of gastroparesis and are associated with nausea and vomiting and gastric neuromuscular dysfunction.

Difference in Cyclic Versus Non-cyclic Symptom Patterns in Patients with the Symptoms of Gastroparesis Undergoing Bioelectric Therapy.

Patients with gastroparesis (Gp) have symptoms with or without a cyclic pattern. This retrospective study evaluates differences in cyclic vs. non-cyclic symptoms of Gp by analyzing mucosal electrogastrogram (mEG), familial dysautonomias, and response to gastric stimulation. 37 patients with drug refractory Gp, 7 male and 30 female, with a mean age of 41.4years, were studied. 18 had diabetes mellitus, 25 had cyclic (Cyc), and 12 had a non-cyclic (NoCyc) pattern of symptoms. Patients underwent temporary mucosal gastric stimulator (tGES) placement, which was done as a trial before permanent stimulator (GES) placement. Electrogastrogram (EGG) by mucosal (mEG) measures, including frequency, amplitude, and frequency-amplitude ratio (FAR), were pre- and post-tGES. Patients' history of personal and familial dysautonomias, quality of life, and symptom scores were recorded. Baseline vs. follow-ups were compared by paired t tests and McNemar's tests. T tests contrasted symptom scores, gastric emptying tests (GET), and mEG measures, while chi-squared tests deciphered comorbidity differences between two groups and univariate and multivariate analyses. There were significantly more patients with diabetes in the Cyc group vs. the NoCyc group. Using a 1 point in symptom outcome, 18 patients did not improve and 19 did improve with tGES. Using univariable analysis, with the cyclic pattern as a predictor, patients exhibiting a cyclic pattern had an odds ratio of 0.22 (95% CI 0.05-0.81, p = 0.054) for achieving an improvement of at least one unit in vomiting at follow-up from baseline. The mucosal electrogastrogram frequency to amplitude ratio (FAR) for the "not Improved" group was 19.6 [3.5, 33.6], whereas, for the "Improved" group, it was 54.3 [25.6, 72.5] with a p-value of 0.049. For multivariate logistic regression, accounting for sex and age squared, patients exhibiting a cyclic pattern had an adjusted odds ratio (OR) of 0.16 (95% CI 0.03-0.81, p = 0.027) for achieving an improvement of at least one unit in vomiting at follow-up from baseline. The two groups had no significant differences in the personal or inherited history of investigated familial patterns. This study shows differences in Gp patients with Cyc vs. NoCyc symptoms in several areas. Larger studies are needed to elicit further differences between the two groups about cycles of symptoms, EGG, findings, familial patterns, and response to mucosal GES.

Nutritional Assessment in Patients after Gastric Electrical Stimulation (GES).

Gastric electrical stimulation (GES) is used for patients with drug-refractory gastroparesis (Gp) symptoms. Approximately two-thirds of patients with Gp symptoms are either overweight or obese. We aimed to assess symptoms and nutritional status pre-GES and post-GES placement in a large sample of drug-refractory Gp patients. We conducted a chart review of 282 patients with drug-refractory Gp who received temporary followed by permanent GES at an academic medical center. Gastrointestinal symptoms were collected by a traditional standardized PRO (0-4, 0 being asymptomatic and 4 being worst symptoms), baseline nutritional status by BMI plus subjective global assessment (SGA score A, B, C, for mild, moderate, and severe nutritional deficits), ability to tolerate diet, enteral tube access, and parenteral therapy were assessed at baseline and after permanent GES placement. Comparing baseline with permanent, GES was found to significantly improve upper GI symptoms in all quartiles. Of the 282 patients with baseline body mass index (BMI) information, 112 (40%) patients were severely malnourished at baseline, of which 36 (32%) patients' nutritional status improved after GES. Among all patients, 76 (68%) patients' nutritional status remained unchanged. Many patients with high BMI were malnourished by SGA. We conclude that symptomatic patients of different BMIs showed improvement in their GI symptoms irrespective of baseline nutritional status. Severely malnourished patients were found to have an improvement in their nutritional status after GES therapy. We conclude that BMI, even if high, is not by itself a contraindication for GES therapy for symptomatic patients.

Profiles of met and unmet care needs in the oldest-old primary care patients with depression – results of the AgeMooDe study

BackgroundUnmet care needs have been associated with an increased risk of depression in old age. Currently, the identification of profiles of met and unmet care needs associated with depressive symptoms is pending. Therefore, this exploratory study aimed to identify profiles of care needs and analyze associated factors in oldest-old patients with and without depression. MethodsThe sample of 1092 GP patients aged 75+ years is based on the multicenter study “Late-life depression in primary care: needs, health care utilization and costs (AgeMooDe)”. Depression (i.e. clinically meaningful depressive symptoms) was determined using the Geriatric Depression Scale (GDS) (cutoff score ≥ 4). Needs of patients were assessed using the Camberwell Assessment of Need for the Elderly (CANE). Associated sociodemographic and clinical factors were examined, and latent class analysis identified the need profiles. ResultsThe main result of the study indicates three need profiles: ‘no needs’, ‘met physical needs’, and ‘unmet social needs’. Members of the ‘met physical needs’ (OR = 3.5, 95 %-CI: 2.5–4.9) and ‘unmet social needs’ (OR = 17.4, 95 %-CI: 7.7–39.7) profiles were significantly more likely to have depression compared to members of the ‘no needs’ profile. LimitationsBased on the cross-sectional design, no conclusions can be drawn about the causality or direction of the relationships between the variables. ConclusionsThe study results provide important insights for the establishment of needs-based interventions for GPs. Particular attention should be paid to the presence of unmet social needs in the oldest-old GP patients with underlying depressive symptoms.

Relationships among symptoms of gastroparesis to those of avoidant/restrictive food intake disorder in patients with gastroparesis.

Patients with symptoms of gastroparesis (Gp) often reduce food intake in attempt to manage their symptoms. Up to 40% of adults with Gp have been reported to have symptoms of a non-body image-based eating disorder, avoidant/restrictive food intake disorder (ARFID). However, whether ARFID symptoms precede or follow the diagnosis of Gp is unknown. From January 2021 to January 2022, consecutive adult patients with Gp at an academic center completed self-report surveys for Gp symptom severity (patient assessment of upper gastrointestinal symptoms; PAGI-SYM) and for ARFID (nine-item ARFID screen; NIAS). One hundred and seven patients (age 45.4 ± 17.2 yrs, 84.1% female, BMI 26.4 ± 7.3) with Gp (4-h gastric retention 33.5 ± 21.8%) were included. Eighty-two of the 107 Gp patients (77%) screened positive for ARFID. Positive ARFID screen was most often on the NIAS appetite subscale (84%) and fear subscale (76%), with a lower positive screen rate on the picky subscale (45%). Of the Gp who screened positive for ARFID, 38% reported that eating difficulties came after their Gp diagnosis, whereas 17% reported that eating difficulties preceded their Gp diagnosis, and 15% reported that both began at the same time. Many (77%) patients with Gp screened positive for ARFID. In Gp patients with ARFID, the Gp diagnosis was more likely to precede the development of eating difficulties. Thus, a subset of patients with Gp may be at risk for developing ARFID. Further longitudinal research is needed to confirm findings and identify risk factors.

Strategic insight into the thresholds &amp; barriers to uptake of Electronic Repeat Dispensing (eRD) by therapeutic area

Abstract Introduction The use of eRD offers a simplified process compared to paper based repeat dispensing and electronic repeat prescribing, and has several benefits for GP practices, community pharmacies and patients. It is estimated that up to 80% of all repeat prescriptions could be replaced with repeat dispensing potentially saving 2.7 million hours of GP and practice time. eRD also has the benefit of reduced medicines and can contribute towards reducing overprescribing and supporting the NHS sustainability agenda. Aim To determine if there are specific thresholds of eRD implementation by GP practices at which barriers to uptake occur. Subsequently to understand if these thresholds are associated with specific therapeutics and if the difficulty in increasing uptake is related to drug specific requirements or differing prescription management processes needed. Methods Dispensed medicines data (Oct-Dec 22, ePACT2) was analysed at practice level nationally to test the hypothesis that there are multiple thresholds of eRD implementation uptake. The percentage of practices achieving less than or equal to each incremental %eRD value was plotted against % eRD implementation. Thresholds were identified by a change in the rate of implementation uptake. Prescribing data was then analysed by BNF chapter at the identified thresholds to determine how this variation was represented clinically. Dispensed medicines data (Jul-Sept 21, North of England (NoE)) was also reviewed by pharmacists at presentation level for appropriateness as an eRD item (excludes patient level considerations). The items considered prescribable by eRD were tagged and the data re-run to estimate the maximum %eRD that might have been achieved. Ethical approval was not required for this study as it utilised non-patient identifiable population level primary care prescribing data. Results There were 8 thresholds (changes in rate of implementation) identified from the national data; occurring at 3, 9, 35, 42, 50, 57, 64 and 72% eRD. There is consistency in three of the most prescribed drug groups for eRD across all the NoE Integrated Care Systems (ICSs), which includes: lipid regulating drugs, proton pump inhibitors and renin-angiotensin system; readily implemented as eRD from the 3% threshold. The other most commonly prescribed drugs by eRD were: Beta-blockers, calcium channel blockers, antiplatelets and antidiabetics. Retrospective data analysis by pharmacists determined that a maximum of 66.6% of items Jul-Sept 21 in the NoE could have been prescribed by eRD if patient factors at individual review had also considered it appropriate. Discussion/Conclusion Further clinical review and guidance on the appropriateness and requirements of specific therapeutics to be prescribed by eRD is required. For instance, rheumatic disease suppressant drugs, which require GP practices to establish monitoring arrangements in conjunction with eRD, increase from the 9% threshold. Whereas adrenoceptor agonists, requiring respiratory/inhaler reviews, increase from the 35% threshold. Further qualitative analysis is ongoing to understand the barriers occurring at different thresholds of eRD uptake. The maximum percentage of eRD achievable in the snapshot data was significantly lower than expected. This work is limited by the volume of items at presentation level that could potentially be prescribed.

Medical centres for the homeless in Hamburg – consultation reasons and diagnoses compared to primary care patients in the regular health care system

BackgroundIn Germany, homeless people are entitled to health care within the regular health care system. However, due to their specific living conditions they make little use of these services. In 2013, three Medical centres for the homeless (MCH) were opened in Hamburg to provide general health care. This study aims to analyse the consultation reasons and diagnoses prevalent among the homeless in comparison to regular primary care patients. It also examines the means and obstacles of integrating the homeless into Germany’s regular health care system.MethodsFrom 2013 to 2014, routine medical data of all patients of the MCH consenting to participate in the study were analysed descriptively, in particular consultation reasons (categorised by ICPC-2), ICD-10 diagnoses and data on health insurance status and the use of the regular health care system. Consultation reasons and diagnoses of homeless patients were compared descriptively with data from regular general practices. Additionally, anonymous data on patient numbers, gender and insurance status was exported from the MCH’s software and analysed descriptively for the years 2013 to 2020.ResultsA total of 840 homeless patients in 2013 and 2014 gave consent to the evaluation of consultation reasons and diagnoses. The most frequent consultation reasons in the MCH in 2013 were skin conditions (24%), musculoskeletal conditions (16%) and psychological disorders (14%), in GP practices these were musculoskeletal conditions (22%), conditions affecting the digestive system (14%) and skin conditions (12%). Essential (primary) hypertension, diabetes mellitus type 2 and back pain are among the top-10-diagnoses in GP practices, as well as in MCH. With regard to the other top-10-diagnoses, there are clear differences between GP practices and MCH: “Psychological behavioural disorder due to alcohol” and diagnoses in connection with trauma, skin infections and acute respiratory infections stand out in MCH. 35% of the homeless patients reported a lack of health insurance as the reason for “not making use of” the regular health care system, while 10% reported they were unable to visit a regular general practitioner due to physical or psychological reasons. In the years 2013–2020 46% to 73% of the 8.380 MCH patients had no health care insurance.ConclusionPatients consulting the MCH suffer from medical conditions typical for the homeless, namely skin diseases, wounds, injuries and behavioural disorders due to alcohol abuse, but also from “typical” symptoms in regular GP care as cough or lower back symptoms. Consultation reasons mostly are acute illnesses. Chronic diseases are equally present in regular GP and MCH patients, but pose a great challenge for the homeless among other things due to their irregular contact with the health care system. The lack of health insurance poses the greatest hurdle to the integration of the homeless into the regular health care system.

Changes in care utilization by patients in low-income neighborhoods during two Covid-19 waves

Abstract Background During the COVID-19 pandemic, general practitioners’ face-to-face consultations were replaced by remote (telephone or digital) consultations. This study aims to gain insight into the impact of the COVID-19 pandemic on GP care and the suitability of remote GP care for patients living in low-income neighborhoods. Methods A follow-up study of GP patients in disadvantaged neighborhoods of Rotterdam, using questionnaires at T1, the outbreak of COVID-19 (N = 213) and T2, after one year with gradual easing of COVID-19 measures (N = 133). At T1 and T2, 56% and 61% respectively were female, 61% and 65% 50 years and over, 48% and 53% had low health literacy. Results The proportion of patients who used remote or other care, i.e. face-to-face care or contact with assistant (56% and 44% respectively) was at T2 similar to T1. A positive attitude toward remote care declined from T1 to T2 from 71% to 58%. At T1 use of remote care was associated with sex and age, with significantly more females using remote care (OR = 3.22, 95% C.I. 1.57 - 6.59) and less respondents 50 years and over using remote care (OR = 0.46, 95% C.I. 0.22 - 0.97). At T2, remote care use was associated with having a migration background (OR = 2.18, 95% 1.00 - 4.74), financial difficulties (OR = 0.30, 95% 0.11 - 0.81), lack of digital skills (OR = 2.73, 95% 1.19 - 6.26) and a chronic disease (OR = 0.40, 95% 0.19 - 0.87). At multivariate level, the associations of age and digital skills with remote care at both time points T1 and T2, compared to remote care only at T1 or T2 or no remote care, were confounded by chronic disease, with lower remote care use by those with a chronic disease (OR = 0.33, 95% 0.13 - 0.87). Conclusions The COVID-19 pandemic rapidly accelerated the use of remote care in Dutch general practices. Experience after one year showed provision of GP remote care should be advised selectively for patients showing vulnerability, such as financial difficulties, low digital skills and chronic diseases. Key messages • At the start of the COVID-19 pandemic, patients were willing to receive GP care remotely and provision was depending on general characteristics sex and age. • Remote GP care is less suitable for vulnerable older patients, patients with financial difficulties and those with low digital skills or chronic diseases living in low-income neighborhoods.

Meal-eating characteristics among patients with symptoms of gastroparesis: Relationships to delays in gastric emptying.

Patients with symptoms of gastroparesis (Gp) often modify their diets and consume small meals. However, the relationship between patients' eating behavior and their gastric emptying is not well understood. This study describes meal-eating characteristics of patients with Gp symptoms and relates them to severity of emptying delay. Adult patients with Gp symptoms underwent 4-h gastric emptying scintigraphy and completed questionnaires including the Patient Assessment of GI Symptoms, a nutrition and diet questionnaire, and the Meal Patterns Questionnaire. Of 119 patients with Gp symptoms, 35 had normal gastric emptying (≤10% gastric retention at 4 h), 26 mildly delayed (>10%-20%), 28 moderately delayed (>20%-35%), and 30 severely delayed (>35%). Most patients (85%) reported eating small meals with an average of 2.4 meals per day. The most common reasons for stopping eating a meal were feeling full (83%), nausea (46%), and abdominal pain (31%). As gastric emptying worsened, patients increasingly made diet modifications such as low-fat, low-fiber, Gp diet, oral supplements, and blenderized meals (r = 0.309, p = 0.0007). Postprandial fullness lasted for 351 ± 451 min for patients with severely delayed emptying versus 207 ± 173 min for patients with normal emptying (p = 0.19). Meal-eating characteristics were found to vary with severity of gastric retention. Patients with severely delayed gastric emptying reported the longest duration of postprandial fullness. Dietary modification increased significantly with gastric retention. These meal-eating characteristics are important to understand as they impact on dietary education given to Gp patients for symptom management.

Hair Loss in Patients with Gastroparesis: A Sign of Nutritional Deficiency in Gastroparesis?

Some patients with gastroparesis (Gp) report hair loss. The aim of this study was to investigate the prevalence of patient-reported hair loss in Gp patients, analyze hair loss association to severity of Gp and nutritional deficiencies, and study effects of multivitamin treatment on hair loss. Patients with Gp were questioned about hair characteristics, Gp symptoms, and diet. Patients with hair loss had blood drawn for vitamin levels. Patients with hair loss were treated with daily multivitamin and assessed 8weeks later. Hair loss was reported in 65 of 143 patients with Gp (45.5%), occurring similarly in idiopathic and diabetic Gp. Hair loss was most commonly noticed while washing and/or combing hair. Patients with hair loss had more severe nausea, abdominal pain, stomach fullness, loss of appetite, abdominal discomfort, bloating, retching, stomach distension, vomiting, early satiety, postprandial fullness, and constipation. Hair loss patients lost more weight over prior 6months. Patients with hair loss had similar gastric retention on gastric emptying scintigraphy. Overall, 29 of 61 (47.5%) patients with hair loss had at least one abnormal bloodwork result. After 8weeks of treatment with a daily multivitamin, 17 of 41 (41%) patients had improvement in hair loss. Hair loss occurred in 46% of patients with Gp, being associated with more severe symptoms, loss of weight, and several vitamin deficiencies, although not a specific one. Treatment with multivitamins improved hair loss in 40% of patients. Presence of hair loss in patients with Gp should prompt nutritional evaluation and supplementation.

Prognostic factors for persistent fatigue after COVID-19: a prospective matched cohort study in primary care.

Persistent fatigue after COVID-19 is common; however, the exact incidence and prognostic factors differ between studies. Evidence suggests that age, female sex, high body mass index, and comorbidities are risk factors for long COVID. To investigate the prevalence of persistent fatigue after COVID-19 in patients with a mild infection (managed in primary care) during the first wave of the pandemic and to determine prognostic factors for persistent fatigue. This was a prospective cohort study in Dutch general practice, combining online questionnaires with data from electronic health records. Patients who contacted their GP between March and May 2020 and were diagnosed with COVID-19 during the first wave of the pandemic were included. Patients were matched to controls without COVID-19 based on age, sex, and GP practice. Fatigue was measured at 3, 6, and 15 months, using the Checklist of Individual Strength. All the participants were GP attendees and included 179 with suspected COVID-19, but who had mild COVID and who had not been admitted to hospital with COVID, and 122 without suspected COVID-19. Persistent fatigue was present in 35% (49/142) of the suspected COVID-19 group and 13% (14/109) of the non-COVID-19 group (odds ratio 3.65; 95% confidence interval = 1.82 to 7.32). Prognostic factors for persistent fatigue included low education level, absence of a partner, high neuroticism (using the Eysenck Personality Questionnaire Revised-Short Form), low resilience, high frequency of GP contact, medication use, and threatening experiences in the past. The latter three factors appeared to be prognostic factors for persistent fatigue specifically after COVID-19 infection. GP patients with COVID-19 (who were not admitted to hospital with COVID) have a fourfold higher chance of developing persistent fatigue than GP patients who had not had COVID-19. This risk is even higher in psychosocially vulnerable patients who had COVID-19.

The role of socio-demographic and health factors during COVID-19 in remote access to GP care in low-income neighbourhoods: a cross-sectional survey of GP patients

ObjectivesRemote consultations were common in general practice during the COVID-19 pandemic. This approach may have affected access to GP care for people with low socio-economic status: this group has a high prevalence of chronic conditions and a higher mortality rate due to COVID-19. This study explores the association of sociodemographic and health factors with the decision to contact a GP practice, and care utilisation, among patients in low-income neighbourhoods in the Netherlands.DesignCross-sectional survey study.SettingGeneral practice in low-income neighbourhoods in the Netherlands.ParticipantsPatients from low-income neighbourhoods were selected from fourteen general practices on the basis of ethnic background, chronic disease or health literacy. Participants were stratified according to categories of these background characteristics to obtain equal numbers per category. A total of 213 surveys were retained for analysis.Main outcome measuresNeed for GP contact, decision to contact a GP practice, and GP service utilisation.ResultsForty-five percent (N = 88) of the participants experienced health problems for which they wished to consult their GP at the start of the outbreak of COVID-19. A majority of them (81%) had contact with a GP service. The need to contact the GP was significantly associated with financial difficulties (OR 2.20 CI (1.10 to 4.39)). An interaction effect was found of health literacy with concerns about COVID-19 with in respondents with low health literacy a significant association between concerns about COVID-19 and a need for a GP appointment (OR 5.33 CI (2.09 to 13.59)) and absence of a significant association in the higher health literacy group (OR 1.14 CI (0.51 to 2.56)) . Moreover, 56% (N = 74) of the participants received remote care at least one time during the first wave of COVID-19. Female participants used remote care more often (OR 3.22 CI (1.57 to 6.59)) and participants aged 50 and over used remote care less often (OR 0.46 CI (0.21 to 0.97)).ConclusionMany patients in low-income neighbourhoods were able to consult a GP, often remotely. However from the equity perspective, access to GP care should be safeguarded for patients with health problems, financial difficulties and low health literacy because of their greater need to consult a GP during times of crisis.

Using an Endoluminal Functional Lumen Imaging Probe (EndoFLIP™) to Compare Pyloric Function in Patients with Gastroparesis to Patients After Esophagectomy

BackgroundGastroparesis (GP) occurs in patients after upper gastrointestinal surgery, in patients with diabetes or systemic sclerosis and in idiopathic GP patients. As pyloric dysfunction is considered one of the underlying mechanisms, measuring this mechanism with EndoFLIP™ can lead to a better understanding of the disease. MethodsBetween November 2021 and March 2022, we performed a retrospective single-centre study of all patients who had non-surgical GP, post-surgical GP and no sign of GP after esophagectomy and who underwent our post-surgery follow-up program with surveillance endoscopies and further exams. EndoFLIP™ was used to perform measurements of the pylorus, and distensibility was measured at 40 ml, 45 ml and 50 ml balloon filling. ResultsWe included 66 patients, and successful application of the EndoFLIP™ was achieved in all interventions (n = 66, 100%). We identified 18 patients suffering from non-surgical GP, 23 patients suffering from GP after surgery and 25 patients without GP after esophagectomy. At 40, 45 and 50 ml balloon filling, the mean distensibility in gastroparetic patients was 8.2, 6.2 and 4.5 mm2/mmHg; 5.4, 5.1 and 4.7 mm2/mmHg in post-surgical patients suffering of GP; and 8.5, 7.6 and 6.3 mm2/mmHg in asymptomatic post-surgical patients. Differences between symptomatic and asymptomatic patients were significant. ConclusionMeasurement with EndoFLIP™ showed that asymptomatic post-surgery patients seem to have a higher pyloric distensibility. Pyloric distensibility and symptoms of GP seem to correspond.

Social and spatial inequalities in healthcare use among people living with dementia in England (2002–2016)

Objectives Healthcare services for people living with dementia (PLWD) are stretched, and government promises of increased funding remain undelivered. With the UK dementia population to surpass 1 million by 2024, and dementia care costs predicted to almost treble by 2040, it is essential we understand differences in healthcare use among PLWD. This study aimed to explore social and spatial variations in healthcare use among people diagnosed with dementia (2002–2016). Methods Data were derived from Electronic Health Records of Clinical Practice Research Datalink GP patients in England (n = 142,302). To standardise healthcare contacts, rates of healthcare contacts per year were calculated for three primary (GP observations and medications) and three secondary healthcare types [Accident & Emergency (A&E) attendances and, emergency and elective hospital admissions]. Fully-adjusted generalised linear regression models were used to identify healthcare use variation by social and spatial groups. Twelve models were generated, one for each healthcare type in early- and late-onset populations separately. Results This study highlights numerous social and spatial variations in healthcare use among PLWD. Among PLWD, several groups tended to have healthcare service use more closely associated with negative outcomes, including a greater likelihood of A&E attendances and emergency and elective hospital admissions. These groups include: men, people from White ethnicity groups and people from more deprived and rural areas. Conclusions Systemic and social measures are needed to reduce variations in healthcare use inequalities in PWLD. These include greater healthcare continuity, health checks and medicines reviews, culturally appropriate services, better and more accessible treatment and improved infrastructure.

Unemployed individuals contact GPs more frequently but report lower satisfaction: results of the population-based DEGS1 and the GPCare-1 patient survey

Unemployment is associated with a variety of adverse health-related outcomes, yet little data on primary care services for this risk group exist. Using data from two surveys, we analyzed the frequency of GP contacts and patients’ experiences with GPs comparing unemployed with employed individuals. Data of the German Health Interview and Examination Survey for Adults (DEGS1), a nationwide cross-sectional study (n = 8151), were analyzed regarding associations between employment status and the number of GP visits. The General Practice Care-1 study (GPCare-1), a cross-sectional questionnaire survey (n = 813), evaluated patients’ communication with their GP. Data were collected from June to August 2020 in 12 teaching practices affiliated with our university. The statistical analysis included individuals of working age (18–64 years old) (DEGS1 n = 5659, GPCare-1 n = 587). In both studies, working age subpopulations were analyzed (DEGS1: n = 5659 of 8151, GPCare-1: n = 587 of 813). In DEGS1, the prevalence of unemployment was 6.5% (n = 372). Unemployed individuals had more GP contacts in the last 12 months (4.50 vs. 2.86, p < 0.001). In the GPCare-1 study, unemployed individuals (6.6%, n = 39) were significantly less satisfied with GP communication: enough space in consultations (42.9% vs. 60.3%, p = 0.043), feeling comfortable to address sensitive topics (44.1% vs. 65.9%, p = 0.010), problems taken very seriously by GP (48.6% vs. 70.6%, p = 0.007). Yet, they were more willing to accept GPs’ help for psychosocial burdens (67.6% vs. 47.6%, p = 0.024). GPs should be aware that patients with unemployment wish more support to cope with their burdening situation.

High Uses of Emergency Care and High Prevalence of Medication Adverse Effects in Gastroparesis Patients at a Tertiary Academic Center: Cross Sectional Survey

Introduction: Gastroparesis (Gp) syndromes are associated with high healthcare burden with high rates of emergency and inpatient utilization. Urgent care rates for Gp remain unknown. In acute care settings, medications are often used to assuage symptoms. Unfortunately, real-world medication use and adverse effects is lacking. We aimed to assess acute care (urgent care, emergency, inpatient) utilization rates and predictors. As a secondary aim, we aimed to assess both exposure of and adverse effects associated with medications used for gastroparesis. Methods: Surveys were administered at a tertiary referral center, returned during that visit, or mailed back. Open-ended questions were used, whenever possible, to prevent response bias for patients to report the adverse effects they experienced. Results: 62 patients (93.5% women) completed the survey. Patients were most frequently exposed to metoclopramide (71.0%), ondansetron (83.9%), and promethazine (72.6%). Of prokinetics, metoclopramide had the highest prevalence of adverse effects (59.1%). The rates of Gp-related urgent care visits, emergency visits, and hospitalizations within 6 months were 19%, 47%, and 26%, respectively. Multivariable logistic regression analysis revealed that patients aged 45-64 were a significant predictor for Gp-related urgent care utilization (aOR 8.8 [95% CI 1.2-65.4, p 0.03]). Low income was a significant predictor for gastroparesis-related hospitalization (aOR 6.8 [95% CI 1.1-42.7, p 0.04]). Conclusion: This survey found high rates of emergency care usage and high prevalence of adverse effects in commonly used medications for Gp patients. Urgent care may be an underutilized tool to reduce emergency care usage in Gp. Treatment algorithms for gastroparesis patients built on balancing adverse effects compared with efficacy are needed. Additionally, early integration of safe complementary integrative Gp therapies may minimize patient exposure while preserving treatment efficacy.

Incidence and risk factors of depressive symptoms in the highest age groups and competing mortality risk. Evidence from the AgeCoDe-AqeQualiDe prospective cohort study

IntroductionOnly a few studies have investigated incidence and risk factors of depression in the highest age groups. This study aims to determine incidence rates as well as risk factors of incident depressive symptoms in latest life, adjusting for the competing event of mortality. MethodsData of a prospective, longitudinal, multi-centered cohort study conducted in primary care – the AgeCoDe-/AgeQualiDe study. 2436 GP patients aged 75+ years were assessed from baseline to sixth follow-up every 18 months and from seventh to ninth follow-up every 10 months. Depressive symptoms were assessed using the 15-item version of the Geriatric Depression Scale (cut-off ≥6). Competing risk regression models were used to assess determinants of incident depressive symptoms, taking care of accumulated mortality. ResultsThe incidence of depressive symptoms was 39 per 1000 person-years (95% CI 36–42; last observed exit 13.26 person-years at risk). In a competing risk regression model, female sex, unmarried family status, subjective cognitive decline as well as vision and mobility impairment were significant risk factors of incident depression. LimitationsExcluding individuals with a lack of ability to provide informed consent at baseline may have influenced the incidence of depression. Depressive symptoms were not assessed by DSM criteria. Furthermore, in studies with voluntary participation, participation bias can never be completely avoided. ConclusionFindings provide a better understanding of risk and protective factors of depressive symptoms in the oldest age taking mortality as a competing event into account. Addressing this aspect in future research may yield new insights in that research field.

Are self-managed online interventions for depression effective in improving behavioral activation? A secondary analysis of a cluster-randomized controlled trial

BackgroundOnline interventions can effectively improve depressive symptoms. They often include behavioral activation (BA) techniques, but research on the effects on behavioral activation is scarce. This study aims to examine short- and long-term effects of online interventions on behavioral activation in routine care. MethodsThis study is a secondary analysis of a pragmatic cluster-randomized controlled trial (@ktiv) with a sample of N = 647 GP patients with mild to moderate depression. The intervention group (IG) received treatment-as-usual (TAU) and adjunct access to an online intervention; the control group (CG) received TAU. BA was assessed in terms of the frequency and enjoyment of pleasant activities at baseline, after six weeks and after six months. Intention-to-treat analyses were performed via multilevel mixed linear regression. ResultsThe frequency of pleasant activities was significantly higher in the IG than in the CG six months after baseline (t(1406) = 2.25, p = .024). The enjoyment of pleasant activities was significantly higher in the IG than in the CG both six weeks (t(1405) = 2.11, p = .035) and six months after baseline (t(1405) = 3.44, p = .001). Initial depressive symptoms significantly moderated the treatment effect on the enjoyment but not the frequency of pleasant activities. LimitationsBA measures have not been validated in a clinical context. ConclusionsGP patients with mild to moderate depressive symptoms profited from access to an online adjunct intervention in terms of improved behavioral activation. The findings emphasize the usefulness of online interventions as supportive options in mental health care.