Implications For Primary Care Research Articles

‘I’m fine’: exploring patient and carer assertions of status in advanced chronic obstructive pulmonary disease (COPD) and implications for primary care

BackgroundPatients can be reluctant to say that they need support, telling clinicians they are ‘fine’ despite having unmet needs. Research in mental health settings suggests patients who do this they are less likely to follow treatment plans, and their carers are at a risk of depression. To-date these findings have not been explored in patients with advancing physical health conditions, or their carers.AimTo explore the presence, role and impact of assertions of ‘I’m Fine’ in patients with advanced chronic obstructive pulmonary disease (COPD) and their carers.MethodCriteria based on Attachment Theory were used to identify ‘I’m Fine’ cases from the Living with Breathlessness Study (LwB) dataset of 235 patients and 115 carers. Quantitative analysis explored variables such as health service use between ‘I’m Fine’ and non ‘I’m Fine’ cases, whilst narrative analysis is being used to explore discourses within cases.Results21 patients and six carers asserted they were ‘fine’ despite unmet needs. Patients’ minimised disease impact and symptoms, avoided thinking about the future and used stoical language. Despite ‘I’m Fine’ cases being more likely to report no exacerbations and more likely to score less on the COPD Assessment Test (CAT), all wanted to see more of their GP. Carers focused on the needs of the patient whilst downplaying their own problems.ConclusionThe existence of a sub-group of patients with advanced COPD who assert that they are ‘fine’ may have implications for primary care. This will be explored in planned focus groups with clinicians.

New guidelines on managing generalised pruritus

The British Association of Dermatologists (BAD) published new evidence‐based guidelines on the management of generalised pruritus (itch) in adults in 2018. This article provides an overview of the new guidance and its implications for primary care.

National Clinical Programme in Surgery - General Surgery Minor Ops “See & Treat” Clinic

Introduction: General Surgery is currently ranked number 3 for highest numbers on Out Patient Department (OPD) waitlists. Minor operative skin procedures represent 69% of General Surgery day case activity, excluding endoscopy. A significant proportion are seen and referred by the GP to OPD first for a booking visit, then a second appointment for their operation and finally back to OPD to discuss histology. This protracted process can be simplified into “See and treat” clinics where the patient is seen and treated at their first hospital appointment post GP referral. Description of Changes: This project created a “See & Treat” clinic for General Surgery Minor Procedures Outpatient appointments. The “See and Treat” model has resulted in patients being seen and treated for minor procedures at the same appointment. This has been achieved by a streamlined referral process from primary care, enabling ‘see and treat’ on initial hospital appointment. Following treatment, patients are referred back to their GP for suture removal and histology results. The study will include an elaboration of the resourcing implications enabling the model to scale. Aim & Theory: The aim is to reduce the number of visits to hospital for outpatient minor operative procedures from 2-3 visits to one per patient. This is done by providing adequate information through e-referral to complete a procedure on the patient’s first visit to hospital, and referring patients to their GP for aftercare. Targeted Populations: Patients suitable on the OPD waitlist for selected minor operative general surgery procedures. Stakeholders include general surgery minor operative outpatients, consultants, GPs, nurses and clerical staff, National Clinical Programme in Surgery (NCPS), General Practice Information Technology (GPIT), and The National Treatment Purchase Fund (NTPF). Timeline: Project inception was August 2016. Pilot clinics began “Seeing and Treating” in October 2016. First review of data took place after 5 weeks. Data will be reviewed again at 12 weeks. Highlights: Within 5 weeks, 20% of the 241 identified appropriate patients were treated through the clinic, with a further 6% removed from the waitlist through validation. The current waitlist has been reduced from 13 months to 9 months, and is projected to reduce below best-practice guidelines of 6 months before the end of the project. Sustainability & transferability: An SOP was developed as part of the project, detailing all necessary resources, which ensures sustainability and transferability across M3 and Model 4 Acute Hospitals in Ireland. The study will include detailed consideration of cost implications for primary care & general practice, given that there is no provision at present in the current PCRS Scheme for public patients to have post operative consultations following minor surgical procedures carried out in the primary care setting. Conclusion & Discussion: The “see and treat” pilot clinic has proved effective in reducing the waiting time and number of appointments for patients waiting for a minor operative procedure. This increased efficiency also has the potential to free-up time for surgeons to attend to other inpatient, day-case and outpatient wait lists. Lessons learned: Patient flow and improving care pathways across care settings is feasible and possible given cooperation between primary and secondary care working collaboratively with GPs, Acute Hospital OPD clinics and the HSE Outpatient Services. Streamlining referral and transferring post operative care into the primary care is shown to reduce OPD waiting lists for General Surgery.

A solution-focused approach to understanding patient motivation in diabetes self-management: Gender differences and implications for primary care.

Healthcare providers often neglect to recognize the role they play in motivating patients with diabetes to perform self-management. Our aims were to understand what motivates patients with diabetes to implement recommended self-management practices and understand the role of the primary care team in patient motivation. We use a solution-focused qualitative approach, supplemented with a quantitative scale. We used a purposive sampling strategy to invite patients with uncontrolled diabetes. Semi-structured telephone interviews were conducted and analyzed using content and thematic analysis. Key motivators were strong support systems that included family and friends, the physician's communication style and message, fear of deterioration, and other intrinsic factors. Female family members were described as supportive; not all married women felt supported by their husbands. Women were more influenced by empathy and concern from their doctor, compared to men who were motivated by improved health literacy. Women with few family or friends were more disadvantaged, regardless of race/ethnicity. While physicians play a vital role in motivating their patients, female patients may depend on this empathy more than males. The interdisciplinary care team can play an important role in helping patients create a support network where it may not exist.

Anti-PCSK9 antibodies for hypercholesterolaemia: Overview of clinical data and implications for primary care.

SummaryObjectivesTo put data from our recent systematic review of phase 3 studies of anti‐proprotein convertase subtilisin/kexin type 9 (PCSK9) antibodies into the context of clinical practice.MethodsData from studies previously identified by a systematic review of phase 3 studies of alirocumab and evolocumab and additional references from non‐systematic literature searches were used. We evaluated the hypothetical cardiovascular (CV) benefit in cases of typical patients in whom anti‐PCSK9 antibodies may be recommended, using preliminary major CV event (CVE) rates from long‐term clinical trials of anti‐PCSK9 antibodies and from extrapolations derived from correlation between low‐density lipoprotein cholesterol (LDL‐C) reduction and CV benefit with other lipid‐lowering therapies (LLTs).ResultsRapid (within 1‐2 weeks) and persistent (8‐74 weeks) reductions in LDL‐C levels were achieved with anti‐PCSK9 antibodies. When combined with statins (± ezetimibe), high rates of LDL‐C goal achievement were observed (41%‐87% with alirocumab and 63%‐100% with evolocumab). In long‐term alirocumab and evolocumab studies, reductions in major CVEs of 48% and 53%, respectively, were observed. For every 38.7 mg/dL (1 mmol/L) reduction in LDL‐C, a 22% reduction in relative CVE risk is predicted. Applying these assumptions to typical patients who have high–very high risk (15%‐60% absolute 10‐year CVE risk) and elevated LDL‐C despite maximally tolerated statins, the 10‐year number needed to treat with an anti‐PCSK9 antibody to prevent one additional CVE varies from 4 to 26, depending on baseline LDL‐C levels and residual absolute CVE risk.ConclusionsAnti‐PCSK9 antibodies effectively lower LDL‐C levels in a broad patient population. While awaiting comprehensive data from CV outcome trials, these agents should be considered in very high risk patients, such as those in secondary prevention and those with familial hypercholesterolaemia who are already receiving maximally tolerated LLTs, have not achieved their LDL‐C goal and require substantial reductions in LDL‐C.

Maternal depressive symptoms at three months postpartum and breastfeeding rates at six months postpartum: Implications for primary care in a prospective cohort study of primiparous women in Australia.

The World Health Organisation recommends exclusive breastfeeding to six months postpartum, but most women in developed countries do not breastfeed this long. Prior studies exploring the relationship between breastfeeding duration and maternal depression show ambiguous findings. To explore associations between maternal depressive symptoms at three months postpartum, and breastfeeding status over the first six months postpartum. Prospective pregnancy cohort study of nulliparous women. 1507 women were recruited from six public hospitals in early pregnancy, completing baseline data in early pregnancy (mean gestation 15 weeks). Follow-up questionnaires were completed at three and six months postpartum. Women reported how many months they breastfed for (breastfeeding refers to 'any' breastfeeding, including expressed breastmilk). Depressive symptoms were measured at three months postpartum with the Edinburgh Postnatal Depression Scale (scores ≥13 indicated probable major depression). Of the almost 95% of women who initiated breastfeeding, 76% were still breastfeeding at three months postpartum, and by six months postpartum this dropped to 61%. Women who reported depressive symptoms at three months had significantly lower rates of breastfeeding at six months postpartum compared to women without depressive symptoms (49% vs. 61%; adjusted OR=0.55, 95% CI 0.34-0.90). Maternal social characteristics associated with not breastfeeding at six months postpartum were: young maternal age; lower education; and smoking in pregnancy. Women's decisions around infant-feeding are influenced by a range of psycho-social factors, and early postnatal depressive symptoms appear to be a significant part of this picture, as either a cause or consequence of decisions to cease breastfeeding.

Care Managers and Knowledge Shift in Primary Care Patient-Centered Medical Home Transformation

Primary care practices across the United States are implementing a new model of care, the patient-centered medical home (PCMH), in an effort to improve care to patients and, consequently, control health care costs. The addition of care managers is a key aspect of PCMH implementation with important implications for the production and reproduction of authoritative knowledge in primary care. Redistribution of patient interaction from the primary care provider to a range of other health care providers in this model of care is a significant means by which primary care approaches to the prevention and management of chronic diseases such as diabetes are being transformed. Based on a study of a health insurance company-sponsored primary care transformation project in Michigan, we explore the perceptions of care management from the perspective of providers and practice staff to examine these shifts in knowledge and their broader implications for primary care. This research demonstrates how the diffusion of clinica...

Emerging infectious diseases: Implications for primary care

It is important for practice nurses to be aware of emerging infectious diseases. Gail Beckett and Alexander Kumar explain how two significant diseases have recently emerged

Update on Diverticular Disease and Implications for Primary Care

Recent data would seem to suggest a change in primary care management of diverticulosis. Studies now question the etiology, management, and recommendations for primary and secondary prevention of diverticular disease in the primary care setting. Although diverticulosis is commonly found on colonoscopy, few patients will go on to develop diverticular disease, which is characterized by abdominal symptoms and the presence of chronic inflammation in some cases. Data suggest more active management and specialty referral for patients with diverticular disease to prevent complications of bleeding, diverticulitis, colitis, abscess formation, fistula, stricture, and perforation and, possibly, neoplasia.

Transitioning youth to adult healthcare: new tools from the Illinois Transition Care Project.

To improve youths' transition to adult healthcare, especially for youth with disabilities, The Illinois Transition Care Project created separate, yet complementary, curricula for pediatric and adult-oriented providers. Content from the curricula was tested by practicing physicians. The project created a library of skill worksheets with functional goals for patients. All methods included opportunities to teach life skills to patients to independently manage their conditions. The curricula used Maintenance of Certification (MOC) Part 4 credit as an incentive for physician participation. Pediatric pilot data indicate improvement across all sites and activities. Adult medicine results indicate increased perceived importance and feasibility of accepting young adult patients with childhood conditions. Patient/parent reviewers indicate the tools are understandable, interesting, and effective. Findings suggest the curricula, with MOC Part 4 credit for physicians, are effective in improving transition care. Project results provided new information on population management for transitioning youth and on the use of MOC Part 4 credit as an incentive. Findings have implications for primary care and specialty physicians, team-based care, teaching self-management skills to patients and methods for engaging adult-oriented physicians in the transition process.

Child Sexual Abuse in Boys: Implications for Primary Care

Child sexual abuse occurs in both girls and boys. The public is more aware of the occurrence of sexual abuse in boys, but boys who experience sexual abuse are not always detected because of disclosure concerns. The sequelae of child sexual abuse in boys can lead to risky health behaviors and psychological problems later in life. Primary care nurse practitioners can screen and identify child sexual abuse in their patients. This article discusses recent evidence on child sexual abuse in boys, provides clinical practice guidance for its identification, and recommends referral sources and follow-up visits.

Heartburn, Barrett’s oesophagus and cancer: implications for primary care

The incidence of oesophageal adenocarcinoma (OAC) has increased eightfold in the past three decades to become the sixth most common cancer in the UK. Before the 1970s, 90% of oesophageal cancers were squamous but now 70% are adenocarcinomas. The reason for this major epidemiological shift is an increase in gastro-oesophageal reflux disease (GORD) and its principal complication, Barrett’s oesophagus, the only known precursor lesion for OAC.1 Barrett’s oesophagus, described in 1950 by thoracic surgeon Norman Barrett, is a replacement of normal squamous epithelium by a metaplastic columnar epithelium in the distal oesophagus consequent on chronic GORD. A landmark Swedish study quantified the link between heartburn and OAC, finding an odds ratio (OR) for OAC development of 8 in patients suffering heartburn once weekly, OR = 11 in those with the more damaging nocturnal reflux, and OR = 44 in those with severe, long standing heartburn.2 Therefore, heartburn, previously regarded as a trivial symptom, has a strong association with OAC development. Approximately 30% of the UK population experience regular heartburn.3 In 2010, the number of prescriptions for heartburn and/or dyspepsia totalled 58 million at a cost of £336 million.4 Some 5% of heartburn sufferers, or 1 million people, have Barrett’s oesophagus in whom the lifetime risk of OAC development is 7–12.5%. The risk is higher in white males, smokers, obesity, Rh– blood group, and those with Barrett’s segments >7 cm.5 OAC usually presents late and 5-year survival is only 5–10%. To compound these depressing statistics, the incidence of Barrett’s continues to increase and age at diagnosis is falling, 27% of the 12 000 patients registered with the UK National Barrett’s Oesophagus Registry (UKBOR) being diagnosed aged <55 years. Controversial issues in management of heartburn and its sequelae include endoscopy prior to long-term proton pump inhibitors (PPI) …

Cardiovascular morbidity and mortality in schizophrenia: Implications for primary care

People with schizophrenia have substantial premature mortality compared to individuals without schizophrenia. They also have a wide range of co-morbidities and multiple physical health conditions but are less likely than people without schizophrenia to have a primary care record of cardiovascular disease. This suggests a systematic underrecognition and under-treatment of cardiovascular disease, which may contribute to the increased mortality seen in this vulnerable patient group.

The resurgence of tuberculosis and the implications for primary care

Tuberculosis (TB) is not a disease of the past. The World Health Organization (WHO) estimated that in 2011 there were 8.7 million new cases of TB and 1.4 million people died from the disease. In addition it is estimated that up to one-third of the world’s population have latent tuberculosis infection (LTBI). TB is a preventable disease and most forms of tuberculosis are treatable. In recent years the global health community is making progress with concerted and coordinated TB control measures, which have achieved the Millennium Development Goal of halting and reversing the global TB epidemic by 2015. Closer to home, tuberculosis has been increasing in the UK over the last 30 years, despite significant efforts. TB rates in the UK are now among the highest in Western countries. In 2011 the total number of reported TB cases in the UK was just below 9000, a rate of 14.4 cases per 100 000 of the population.1 There is significant regional variation and most disease is concentrated in large conurbations. London accounts for the highest proportion of cases (39%) and the highest rate of disease (44.9 cases per 100 000) followed by the West Midlands (11% and 18.5 cases per 100 000). The majority of TB cases are seen among young adults (>60% cases are aged 15–44 years) but the majority of TB mortality is seen in older age groups (>65 years). TB is also associated with social risk factors and homeless persons, and those with problem alcohol and illicit drug use, or those with a history of imprisonment are at much greater risk of TB. Nearly three-quarters of TB cases were reported among individuals born outside the UK, many of these were from high TB …

Frailty prevalence and slow walking speed in persons age 65 and older: implications for primary care

BackgroundFrailty in the elderly increases their vulnerability and leads to a greater risk of adverse events. According to various studies, the prevalence of the frailty syndrome in persons age 65 and over ranges between 3% and 37%, depending on age and sex. Walking speed in itself is considered a simple indicator of health status and of survival in older persons. Detecting frailty in primary care consultations can help improve care of the elderly, and walking speed may be an indicator that could facilitate the early diagnosis of frailty in primary care. The objective of this work was to estimate frailty-syndrome prevalence and walking speed in an urban population aged 65 years and over, and to analyze the relationship between the two indicators from the perspective of early diagnosis of frailty in the primary care setting.MethodsPopulation cohort of persons age 65 and over from two urban neighborhoods in northern Madrid (Spain). Cross-sectional analysis. Bivariate and multivariate analysis with binary logistic regression to study the variables associated with frailty. Different cut-off points between 0.4 and 1.4 m/s were used to study walking speed in this population. The relationship between frailty and walking speed was analyzed using likelihood ratios.ResultsThe study sample comprised 1,327 individuals age 65 and older with mean age 75.41 ± 7.41 years; 53.4% were women. Estimated frailty in the study population was 10.5% [95% CI: 8.9-12.3]. Frailty increased with age (OR = 1.14; 95% CI: 1.10-1.19) and was associated with poor self-rated health (OR = 2.52; 95% CI: 1.43-4.44), number of drugs prescribed (OR = 1.17; 95% CI: 1.08-1.26) and disability (OR = 6.58; 95% CI: 3.92-11.05). Walking speed less than 0.8 m/s was found in 42.6% of cases and in 56.4% of persons age 75 and over. Walking speed greater than 0.9 m/s ruled out frailty in the study sample. Persons age 75 and older with walking speed <0.8 m/s are at particularly high risk of frailty (32.1%).ConclusionsFrailty-syndrome prevalence is high in persons aged 75 and over. Detection of walking speed <0.8 m/s is a simple approach to the diagnosis of frailty in the primary care setting.

Investigating the role of the general practitioner in cancer prevention: a mixed methods study

BackgroundDespite evidence of the effectiveness of cancer preventive services and the increasing development of guidelines, actual rates of delivery of cancer prevention activities remain low. Due to their frequent front-line contact with the public, family physicians (GPs) have the potential to play an important role in the primary prevention of cancer. However, there is a lack of information about their actual role in cancer prevention. The aim of this study was to investigate the actual and potential roles of general practitioners (GP) in the prevention of cancer.MethodsA sequential exploratory mixed methods approach was used. The sample included all the General Practice (GP) practices in a region in the UK (n=345). Postal questionnaires were administered to GPs (n=1249); following 290 returns (response rate 23%), semi-structured interviews were undertaken with GPs (n=14).ResultsThe majority of the GP respondents (66.4%, n=184) considered that they routinely provided cancer prevention information. This was specifically focusing on smoking cessation as almost all GPs (96.8%, n=270) enquired about a patient’s smoking status. Overall, 47.2% (n=128) of GP respondents indicated that they felt they did not have time to perform a cancer prevention role; however, 88.3% (n=242) still felt that they had the ‘opportunity’ to do so. Over half the sample (61.3%, n=168) indicated that imposed health priorities and targets militated against providing cancer prevention activities. Almost all the GP respondents (98.9%, n=273) agreed with empowering individuals to take responsibility for their health issues. The GPs identified the need for alternative models for cancer prevention beyond current face to face patient care, including other health and non-health professionals. Whilst lack of time was identified as a critical factor, the GPs indicated that significant efforts were made to encourage patients to take personal responsibility for lifestyle choices.ConclusionsThe GPs indicated a need for training around behavioural change and theories of motivation and action. This has implications for primary care and family physicians worldwide. While doctor–patient consultations and the physicians’ credibility offer great potential for cancer prevention, time pressures and imposed government targets often mean that their actual cancer prevention role is reduced.

Depression as a culture-bound syndrome: implications for primary care

This month sees the publication of the fifth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-V). Headline features include new diagnostic categories of anxious depression and somatic symptom disorder, and blurring of boundaries between grief and depressive disorder. However its relevance to primary care may be less than anticipated. According to its predecessor, DSM-IV, culture-bound syndromes are indigenously considered to be ‘illnesses’, limited to specific societies or culture areas, composed of localised diagnostic categories, and used to frame coherent meanings for certain repetitive, patterned, and troubling sets of experiences and observations.1 Examples commonly cited include koro in eastern Asia, latah in Malaysia, and ataque de nervios in Latin America. It can be argued that depression also fulfils the criteria for a culture-bound syndrome, in westernised societies. Our indigenous beliefs are based on the premise that depression is an illness of common and increasing prevalence, destined to become the second most disabling disease by 2020. These beliefs have societal and cultural limitations. They predominate in anglophone societies, although there is wide variation in their understanding and acceptance within these societies, depending on class, gender and culture.2 Depression can therefore be understood as a set of localised diagnostic categories, albeit currently operating on a larger scale than other culture-bound syndromes. If depression as a diagnostic category had validity and utility, it could be seen as a universal, transcultural concept. But it …

Potential impact of new oral anticoagulants on the management of atrial fibrillation‐related stroke in primary care

AimAnticoagulant prophylaxis with vitamin K antagonists (such as warfarin) is effective in reducing the risk of stroke in patients with atrial fibrillation (AF). New oral anticoagulants have emerged as potential alternatives to traditional oral agents. The purpose of this review was to summarise the effectiveness and safety of rivaroxaban, dabigatran and apixaban in stroke prevention in patients with AF in phase III trials, evaluate their cost-effectiveness and consider the implications for primary care.MethodologyA literature search was performed between 2007 and 2012, selecting all phase III trials (ROCKET AF, RE-LY and ARISTOTLE) of new oral anticoagulants and relevant cost–benefit studies.ResultsEvidence shows that all three agents are at least as effective as warfarin in the prevention of stroke and systemic emboli, with similar safety profiles. Cost–benefit studies of rivaroxaban and dabigatran further confirm their potential use as alternatives to warfarin in clinical practice. These observations may allow stratification of the general practice AF population, to help prioritise which patients may benefit from receiving a new oral anticoagulant.ConclusionThe clinical and economic benefits of the new oral anticoagulants, along with appropriate risk stratification, may enable a higher number of patients with AF to receive effective and convenient prophylaxis for stroke prevention.

Implications of new anticoagulants in primary practice

Effective prophylaxis and treatment of thromboembolic disorders remain suboptimal in many healthcare systems, partly owing to limitations of traditional anticoagulants. New oral anticoagulants have been developed and among these, rivaroxaban, apixaban and dabigatran etexilate are in the most advanced stage of clinical development. A literature search using the PubMed and ClinicalTrials.gov databases was performed to identify English-language publications. The search was performed up to 31 December 2011 with the terms rivaroxaban OR Xarelto, apixaban OR Eliquis and dabigatran OR Pradaxa. Ongoing, completed and published phase III randomised controlled trials were selected as the primary source of information for the clinical development programme of each drug. The new oral agents demonstrate several advantages over traditional anticoagulants, including administration at fixed doses and no requirement for routine coagulation monitoring On the basis of phase III clinical trials, rivaroxaban, apixaban and dabigatran etexilate have been approved in many countries for the prevention of venous thromboembolism after hip and knee replacement surgery. Dabigatran etexilate and rivaroxaban have also been approved for the prevention of stroke and systemic embolism in patients with non-valvular atrial fibrillation in Europe and the US. In addition, rivaroxaban has been approved in Europe for the treatment of acute deep vein thrombosis and prevention of recurrent venous thromboembolism. Approval of these agents and postapproval monitoring of their safety and efficacy will have implications for primary care. Rivaroxaban, apixaban and dabigatran etexilate offer the possibility of simplified prevention and treatment strategies for thromboembolic disorders in the outpatient setting.

GOLD guidelines 2011: what are the implications for primary care?

A major revision of the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines was published in December 2011, which takes account of the fact that chronic obstructive pulmonary disease (COPD) is a multi-system disease with effects on the patient beyond the effects of airflow limitation alone. The guidelines present a novel way of assessing the patient with COPD, linked to the major goals of stable COPD management of reducing symptoms (measured by the modified Medical Research Council Dyspnoea Score and/or COPD Assessment Tool) and reducing future risk (measured by the severity of airflow limitation and/or exacerbation history in the previous 12 months). Four patient groups are identified on the basis of their symptom/risk profile and a pharmacotherapy strategy is described using this profile. Emphasis is still placed on three pivotal features of non-pharmacological management: (1) reduction of exposure to risk factors (principally tobacco smoke); (2) promotion of exercise; and (3) immunisation against influenza and pneumococcal disease. In addition, there is a new chapter on the importance of assessing and treating co-morbid disease. The guidelines are a welcome advance in the management of COPD, but need further development to guide the more holistic approach to the management of patients with COPD in primary care.