Local General Practitioners Research Articles

IMPROVEMENT OF ORGANIZATIONAL APPROACHES TO REGULAR MEDICAL CHECKUP SERVICE IN THE METROPOLITAN HEALTHCARE SYSTEM

An adequate response to the challenges people face in the context of continuing urbanization, increasing life expectancy and, at the same time, falling birth rates, is to maximize the containment of chronic non-communicable diseases (NCDs) by high level of healthcare organization and medical services provided to the patients with such pathologies. Global economic losses caused by NCDs result in disability and early mortality among working population as well as in significant treatment costs increasing with the advancement of the disease. That is why outpatient care for NCD patients which includes behaviour factors monitoring is an urgent task for the world and Russian healthcare. In this regard, the goal of this study is to find organizational solutions to improve regular medical checkup service for NCD patients in the metropolitan healthcare system, relying on the data provided by medical organizations in the form of statistical observations. Thus, the results of correlation analysis have revealed a connection between the increased number of individuals in the second and third health groups and individuals scheduled for a regular medical checkup at the end of the year and its absence between the clinical examination results and the number of firstly diagnosed patients. It is also reported that the number of diseases registered for a regular medical checkup at the end of the reporting period (year) has increased, so patients with polymorbid conditions are supposed to prevail among the others on these days and require a special approach to their management. Taking into account the results obtained, possible ways for optimizing the organizational model of a regular medical checkup are the following: special hours (days) for such patients admission, permanent cooperation of a doctor (local general practitioner, GP, family doctor) and a health worker with a secondary medical education (to deal with organizational issues), etc.

Health needs assessment in a regional community pharmacy using the PRECEDE-PROCEED model

Community pharmacies have capacity to provide a variety of professional pharmacy services. However, planning models are underutilised when guiding pharmacists in assessing local health and social needs for providing tailored services to meet community needs and priorities. The objective of this was to utilize the PRECEDE-PROCEED model to perform a health needs assessment to identify health concerns in a regional Australian community for guiding professional pharmacy service development. A health needs assessment using the PRECEDE-PROCEED model was conducted in November 2019 using a convergent mixed-methods design through: (1) convenience sampling of pharmacy customers with a survey, (2) purposive sampling of a sole community pharmacist with a semi-structured interview, and (3) collection of regional health and social data from online databases. The community survey response rate was 44.8%. Of 113 participants, the majority were female (71.7%) and town dwellers (89.4%), representing 6.4% of the town's population. Mental illness was cited by 35.3% of community survey participants to be impacting local health and wellbeing, with depression/anxiety the most prevalent self-reported condition (44.2%), predominantly affecting women (72%). The community pharmacist and regional secondary data provided additional support for the prioritization of mental illness. Depression/anxiety was associated with delays/avoidance of prescription medicine due to cost (p=.002), poor self-rated health (p=.012), worsening health over the past year (p<.001), seeking advice from a pharmacist about health or medicines (p=.03), and receipt of emergency care in the past year (p=.001). The lack of a local general practitioner, social isolation, and environmental issues also impacted health and wellbeing. The PRECEDE-PROCEED model identified mental health as the greatest health priority in the community, using multiple data sources and participatory methods. Using this model provides insight into the development of tailored community pharmacy interventions that address health priorities such as mental health needs in a community.

The Effectiveness of Individual or Group Physiotherapy in the Management of Sub-Acromial Impingement: A Randomised Controlled Trial and Health Economic Analysis.

Background: Shoulder pain is common in primary care. The management of subacromial impingement (SAI) can include corticosteroid injections and physiotherapy. Physiotherapy can be on an individual or group basis. Aim: To examine the clinical effectiveness and make an economic analysis of individual versus group physiotherapy, following corticosteroid injection for SAI. Design and Setting: A single-blind, open-label, randomised equivalence study comparing group and individual physiotherapy. Patients referred by local general practitioners and physiotherapists were considered for inclusion. Method: Patients were randomised to individual or group physiotherapy groups, and all received corticosteroid injection before physiotherapy. The primary outcome measure was shoulder pain and disability index (SPADI) at 26 weeks. An economic analysis was conducted. Results and Conclusion: 136 patients were recruited, 68 randomised to each group. Recruitment was 68% of the target 200 participants. SPADI (from baseline to 26 weeks) demonstrated a difference (SE) in mean change between groups of −0.43 (5.7) (p-value = 0.050001), and the TOST (two-one-sided test for equivalence) 90% CI for this difference was (−10.0 to 9.14). This was borderline. In a secondary analysis using inputted data, patients without SPADI at week 26 were analysed by carrying forward scores at week 12 (mean difference (95% CI) = −0.14 (−7.5 to 7.3), p-value = 0.014). There is little difference in outcome at 26 weeks. Group physiotherapy was cheaper to deliver per patient (£252 versus £84). Group physiotherapy for SAI produces similar clinical outcomes to individual physiotherapy with potential cost savings. Due to low recruitment to our study, firm conclusions are difficult and further research is required to give a definitive answer to this research question. (NCT Clinical Trial Registration Number NCT04058522).

Hormone therapy for trans and gender diverse patients in the general practice setting.

In recent years there has been a significant increase in the number of trans, gender diverse and non-binary (TGDNB) people accessing healthcare. For many of these individuals the first port of call will be to their local general practitioner (GP). The TGDNB community is a high-priority population with the highest suicide rates of any population group in Australia. There is evidence that mental health outcomes improve significantly when individuals areable to access gender-affirming hormones. The aim of this article is to provide GPs working in Australia with a practical guide to prescribe gender-affirming hormone therapy to TGDNB patients. GPs are ideally placed to provide care forTGDNB patients in the primary care setting. Gender incongruence is no longer viewed as a mental health disorder. In recent years there has been a move away from mandatory psychiatric assessment to more contemporary patient-centred models of care.

P1489An audit of 215,000 patients on primary care registers using novel electronic searches to identify patients with heart failure requiring treatment optimisation and complex device therapies

Abstract INTRODUCTION Patients with heart failure (HF) may not routinely receive review from a HF specialist and understanding of which patients may benefit from specialist therapies is not widely appreciated by non-specialists. Therefore, there may be frequent missed opportunities for patients under non-specialist care to access prognostically important therapies. PURPOSE To identify high-risk patients in primary care with HF and left ventricular systolic dysfunction (LVSD) that require optimisation and consideration for complex device therapy. METHODS 15 general practitioner (GP) practices across Cornwall were audited between between July 2018 and August 2019 with a total population of 215,114 patients. The total combined HF register in these practices was 2,925. A further 2,238 patients were identified using the case finder element of GRASP-HF, an electronic search tool, to identify patients with HF +/- LVSD not coded correctly in GP records. Electronic records were manually reviewed and selected patients, potentially benefitting from further optimisation, were electronically reviewed by a Consultant Cardiologists for final screening before being invited into a specialist HF clinic at their local GP practice. All patients received an up to date ECG prior to specialist review. Outcomes of each patient clinical review were followed-up for a minimum of 1 month. RESULTS From 5,163 patients audited, 157 underwent clinic review with a Consultant Cardiologist at their local GP practice and are described below. Patient characteristics Mean age was 75 years, 78% were male, 51% had ischaemic cardiomyopathy and 27% had AF. 66% had severe LVSD (EF &amp;lt;35%), 48% had broad QRS (&amp;gt;120ms) and only 44% were deemed to be on optimal medical therapy. Of 88 patients not fully optimised, the proportion requiring optimisation of ACEi/ARB, beta-blocker, MRA, sacubitril-valsartan and ivabradine were 57%, 30%, 36%, 7% and 1%, respectively. Patient outcomes Median follow up period was 7 months (range 2-15). 65% of all patients required further imaging of LV function to help determine onward management. 48% were potential candidates for device therapy and 3 patients (2%) were listed directly for device therapy while 5 patients (3%) declined. In total, following complete assessment, 18 patients (11%) received device implantation (12 CRT-P, 2 CRT-D, 2 ICD and 1 loop recorder) and 25 patients (16%) received sacubitril-valsartan. A change in patient clinical management was instituted in 64% of patients following specialist review. CONCLUSION This comprehensive audit of GP registers demonstrates a significant burden of patients with HF and LVSD who are not appropriately coded. This audit also identifies frequent opportunities to intensify 1st and 2nd line medical therapies and patients that may benefit from specialist therapies including complex devices. Primary care teams would benefit from regular review of their HF registers and from specialist outreach initiatives.

Andrew Veitch Foote

Andrew Veitch Foote was brought up in Lochgelly, Fife, where his father was the provost and a local general practitioner. He studied medicine at the University of Edinburgh. After a period of national service in the Royal Air Force, he entered surgical training in Yorkshire, thereafter moving to Edinburgh as registrar in cardiothoracic surgery to Andrew Logan. He then undertook research—initially in the cardiac surgery department UCLA, Los Angeles, and subsequently under the watchful gaze of Sir John Bruce at the gastrointestinal unit, Western General Hospital. Although he …

Clinical and cost-effectiveness of a diabetes education and behavioural weight management programme versus a diabetes education programme in adults with a recent diagnosis of type 2 diabetes: study protocol for the Glucose Lowering through Weight management (GLoW) randomised controlled trial

IntroductionPeople with type 2 diabetes (T2D) can improve glycaemic control or even achieve remission through weight loss and reduce their use of medication and risk of cardiovascular disease. The Glucose...

Electrolyte outpatient clinic at a local hospital \u2013 experience from diagnostics, treatment and follow-up

BackgroundElectrolyte imbalances (EI) are common among patients. Many patients have repeated hospitalizations with the same EI without being investigated and treated. We established an electrolyte outpatient clinic (EOC) to diagnose and treat patients with EI to improve symptoms and increase their quality of life (QoL). In addition, we also wanted to reduce the number of admissions with the same EI.MethodsUncontrolled before-after study reporting experiences from this outpatient clinic as a quality assurance project. From October 2010 to October 2015, doctors at our local hospital and general practitioners could refer adult patients with EI to the EOC. Ninety patients with EI were referred, of whom 60 were included. Medical history, clinical examination and laboratory tests were performed, and results registered. Admissions with the same EI were recorded 1 year before and 1 year after consultation at the EOC. Patients responded to a questionnaire, composed by the authors, about symptoms before the first consultation, as well as symptom and QoL improvement after the last consultation.ResultsHyponatremia was the reason for referral in 45/60 patients. The total number of admissions with the same EI 1 year before the first consultation was 71, compared with 20 admissions 1 year after the last consultation. Improvement of symptoms was reported by 60% of patients, and 62% reported improvement in QoL.ConclusionsAn EOC may be an appropriate way to organize the assessment and treatment of patients with EI.

Informing the Model of Care for an Academic Integrative Health Care Center: A Qualitative Study of Primary Care Stakeholder Views.

Objectives: To engage with local primary care stakeholders to inform the model of care for a proposed academic integrative health care center incorporating evidence-informed traditional, complementary, and integrative medicine (TCIM) in Sydney, Australia. Design: In-depth semistructured interviews, informed by community-based participatory research principles, were conducted to explore primary care stakeholder preferences and service requirements regarding the proposed Western Sydney Integrative Health (WSIH) center in their local district. Setting: Telephone and face-to-face interviews at primary care clinics in Sydney. Subjects: Thirteen participants took part in the study: eight general practitioners (GPs) and five primary care practice managers (PMs). Methods: GPs were recruited through local GP newsletters, closed GP Facebook groups, and snowballing. PMs were recruited through a national PM newsletter. The semistructured interviews were audiorecorded and transcribed verbatim before conducting a thematic analysis. Results: Three main themes emerged: (1) the rationale for "why" the WSIH center should be established, (2) "what" was most important to provide, and (3) "how" the center could achieve these goals. Participants were willing to refer to the service, acknowledging the demand for TCIM, current gaps in chronic disease care, and negligible Government funding for TCIM. They endorsed a model of care that minimizes out-of-pocket costs for the underserved, incorporates medical oversight, integrates evidence-informed TCIM with conventional health care, builds trust through interprofessional communication and education, and provides sound clinical governance with a strong focus on credentialing and risk management. It was proposed that safety and quality standards are best met by a GP-led approach and evidence-based practice. Conclusions: Our findings demonstrate that participants acknowledged the need for a model of care that fits into the local landscape through integrating conventional health care with TCIM in a team-based environment, with medical/GP oversight to ensure sound clinical governance. Findings will be used with input from other stakeholder groups to refine the WSIH model of care.

Improving the Delivery of Musculoskeletal Education in Primary Care Using the Innovative Echo (Extension for Community Healthcare Outcomes) Technology

Background: Extension for Community Healthcare Outcomes (ECHO) is a programme that employs videoconferencing technology to train community-based primary care providers to improve and standardize care across a wide geographical region. This method has not yet been trialled in the UK for improving the capacity of primary care services in managing common musculoskeletal (MSK) complaints. Aim: The aim was to assess the impact of introducing a year-long MSK ECHO education programme in Northern Ireland for general practitioners (GPs). Design and setting: Monthly sessions were held consisting of teaching and case based discussions. Each session lasted on average 90 minutes. A ‘hub’ consisting of local GP lead educators, supported by colleagues from secondary care, where linked to GPs around Belfast using video conferencing technology. Methods: Topics covered were chosen by participants at the start and covered common MSK complaints in primary care. An initial questionnaire was performed at the start and compared to an evaluation questionnaire at the end. Results: Ten GPs completed the evaluation one year after the project was initiated. The weighted average of the selfconfidence scores in examining a range of individual body parts in general practice increased from a baseline of 3.45 to 4.08. There was an increase in self-assessed ability in diagnosing and treating a number of common MSK complaints and the whole year-long programme was delivered for £ 14,980. Conclusion: This trial shows how a 12-month ECHO intervention can improve self-efficacy in a number of MSK capacities within GP. These preliminary results suggest that ECHO is an affordable, effective solution for providing postgraduate education to working GPs.

10 Improving Communication About Death Between Primary and Secondary Care: A Quality Improvement Project

Abstract Introduction Communication between the hospital and primary care regarding the death of a patient is incredibly important. Previous literature surrounding this area has shown that it is often done poorly, resulting in substandard documentation. Furthermore, lack of information for General Practitioners (GPs) means it is difficult for them to enter discussions with families, which can negatively impact on the bereavement process. The previous expectation was that an electronic discharge summary was completed, but that this was not optimally designed to inform GPs about the circumstances surrounding the death. Reasons given that summaries were not completed included: the busy workload of junior doctors and the lack of awareness of their importance. Methods The aim of our quality improvement project was to ensure 80% of GPs received notification and information about a patient’s death by August 2018. Following an initial cycle to assess the baseline notification rates, we developed a standardized death notification letter following feedback from local GPs. This included information such as date of death, if the coroner had been informed and a brief summary of events. Following introduction of the letter, we recorded the uptake and then gained further feedback regarding the ways in which it could be improved. A final cycle was then implemented. Results Baseline data showed an electronic discharge letter was only being completed in 13.3% of cases (n=3/21). Following introduction of the new letter, 83.6% were completed (n=56/67). Conclusions In conclusion, the introduction of a simple and standardized letter template has vastly increased the notification of GPs about a patient’s death from our hospital. Limitations of our project included the varying numbers of deaths in audited periods and some hospital teams having a separate process in place.

A novel 2-week wait lung cancer pathway starting with a telephone consultation, with patient satisfaction survey results

Nationally, 2-week wait (TWW) referral rates are increasing. This is reflected locally, with no corresponding rise in numbers of new cancers diagnosed. In May 2018, in collaboration with local general practitioners (GPs), we redesigned our pathway to enable speedier diagnosis and reassurance. First, the referring GP requests computed tomography (CT) of the chest/abdomen and blood tests, at the same time as electronically booking a TWW telephone appointment (OPA) with a respiratory consultant. Initially local GPs were reluctant to book the CT as they did not want the responsibility for chasing and acting on the results, but agreement was reached and …

Factors affecting the embedding of integrated primary–secondary care into a health district

With the aging population, the tide of chronic disease is rising with attendant increases in health service need. Integrated care and patient-centred approaches, which established partnerships between a regional Hospital and health service (HHS), the local primary health network and local general practitioners (GPs), were identified as exemplars of an approach needed to support growing community health needs. This paper summarises the findings from a process evaluation of four GP-specialist care integration programs with the aim of identifying recommendations for embedding integrated GP-specialist care into routine practice within the HHS. The process evaluation of the integration programs drew on input from a multidisciplinary expert advisory group and data collected through face-to-face semi-structured interviews with key stakeholders, as well as surveys of participating GPs and patients. Overarching findings were identified and grouped under six themes: interdisciplinary teamwork; communication and information exchange; the use of shared care guidelines or pathways; training and education; access and accessibility; and funding. Within each theme, key challenges and enablers emerged. The findings of this study highlight benefits and challenges associated with the establishment of integrated care between primary and secondary care providers, leading to the development of key recommendations for routine integration.

Letter. Novel subgroups of adult‐onset diabetes in a UK community setting

Sir, A recent study by Ahlqvist et al. proposed that individuals with adult-onset diabetes could be grouped into five clusters based on six variables: i.e. age, BMI, HbA1c, presence of glutamic acid decarboxylase (GAD) antibodies, and homeostasis model assessment (HOMA) of insulin resistance.1 We investigated the applicability of this new classification among a multi-ethnic UK population. We analysed data from the electronic care record for participants attending community diabetes clinics in Sutton, an ethnically diverse London borough, between October 2016 and February 2017. We defined the diabetic clusters as close to the Swedish paper as possible. Thus, participants with evidence of autoimmune (GAD positive) insulin-requiring diabetes were classified as cluster 1. This cluster included individuals with latent autoimmune disease of adults (LADA). We categorised participants in cluster 2 as severely insulin-deficient if they were insulin requiring but GAD antibody negative with very low 2-hour post meal C-peptide concentrations <94pmol/L. In the absence of HOMA assessments, we defined severe insulin resistance (cluster 3) as participants requiring >1 unit/kg insulin.2 We included participants in cluster 4 if they required <1 unit/kg insulin or were only on oral medication. Participants classified as having mild age-related diabetes (cluster 5) were aged >60 years at diagnosis with modest metabolic derangement. Fisher's test was used to compare categorical variables and the level of significance was p<0.05. Mann-Whitney U test was used to compare non-parametric data. Compared with the Swedish dataset in which mild obesity-related diabetes (cluster 4) comprised 21.6% of participants, we classified 72.5% in this category (Figure 1). This discrepancy may have resulted from our definition of severe insulin resistance based on insulin dose/kg rather than on HOMA-IR assessment. The second largest subgroup were classified as having severe insulin-resistant diabetes (cluster 3) comprising 13.5% (15.3% in the Swedish dataset) and had the highest incidence of macroalbuminuria, chronic kidney disease (CKD) and non-alcoholic fatty liver disease (NAFLD); (Table 1). By contrast, cluster 3 participants in our study were younger compared with the Swedish subgroup and this may account for a low incidence of coronary artery disease and stroke in our group. We categorised 7% of our participants within the severe autoimmune insulin deficient cluster, a result similar to that reported by Ahlqvist et al. (6.4%).1 As expected, participants were younger, non-obese, had poor metabolic control, and had the shortest time to sustained insulin use. We observed the highest risk of retinopathy (79%) in this cluster. The severe insulin-deficient diabetes cluster 2 comprised 4.5% of our study group and at diagnosis were non-obese with median HbA1c of 67mmol/mol; range 57–93mmol/mol (8.3% [7.4–10.7%] in NGSP units). In accordance with the Swedish findings, the mild age-related diabetes cluster (2.5%) had only mild metabolic derangement with median HbA1c at diagnosis of 48mmol/mol (6.5% in NGSP units). Cluster 1 (n=14) Cluster 2 (n=9) Cluster 3 (n=27) Cluster 4 (n=145) Cluster 5 (n=5) Retinopathy at diagnosis: no. (%) Any retinopathy Maculopathy 0 0 0 0 3 (11) 0 16 (11) 3 (2) 0 0 Current retinopathy: no. (%) Any retinopathy Maculopathy 11 (79) 3 (21) 3 (33) 1 (11) 17 (63) 9 (33) 88 (61) 23 (16) 0 0 We further examined our data by ethnicity; Caucasians represented 74% of the participants, South Asians 22.5% and African/Afro-Caribbeans 3.5%. Eighty-one percent of non-Caucasians were classified to the mild obesity-related diabetes subgroup (cluster 4). Non-Caucasians within this cluster were younger, had lower BMI and a lower incidence of current retinopathy (46% vs 74%; p<0.001) compared with Caucasians. It is well recognised that diabetes occurs at younger ages and lower levels of BMI in South Asians.3, 4 Our data suggest that it may be possible to characterise a UK population with diabetes into the novel subgroups based on simple clinical criteria. A community registry-based study such as this has limitations. Some participant subgroups, like the mild age-related diabetes cluster, are largely managed by local general practitioners and not referred to community clinics, and are therefore under-represented in this work. Another limitation is that we had no data on HOMA-IR. Nevertheless, we identified a similar subgroup, who had severe insulin resistance and a significantly higher incidence of NAFLD when compared with those classified as mild insulin resistance (66% [cluster 3] vs 11% [cluster 4]; p<0.001). This may have implications for their management and risk of complications. Larger population-based studies are needed to confirm the generalisability of the Swedish classification in more diverse populations. There are no conflicts of interest declared.

A052 Investigation of Exhaled Nitric Oxide as a Measure of Left Atrial Pressure

During left-sided heart failure, left atrial pressure (LAP) increases, producing pulmonary congestion. Previous studies examining patients with symptomatic heart failure or rheumatic heart disease suggest a relationship between increased left atrial pressure (LAP) and fractional exhaled nitric oxide (FeNO), which can be measured by a reliable portable hand-held analyzer. If such a relationship existed, a portable diagnostic test could be used to supplement current assessments. This observational study examined a subset of the OxVALVE cohort, a UK population-based cohort aged 65 years and older. Participants were eligible for inclusion if they did not have a previous diagnosis of valvular heart disease, and could provide informed consent. Each participant had echocardiography performed at their local general practice. The E/e' ratio, measured via transthoracic echocardiography, was used as a surrogate of LAP. A consecutive subset of 277 participants had FeNO measurement attempted using a NIOX VERO electrochemical analyzer. Mean age of participants was 73.5±6.3 years, with 45% female. Only 10 participants had an NYHA class of III or more. FeNO was successfully measured in 227 participants, with a mean FeNO of 24.2 + 15.6ppb. Mean E/e' was 11.5±3.5. There were 58 participants with high E/e' (>14), and these were older than those with normal E/e' (<8) (76.8±7.4years vs 72.0±5.5 years, p<0.001). No relationship between FeNO and E/e' was seen on regression analysis. FeNO is not an accurate predictor of elevated E/e' in predominantly asymptomatic patients in a general practice setting.

Validity of thermography for measuring burn wound healing potential.

Accurate assessment of burn wound depth and the associated healing potential is vital in determining the need for surgical treatment in burns. Infrared thermography measures the temperature of the burn wound noninvasively, thereby providing indirect information on its blood flow. Previous research demonstrated that a small, low‐priced, handheld thermal imager has an excellent reliability, but a moderate validity for measuring burn wound healing potential. A new and more sensitive version of this convenient device has become available. The aim of this study was to evaluate the validity of thermography for measuring burn wound healing potential, compared to Laser Doppler Imaging (LDI) as a reference standard. Thermal images and LDI scans were obtained from burn wounds between 2 and 5 days postburn. Temperature differences between burned and nonburned skin (ΔT) were calculated. To evaluate validity, ΔT values were compared to the healing potential categories assessed by LDI. Two receiver operating characteristic curves were created and two ΔT cutoff values were calculated to illustrate the ability to discriminate between burn wounds that heal in a time period of less than 14 days, between 14 and 21 days, and more than 21 days. Between June and October 2018, 43 burn wounds in 32 patients were measured. ΔT cutoff values of 0.6°C (sensitivity 68%, specificity 95%) and −2.3°C (sensitivity 30%, specificity 95%) were calculated to discriminate between burn wounds that heal in <14 and ≥14 days, and burn wound that heal in ≤21 and >21 days, respectively. This study shows a good validity of the feasible thermal imager for the assessment of burn wound healing potential. Therefore, we consider it a promising technique to be used for triage in local hospitals and general practices, and as a valuable addition to clinical evaluation in burn centers.

Introduction of a referral pathway guide for general dental practitioners in Cheshire & Merseyside: the effect on two-week suspected cancer referrals.

Introduction In 2017, Cheshire and Merseyside Local Dental Network introduced an Oral Cancer Care Guide for dental teams, emphasising the importance of early detection, appropriate referral, and effective patient communication. This study looks at the effect on two-week-wait (TWW) referrals to one unit, following the introduction of the guide and regional educational intervention.Methods Somerset Cancer Register, provided data from two three-month cohorts of TWW suspected head and neck cancer referrals, before and after introduction of the guide.Results There were 390 and 481 referrals respectively during the two three-month time-periods. The number of general dental practitioner (GDP) referrals rose from 24 to 59 (6.2% to 12.3%, P = 0.002) following introduction of the guide. The cancer conversion rate remained the same for general practitioner (GP) referrals (6.3% and 6.2%) but was lower for GDP referrals (21% vs 12%, P = 0.31).Conclusions We observed an increase in referrals following the introduction of the guide; however, the conversion rate for GDP referrals reduced. Education and ease of referral are essential for reducing the number of advanced cancers presenting to secondary care, but more research is required to inform an improvement in specificity. Future work is required looking at the long-term impact of the guide including adaption for local GP usage.

The modern characteristics of quality of ambulatory polyclinic medical care of patients of elderly age

The organization of out-patient care of elderly people has its own clinical and organizational characteristics. The study was carried out to establish quality factors of ambulatory polyclinic medical care of elderly people from the position of attending physician. The sampling consisted of 80 physicians interviewed. Out of them 70 were females (87.5%), 50 local therapists and general practitioners and 30 physicians of various specialties. The genuinely elaborated questionnaire was applied. Results and discussion. It is established that most physicians are aware of the need of improving quality of medical care of elderly patients and developing geriatric care. The percentage of elderly patients in ambulatory polyclinic network makes up to 50%, and in particular cases up to 60-70%. The majority of elderly patients visit their physician 1-2 times per month. More than 50% of physicians consider elderly patients have to be observed by physicians of geriatric profile that confirms actual need in this medical specialty. The social and organizational factors of quality of medical care are identified: insufficient duration of physician admission, low level of preferential medications support, lacking of cash resources in patients to purchase prescribed medications, difficulties in making an appointment to medical specialist and district physician, difficult access of medical organization. The orientation of doctors in provision of care to elderly patients only to medication therapy is established. Conclusion. The specific characteristics of identified factors of quality of medical care of elderly patients are to be considered in developing directions of optimizing medical care for this contingent.

StopBlues: a French e-health device to prevent suicide in the general population

Abstract Background France is one of the Western European countries most affected by suicide, an epidemiological burden and high societal cost of several million euros/year. Several European projects have either implemented web-based interventions for care of mental disorders or recommended online actions which have demonstrated their effectiveness for suicide prevention. The objective of the project was the construction of an application and website to prevent suicide in the general population, with its promotion being supported at the local authority level. Methods The detailed content of the devices and promotional tools available to local authorities was determined through literature reviews and expert groups (psychiatrists, local authorities’ workers and potential users). Results An application and website were constructed with two parts: a public interface with videos (psychological suffering, coping strategies and help available), an emergency button, a map with local resources and contact information (psychiatrists, psychologists, associations...), tips and videos to overcome a period of psychological suffering; and a private interface requiring registration giving access to self-assessment questionnaires and a safety plan to fill in case of crisis. 40 local authorities are involved in StopBlues promotion, with a referent each, responsible of contact with our team, and local organization of promotion. Conclusions Since 04-2018, StopBlues is available at www.stopblues.fr and can be downloaded on iOs and Android. Its promotion is part of a cluster randomized trial with 3 arms: a control group with no promotion, a group with promotion by local authorities, and a group with promotion by local authorities and general practitioner’s waiting room. As promotion could have different intensities depending on budgets and referent’s involvement, we decided to extend it for another year, with local authorities of group control receiving additional financial and organizational support. Key messages As the first e-health program for suicide primary prevention in the French general population, StopBlues’ main goal is to help people find solutions that suit them and direct them to the right help. Local authorities are a key level to promote primary health prevention programs.

Collaboration Between GPs and Psychologists: Dissatisfaction from the Psychologists' Perspective-A Cross-Sectional Study.

Collaborative mental health practices in primary care significantly enhances patients' health. Collaboration between general practitioners (GPs) and psychologists could improve non-drug mental care. Little is known of psychologists' perception of GPs and their collaboration. This study aimed to assess the quality of collaboration between GPs and psychologists from the psychologists' perspective and to identify factors associated with satisfactory collaboration. A questionnaire was sent by post to all private psychologists in a region of France in February, 2017. We carried out descriptive and multivariate analysis of factors associated with satisfactory collaboration. The response rate was 38% (n = 434 out of 1128). Collaboration between GPs and psychologists was considered unsatisfactory by 64% (n = 278) of psychologists. The main barriers reported were lack of time, lack of understanding and poor interactions/communication. Sixty-nine percent of psychologists felt that GPs knew little about their work. Psychologists had professional exchanges with an average of three local GPs and received referral information for 12% of new patients. Out of 10 new patients, 2 were referred by a GP.In a multivariate analysis, satisfactory collaboration was significantly associated with the number of GPs psychologists exchanged with (OR 1.29), receipt of referral information (OR 2.18) and a positive assessment of GPs' understanding of psychologists' activity (OR 3.35). Psychologists considered the collaboration between GPs and psychologists as substandard, as well as GPs' knowledge of psychologists' activity. More interactions and better understanding would improve their collaboration.