General Practice Patients Research Articles

Physical activity prescription for general practice patients with cardiovascular risk factors\u2013the PEPPER randomised controlled trial protocol

BackgroundThe health benefits of physical exercise have been shown to be important in the prevention of cardiovascular diseases in patients with hypertension, dyslipidaemia or diabetes. However, few strategies have demonstrated efficacy and practicality in the promotion of physical exercise among this group of patients in general practice.MethodsThe PEPPER clinical study is a randomised controlled trial to evaluate the efficacy over a period of 12 months, in terms of physical activity level, of an intervention based on structured information delivery, a personalised written physical activity prescription in number of steps per day, a pedometer and a pedometer logbook, in 35 to 74-year-old patients with cardiovascular risk factors. 140 patients will be recruited in 15 GP practices and randomised in the intervention group or in the control group where patients will receive verbal advice of physical exercise. The primary outcome is the change at three months in total energy expenditure measured by an accelerometer over a 7-day period. Secondary outcomes include changes at 3 and 12 months in physical activity levels (accelerometer and International Physical Activity Questionnaire), quality of life (SF-36), blood pressure, weight, waist circumference, perceived obstacles to physical activity and patient compliance with the recommended strategy. Both groups will be compared using mixed models.DiscussionThe results are expected at the end of 2019. If the intervention proves effective in durably increasing the level of physical activity, this strategy could be tested in a larger trial to examine its impact on cardiovascular diseases.Trial registrationUS National Institutes of Health Clinical Trials Registry NCT02317003, December 15, 2014.

Comorbid insomnia, psychological symptoms and widespread pain among patients suffering from musculoskeletal pain in general practice: a cross-sectional study.

ObjectiveThe aim of this study was to examine the association between musculoskeletal (MSK) pain, insomnia, anxiety and depressive symptoms in patients from general practice.DesignThis is a cross-sectional study.SettingThis study was conducted in general practice in Denmark.ParticipantsA consecutive sample of 390 general practice patients (aged 12 years or older) were included; 183 patients with MSK pain and 207 patients without MSK pain. To be included in the MSK pain group, participants with MSK pain were required to report MSK pain at least weekly during the preceding month, which had a negative impact on daily activities.Primary and secondary outcomes measuresThe primary outcome was insomnia evaluated by the Athens Insomnia Scale. The secondary outcomes were psychological symptoms assessed by the Hospital Anxiety and Depression Scale.ResultsPatients with MSK pain had a significantly higher prevalence of insomnia (difference 25.5%, p<0.0001), anxiety (difference 24.3%, p<0.0001) and depressive symptoms (difference 11%, p<0.0001) compared with patients without MSK pain. Furthermore, patients with MSK pain and comorbid insomnia had significantly higher levels of anxiety and symptoms of depression compared with patients with MSK pain without insomnia (p<0.0001). These relationships remained robust when controlling for age, sex and body mass index in linear regression.ConclusionOne in two patients in general practice report MSK pain. Comorbid MSK pain and insomnia are common and are associated with a higher prevalence of anxiety and depression. This highlights the importance of establishing the presence of insomnia and affective disorders as potentially modifiable factors during treatment of MSK pain in general practice.

General practice (GP) level analysis shows that patients’ own perceptions of support within primary care as reported in the GP patient survey (GPPS) are as important as medication and services in improving glycaemic control

BackgroundThe way that GP practices organize their services impacts as much on glycaemia in type 2 diabetes as does prescribing. AimOur aim was to evaluate the link between patients’ own perception of support within primary care and the % patients at each GP practice at target glycaemic control (TGC) and at high glycaemic risk (HGR). Design and SettingUtilisation of National Diabetes Audit (NDA) available data combined with the General practitioner patient survey (GPPS). MethodThe NDA 2016_17 published data on numbers of type 2 patients, levels of local diabetes services and the target glycaemic control (TGC) % and high glycaemic risk (HGR) % achieved. The GPPS 2017 published % “No” responses from long term condition (LTC) patients to the question “In the last 6 months, had you enough support from local services or organisations to help manage LTCs?”. Multivariate regression was used on the set of indicators capturing patients’ demographics and services provided. Results6498 practices were included (with more than 2.5 million T2DM patients) and median values with band limits that included 95% practices for % “No” response to the question above was 12% (2%–30%), for TGC 67% (54%–78%) and for HGR 6% (2%–13%). The model accounted for 25% TGC variance and 26% HGR variance.The standardised β values shown as (TGC/HGR) (+=more people; −=less people) for older age (+0.24/−0.25), sulphonylurea use (−0.21/+0.14), greater social disadvantage (−0.09/+0.21), GPPS Support %No (−0.08/+0.12), %Completion 8 checks (+0.09/−0.12) and metformin use (+0.11/−0.05). ConclusionThe relation between the person with diabetes and clinician in primary care is shown to be quantitatively potentially as important in influencing glycaemic outcome as the services provided and medication prescribed. We suggest that all of us in who work in the health care system can bear this in mind in our everyday work.

Prevalence and incidence rate of lower-extremity tendinopathies in a Danish general practice: a registry-based study

BackgroundTendinopathies of the lower extremity (e.g. Achilles, patellar, and plantar heel pain) are common in both general and sporting populations. However, the prevalence and incidence in Danish general practice is unknown. The aim was to determine the prevalence and incidence rate of lower-extremity tendinopathies in a Danish general practice.MethodsIn this registry-based study, we extracted data from the electronic patient files of all patients in a single Danish general practice. The practice included 8836 patients. We searched ICPC-2 codes to identify patients with either of the following lower-extremity tendinopathies: plantar heel pain; Achilles tendinopathy; patellar tendinopathy; greater trochanteric pain syndrome or adductor tendinopathy. We defined an incident and prevalent case as a patient with a consultation because of tendinopathy in 2016 only. A prevalent, but not incident case was a patient with consultations in both 2015 and 2016. Incidence and prevalence were expressed as the number of patients with a tendinopathy per 1000 registered patients.ResultsThe prevalence and incidence rate were 16.6 and 7.9 per 1000 registered patients, respectively. Plantar heel pain was the most prevalent tendinopathy and accounted for 39% of lower-extremity tendinopathies. Patients with tendinopathies were significantly older than all registered patients (46.0 years (95%CI: 43.3;48.7) versus 38.8 years (95%CI: 38.4;39.3), respectively).ConclusionsLower-extremity tendinopathies, especially plantar heel pain, had a high prevalence and incidence rate in a Danish general practice. In a typical general practice with 5000 patients, general practitioners should expect to see more than 80 patients with a lower-extremity tendinopathy every year.

Prevalence of Anxiety Symptoms and Their Association With Loss Experience in a Large Cohort Sample of the Oldest-Old. Results of the AgeCoDe/AgeQualiDe Study.

Background: Anxiety in adults is a common mental health problem. However, studies on anxiety in the oldest-old are lacking. We sought to identify the age- and gender-specific prevalence of anxiety symptoms in a large sample of general practice patients. Furthermore, we investigated relevant associations of anxiety specifically with respect to recent experience of loss. Methods: Based on the German Study on Ageing, Cognition and Dementia in general practice patients, a sample of 897 patients aged 82 years and older was assessed. Anxiety was assessed using the short form of the Geriatric Anxiety Inventory (GAI-SF). For the assessment of loss, patients were asked whether there were cases of death in their closer social environment since the last assessment. Descriptive and logistic regression analyses were run. Results: Of the oldest-old individuals (aged 82+ years, mean age: 86.8), 14.5% (95% CI 12.4–16.8) suffered from anxiety symptoms. Highest prevalence rates were found for 82- to 85-year-old women (17.2%, 95% CI 12.6–22.1) and for 86- to 90-year-old patients (both sexes) in general (15.9%, 95% CI 12.6–19.2). Older individuals who experienced cases of death in their close social environment within the last 18 months had almost twice the odds [odds ratio (OR) 1.91, 95% confidence interval (CI) 1.15–3.17] of reporting anxiety compared to those without a recent loss. As expected, depression and impaired cognitive status were associated with the presence of anxiety symptoms. No relation was found between social network, gender, age, frailty, or physical illness and anxiety in regression analysis. Conclusions: This study provides for the first time age- and gender-specific prevalence rates of anxiety symptoms and associated risk factors among a large population-based sample of oldest-old primary care attenders. Anxiety is highly prevalent in individuals aged 82 years and older. Depression, impaired cognitive status, and recent experience of loss are associated with late-life anxiety. Our findings support the idea that recent experience of loss should be taken seriously in the context of clinical practice with respect to diagnosing and treating anxiety in old age.

Association of continuity of care with blood pressure control in patients with chronic kidney disease and hypertension

Hypertension frequently co-exists with chronic kidney disease (CKD). The objective of this study was to investigate blood pressure (BP) control among general practice patients with CKD and hypertension, and whether control was related to continuity of care. We analysed data from NPS MedicineWise MedicineInsight, examining the achievement of guideline-recommended BP levels in patients with CKD and hypertension, and the relationship with sociodemographic, clinical and health-system variables, including continuity of care (CoC) in general practice. Of 37,425 patients in the cohort, 46.7% had achieved the recommended BP targets. Patients with higher relational CoC and more general practitioner (GP) visits were more likely to achieve BP targets, while this was less likely when the target was lowered by concomitant diabetes or cardiovascular disease. Reaching BP targets in patients with CKD is a challenge, especially when the target is lower because of co-existing risk factors. Greater CoC from the same GP increased the likelihood of achieving target BP values.

Care of general practice patients preceding and following a suicide attempt: observational study in Flemish general practices

ObjectivesFirst, to examine general practitioner (GP) knowledge about the care (needs) of their patients; second, to examine the quality of GP follow-up care; third, to examine the transmission of patient...

Prescription patterns of lipid lowering agents among older patients in general practice: an analysis from a national database in the Netherlands.

Dutch cardiovascular risk management guidelines state almost every older adult (≥70 years) is eligible for a lipid lowering drug (LLD). However, life expectancy, frailty or comorbidities may influence this treatment decision. investigate how many older adults, according to age, frailty (Drubbel-frailty index) and comorbidities were prescribed LLDs. data of 244,328 adults ≥70 years from electronic health records of 415 Dutch general practices from 2011-15 were used. Number of LLD prescriptions in patients with (n = 55,309) and without (n = 189,019) cardiovascular disease (CVD) was evaluated according to age, frailty and comorbidities. about 69% of adults ≥70 years with CVD and 36% without CVD were prescribed a LLD. LLD prescriptions decreased with age; with CVD: 78% aged 70-74 years and 29% aged ≥90 years were prescribed a LLD, without CVD: 37% aged 70-74 years and 12% aged ≥90 years. In patients with CVD and within each age group, percentage of LLD prescriptions was 20% point(pp) higher in frail compared with non-frail. In patients without CVD, percentage of LLD prescriptions in frail patients was 11pp higher in adults aged 70-74 years and 40pp higher in adults aged ≥90 years compared to non-frail. Similar trends were seen in the analyses with number of comorbidities. in an older population, LLD prescriptions decreased with age but-contrary to our expectations-LLD prescriptions increased with higher frailty levels.

Nighttime Blood Pressure Measured by Home Blood Pressure Monitoring as an Independent Predictor of Cardiovascular Events in General Practice.

We developed an innovative automated home blood pressure (BP) monitoring method that measures BP while asleep repeatedly over several days. Our aim was to assess the predictive ability of nighttime BP obtained using the home BP device for incident cardiovascular disease (CVD) in general practice patients. We used data from the nationwide practice-based J-HOP (Japan Morning Surge-Home Blood Pressure) Nocturnal BP Study, which recruited 2545 Japanese with a history of or risk factors for CVD (mean age 63 years; antihypertensive medication use 83%). The associations between nighttime home BPs (measured at 2:00, 3:00, and 4:00 am using validated, automatic, and oscillometric home BP devices) and incident CVD, including coronary disease and stroke events, were assessed with Cox proportional hazards models. The mean±SD office, morning home, and nighttime home systolic BP (SBP)/diastolic BP were 140±15/82±10, 137±15/79±10, and 121±15/70±9 mm Hg, respectively. During a follow-up of 7.1±3.8 years (18,116 person-years), 152 CVD events occurred. A 10-mm Hg increase of nighttime home SBP was associated with an increased risk of CVD events (hazard ratios [95% CIs]: 1.201 [1.046-1.378]), after adjustments for covariates including office and morning home SBPs. The model fit assessed by the change in Goodness-of-Fit was improved when we added nighttime home SBP into the base models including office and morning home SBPs (Δ6.838 [5.6%]; P=0.009). This is among the first and largest nationwide practice-based study demonstrating that nighttime SBP obtained using a home device is a predictor of incident CVD events, independent of in-office and morning in-home SBP measurement. Clinical Trial Registration- URL: http://www.umin.ac.jp/icdr/index.html . Unique identifier: UMIN000000894.

Student Exposure to Cancer Patients: an Analysis of Clinical Logbooks and Focus Groups in Clinical Year Medical Students

Despite cancer being the leading cause of mortality, cancer education and patient exposure are lacking in many medical schools. The aim of this study was to evaluate the nature of cancer patient exposure, relative to the clinical setting for medical students on placement and to explore their experiences. Participants were asked to maintain a logbook of cancer patient encounters and were invited to attend a structured focus group upon completion of the academic year. Eleven students submitted logbooks (rr = 6.15%) and eight participated in the focus groups (4.47%). A total of 247 cancer patient encounters were recorded. Third-year students primarily saw cancer patients in surgery (18.62%) and general practice (8.50%), whilst final year students saw cancer patients most frequently in palliative care (35.22%) and ENT surgery (13.77%). Students highlighted that the quality of their interactions with cancer patients varied significantly between clinical settings. Outpatient clinics and surgical in-patients had the lowest level of interaction, with students having a predominantly observatory role. Repeated themes of uncertainty and awkwardness regarding history, examination and discussing death and dying were outcomes of the thematic analysis. Exposure to cancer patients remains highly variable and opportunistic. Students voiced concerns for preparedness to practice and many found it worrisome that they will likely examine aprimary cancer when they have graduated, without having done so during their training. Our study suggests that a more structured approach to teaching and clinical exposure to cancer patients is required.

Real-world prevalence of the inclusion criteria for the LEADER trial: Data from a national general practice network.

AimsTo explore the prevalence and describe the clinical characteristics of people with type 2 diabetes with a similar cardiovascular (CV) profile to that of the LEADER trial participants in a primary care setting in England.Materials and methodsIn this cross‐sectional analysis, using the Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC) network database, we identified people with type 2 diabetes meeting the LEADER inclusion criteria. We identified people's CV risk factors using computerized medical records. Additionally, we assessed the prescription pattern of glucagon‐like peptide‐1 receptor agonists (GLP‐1RAs) in this cohort.ResultsOf 1 275 461 adults, we identified 84 394 with type 2 diabetes, of whom 14 000 (16.6%) met the LEADER inclusion criteria for established or high‐risk CV disease (RCGP RSC‐CVD group). The LEADER cohort was younger than the RCGP RSC‐CVD group (64.2 vs 73.2 years), had higher mean glycated haemoglobin (71.6 vs 67.1 mmol/mol) and blood pressure (BP) values (systolic BP: 135.9 vs 132.9 mmHg; diastolic BP: 77.2 vs 72.7 mmHg), and a higher mean body mass index (32.5 vs 30.9 kg/m2). In the RCGP RSC‐CVD group, only 1215 people (8.7%) had ever been prescribed a GLP‐1RA and 760 (5.4%) had ever received liraglutide.ConclusionsIn a cohort of English general practice patients, one in six people with type 2 diabetes met the LEADER inclusion criteria, and less than one in 10 of these received liraglutide, a drug which has demonstrated CV benefits amongst others. There is scope to improve the outlook in people with type 2 diabetes and high CV risk through evidence‐based use of specific GLP‐1RAs.

Intraseason decline in influenza vaccine effectiveness during the 2016 southern hemisphere influenza season: A test-negative design study and phylogenetic assessment

BackgroundWe estimated the effectiveness of seasonal inactivated influenza vaccine and the potential influence of timing of immunization on vaccine effectiveness (VE) using data from the 2016 southern hemisphere influenza season. MethodsData were pooled from three routine syndromic sentinel surveillance systems in general practices in Australia. Each system routinely collected specimens for influenza testing from patients presenting with influenza-like illness. Next generation sequencing was used to characterize viruses. Using a test-negative design, VE was estimated based on the odds of vaccination among influenza-positive cases as compared to influenza-negative controls. Subgroup analyses were used to estimate VE by type, subtype and lineage, as well as age group and time between vaccination and symptom onset. ResultsA total of 1085 patients tested for influenza in 2016 were included in the analysis, of whom 447 (41%) tested positive for influenza. The majority of detections were influenza A/H3N2 (74%). One-third (31%) of patients received the 2016 southern hemisphere formulation influenza vaccine. Overall, VE was estimated at 40% (95% CI: 18–56%). VE estimates were highest for patients immunized within two months prior to symptom onset (VE: 60%; 95% CI: 26–78%) and lowest for patients immunized >4 months prior to symptom onset (VE: 19%; 95% CI: −73–62%). DiscussionOverall, the 2016 influenza vaccine showed good protection against laboratory-confirmed infection among general practice patients. Results by duration of vaccination suggest a significant decline in effectiveness during the 2016 influenza season, indicating immunization close to influenza season offered optimal protection.

Gathering data for decisions: best practice use of primary care electronic records for research.

Summary In Australia, there is limited use of primary health care data for research and for data linkage between health care settings. This puts Australia behind many developed countries. In addition, without use of primary health care data for research, knowledge about patients’ journeys through the health care system is limited.There is growing momentum to establish “big data” repositories of primary care clinical data to enable data linkage, primary care and population health research, and quality assurance activities. However, little research has been conducted on the general public's and practitioners’ concerns about secondary use of electronic health records in Australia.International studies have identified barriers to use of general practice patient records for research. These include legal, technical, ethical, social and resource‐related issues. Examples include concerns about privacy protection, data security, data custodians and the motives for collecting data, as well as a lack of incentives for general practitioners to share data.Addressing barriers may help define good practices for appropriate use of health data for research. Any model for general practice data sharing for research should be underpinned by transparency and a strong legal, ethical, governance and data security framework.Mechanisms to collect electronic medical records in ethical, secure and privacy‐controlled ways are available.Before the potential benefits of health‐related data research can be realised, Australians should be well informed of the risks and benefits so that the necessary social licence can be generated to support such endeavours.

Health care inequality in free access health systems: The impact of non-pecuniary incentives on diabetic patients in Danish general practices

Indicators of deprivation based on income and education might offer a blunt tool for inequality analysis in universal health systems with free access to care and thereby preventing the identification of groups experiencing the largest inequality. Also, analysis methods based on ranking the population by income or education, such as concentration curves and indices, are unsuitable for evaluating the impact of a health programme on inequality. This paper uses a new method for inequality analysis based on the Health Care Deprivation profiles’ approach, allowing for: (1) considering multi-dimensional aspects of deprivation in the inequality analysis, (2) a graphical representation of the distribution of inequality, and (3) a range of additive decomposable inequality indices consistent with dominance. We apply this method and a Difference in Differences approach to evaluate the impact of a disease management programme aiming at reducing underutilisation of GP services for diabetic patients in Denmark. The programme introduced a set of non-pecuniary incentives empowering GPs with feedback reports on their performance and comparisons with other peers. Our study population includes 93,849 diabetic patients aged 18 + registered in 563 GP practices in Denmark; a total of 246 of these practices joined the programme, and 317 are used as control. The results show that patients experiencing the largest inequality in the top quintile of the distribution are characterised by deprivation in multiple socio-economic and morbidity dimensions that are not captured fully by income and education. The programme significantly reduced inequality in access to pivotal services, such as blood tests and preventive visits, for all patients and, with greater magnitude, for the most-deprived patients. Non-pecuniary incentives may be an effective tool for GPs to improve access to care in the most vulnerable patients.

CYP2D6 Polymorphism in Patients of General Practice in Austria

CYP2D6 Polymorphism in Patients of General Practice in Austria

Shared decision-making about cardiovascular disease medication in older people: a qualitative study of patient experiences in general practice

ObjectivesTo explore older people’s perspectives and experiences with shared decision-making (SDM) about medication for cardiovascular disease (CVD) prevention.Design, setting and participantsSemi-structured interviews with 30 general practice patients aged 75 years...

Are big data analytics helpful in caring for multimorbid patients in general practice? - A scoping review

BackgroundThe treatment of multimorbid patients is one crucial task in general practice as multimorbidity is highly prevalent in this setting. However, there is little evidence how to treat these patients and consequently there are but a few guidelines that focus primarily on multimorbidity. Big data analytics are defined as a method that obtains results for high volume data with high variety generated at high velocity. Yet, the explanatory power of these results is not completely understood. Nevertheless, addressing multimorbidity as a complex condition might be a promising field for big data analytics.The aim of this scoping review was to evaluate whether applying big data analytics on patient data does already contribute to the treatment of multimorbid patients in general practice.MethodsIn January 2018, a review searching the databases PubMed, The Cochrane Library, and Web of Science, using defined search terms for “big data analytics” and “multimorbidity”, supplemented by a search of grey literature with Google Scholar, was conducted. Studies were not filtered by type of study, publication year or language. Validity of studies was evaluated independently by two researchers.ResultsIn total, 2392 records were identified for screening. After title and abstract screening, six articles were included in the full-text analysis. Of those articles, one reported on a model generated with big data techniques to help caring for one group of multimorbid patients. The other five articles dealt with the analysis of multimorbidity clusters. No article defined big data analytics explicitly.ConclusionsAlthough the usage of the phrase “Big Data” is growing rapidly, there is nearly no practical use case for big data analysis techniques in the treatment of multimorbidity in general practice yet. Furthermore, in publications addressing big data analytics, the term is rarely defined.However, possible models and algorithms to address multimorbidity in the future are already published.

Cluster randomised controlled trial of a guided self-help mental health intervention in primary care

ObjectivesTo ascertain whether an ultrabrief intervention (UBI) improves mental health outcomes for patients in general practice with mild-to-moderate mental health concerns.Trial designTwo-arm cluster randomised controlled trial.MethodsParticipants: general practitioners (GPs) were...

Neutrophil-lymphocyte-ratio distributions in a Danish population from general practice

The neutrophil-lymphocyte ratio (NLR) is a novel biomarker, showing promising both diagnostic and prognostic capabilities. The aim of this study was to present NLR distributions in a Danish population from general practice (GP) and compare levels between patients from intensive care units (ICU) and GP. A register-based study was conducted using results from 31,966 blood samples from GP and ICU located in the admission area of Aarhus University Hospital, Denmark. Exclusion of samples with lymphocytes >40 × 109/L, resulted in 28,582 samples from GP and 3,373 from ICU. Distributions for patients from GP with CRP <8 mg/L were age-dependent and were established for the following three age groups; 0–17 years [0.30:3.76], 18–75 years: [0.74:4.94], above 76 years: [0.89:8.80]. Patients from ICU had a significantly higher median NLR than patients from GP when stratified for CRP, [8.48 and 1.99 respectively]. This study describes for the first time the distributions of NLR in a large European population of GP patients.

An audit investigating the management of diabetic patients in general practice, in relation to periodontal health

Research has found a close relationship between the disease progression of diabetes and periodontitis. The aim of this audit is to determine the compliance of general dental practitioners (GDPs) with recommendations from the Delivering Better Oral Health toolkit (2014) for the management of diabetic patients. The final section of this article discusses the factors that affect the prognosis of immediate natural tooth bridges. Providing information on prognosis is an important part of the consent process; this includes patient factors and clinician factors. CPD/Clinical Relevance: There is evidence of a bi-directional relationship between diabetes and periodontitis.