GP Practices Research Articles

“I’m living in a ‘no’ world now…”- A qualitative study of the widespread impact of living with chronic breathlessness, and experiences of identification and assessment of this symptom in an older, frail community-based population

Chronic breathlessness is a debilitating symptom with detrimental impact on individuals and carers. However, little is known about the experiences of community-dwelling, frail, older adults living with chronic breathlessness. To explore, (i) the psychological impact of living with chronic breathlessness, (older frail adult patients, carers) and (ii) how patients, carers, and clinicians experience identification and assessment of chronic breathlessness in the primary care setting. In-depth semi-structured interviews with eligible older adults (≥65 years; moderate to severe frailty [electronic Frailty Index >0.36]), and carers recruited from a community-based Integrated Care Centre in England. Clinicians were recruited from the Centre and affiliated GP practices. Recorded in-person interviews were transcribed and subjected to reflexive thematic analysis using Total Dyspnoea and Breathing Space conceptual frameworks. 20 patients (9 females), carers (4 spouses, 1 daughter), and clinicians (5 GPs, 3 advanced clinical practitioners, 2 nurses) were interviewed. Four themes were identified: (1) Widespread negative impact of chronic breathlessness. Breathlessness adversely impacts physical and psychological wellbeing. (2) Barriers to optimal health-seeking and identification of chronic breathlessness. Breathlessness is ‘one of many’ symptoms, and not prioritised in ‘one appointment, one problem’ consultations. Clinicians do not routinely ask about breathlessness. Patients are unaware of breathlessness-specific therapies. (3) Variations in chronic breathlessness management. Management is limited; few are offered evidence-based treatments (e.g., handheld fan) and patients find their own strategies. (4) Need for education and information. Clinicians felt helpless about breathlessness management, and patients lacked understanding and had low expectations of receiving help for this symptom. Breathlessness adversely impacts the psychological wellbeing of older frail adults. Chronic breathlessness in older, frail adults is invisible, unidentified and unmanaged in primary care. Evidence-based breathlessness interventions are available, but not routinely implemented with few patients accessing them. Proactive identification, assessment and management of breathlessness in primary care is needed to support adults living with chronic breathlessness.

BHSeP34 Reducing inappropriate hernia ultrasound requests: a quality improvement project

Abstract Introduction The Royal College of Surgeons (RCS) Commissioning Guide states ‘diagnostic imaging should not be arranged at primary care level’ for suspected groin hernias. This quality improvement project aimed to evaluate the prevalence of inappropriate hernia ultrasound requests at Newcastle upon Tyne Hospitals NHS Foundation Trust (NUTH) and identify areas for improvement. Methods Data was collected from the PACS department for ultrasound (US) requests with 'hernia' in the indication or report from August to December 2023. Out of 251 requests from GP practices, 138 were relevant after excluding duplicates and non-hernia indications. Each patient’s notes were reviewed to determine the US report outcomes and subsequent clinical follow-up. Results Among the 138 US requests analysed, 95 confirmed hernias (47 small, 29 moderate, 19 large). Of these, 48 patients were referred to secondary care, with 33 seen in clinic and 24 undergoing surgery. The project identified a significant number of inappropriate scans based on RCS guidelines, resulting in an annual cost of £21 810 for 331 US slots. Conclusions Despite RCS guidelines, 331 US slots per year at NUTH were utilised for suspected hernias, incurring costs and delaying patient care. Direct referral to secondary care for clinically evident hernias could reduce costs, expedite treatment, and optimise US slot utilisation. These findings were presented at NUTH general surgery and radiology departmental meetings, with further presentations planned for local GP practices. The key recommendation is to educate GPs to refer patients with clinically evident hernias directly to secondary care, bypassing primary care imaging.

The Multimorbidity Questionnaire (MMQ1): English translation and validation of a Danish patient reported outcome measure for quality of life in people with multiple long-term conditions in a cross-sectional survey.

MMQ1 is a Danish-language patient-reported outcome measure (PROM) for quality of life (QOL) in people with multiple long-term conditions (MLTC). It measures needs-based QOL across six scales: Physical ability, Concerns and worries, Limitations in daily life, Social life, Personal finances and Self-image. There is currently no such measure available in English. This study aimed to translate and validate MMQ1 for use in the United Kingdom. Translation used a two-panel method (expert panel: n = 5; and lay panel: n = 6). Content validity was assessed via cognitive interviews (n = 6). A postal survey of 2,753 patients with MLTC recruited through eight GP practices in Scotland included EQ-5D-5L and ICE-CAP as comparator measures alongside MMQ1. Classical test theory psychometric analysis of survey responses followed the International Society for Quality of Life Research minimum reporting standards. Translation resulted in an English-language MMQ1 with good face validity. Cognitive interviews established good content validity. 597 survey responses were received (response rate 22%). Good internal consistency reliability and concurrent validity were demonstrated. Confirmatory factor analysis showed acceptable fit to the six-scales of MMQ1. Five of the six scales also demonstrated good discriminative ability for detecting clinically meaningful differences in QOL. However, inter-item and inter-scale correlations suggested item redundancy and scale overlap. The English-language MMQ1 demonstrated adequate psychometric properties using classical test theory. Further validation using Rasch analysis is planned, and may help optimise and abbreviate the measure. This PROM has the potential to improve the measurement of QOL in MLTC research, including trials.

Attitudes of German General Practitioners Toward eHealth Apps for Dementia Risk Reduction: Qualitative Interview Study.

eHealth interventions constitute a promising approach to disease prevention, particularly because of their ability to facilitate lifestyle changes. Although a rather recent development, eHealth interventions might be able to promote brain health and reduce dementia risk in older adults. This study aimed to explore the perspective of general practitioners (GPs) on the potentials and barriers of eHealth interventions for brain health. Understanding the perspective of GPs allows us to identify chances and challenges for implementing eHealth apps for dementia risk reduction. We conducted semistructured expert interviews with 9 GPs working in an outpatient setting in and near Leipzig, Germany. Data were fully transcribed and analyzed using a process model of qualitative content analysis with codes and categories being constructed inductively and deductively. We found generally favorable but balanced views of eHealth apps for brain health. Eight themes were identified and elaborated on in the data as follows: "addressing dementia," "knowledge about dementia," "need for information," "potential for prevention," "chances for apps for prevention," "development of apps for prevention," and "barriers of apps for prevention." GPs talked mostly about how and when to address dementia and the requirements for their use of eHealth apps for dementia prevention. GPs stated that they only addressed dementia once abnormalities were already present or less frequently when a patient or relative expressed a direct wish, while individual dementia risk or standardized diagnostic during routine check-ups were mentioned much less frequently. According to GPs, knowledge about dementia in patients was low; therefore, patients expressed little need for information on dementia risk factors and prevention in GP practices. Most patients wished for quick information regarding diagnostics, treatment options, and progression of the disease. GPs mentioned a lack of overview of the available eHealth apps and their content. They also expressed a fear of inducing health anxiety when talking to patients about risk factors and prevention. GPs want patients to receive relevant and individualized information. Prerequisites for the use of eHealth apps for dementia prevention were app characteristics related to design and content. GPs need to address dementia more routinely, assess relevant risk factors, and aid patients in a preventive role. Concerns were expressed over limited effectiveness, overwhelming patients, limited use in clinical practice, and only targeting patients with an already low risk of dementia.

Qualitative evaluation of the implementation and national roll-out of the NHS App in England

BackgroundThe NHS App launched in 2019 as the ‘digital front door’ to the National Health Service in England with core features including General Practitioner (GP) appointment booking, repeat prescriptions, patient access to records and, later on, COVID-19 vaccination certification. Similar patient portals have been adopted in different formats and with variable levels of success. In this longitudinal study (2021–2023) we examined how the NHS App became implemented in the pandemic context and beyond.MethodsWe recruited 88 participants in 62 qualitative interviews and four focus groups. Participants included patients, carers, members of the public, clinical/non-clinical NHS staff from five GP practices (where we also conducted over 60 h of observations) across England, as well as other industry, policy and civil rights stakeholders. Document analysis also contributed to participant recruitment and data interpretation. Data collection and analysis was informed by the Non-Adoption, Abandonment, Scale-up, Spread and Sustainability (NASSS) framework.ResultsOur study identified the various ways in which complexity manifested as part of the implementation, use and roll-out of the NHS App. Patients had diverse (positive and negative) user experiences as the app evolved, with some of its features described as more useful than others (e.g. prescription ordering, COVID Pass). As the app primarily provided a gateway to general practice systems and infrastructures, not all features were available by default or consistently to all users, with information often appearing fragmented or system-facing (e.g. coded). NHS staff viewed the app as constituting core NHS infrastructure in the long term which made it appealing, even though initially there was less recognition of its immediate value. There was variable organisational capacity to enable implementation and to put in place processes and staff roles required to support patient adoption. Shifting emphasis towards in-person care, challenges with digital inclusion and controversies related to features such as patient access to own records further complicated roll-out.ConclusionsAs the NHS App remains a complex innovation in a shifting landscape, it is clear ongoing work is needed to ensure its potential can be sustained to meet patient, service and policy needs.Clinical study registrationISRCTN72729780.

General practitioners’ clinical decision-making in patients that could have cancer: a vignette study comparing the Baltic states with four Nordic countries

Objective Relative one-year cancer survival rates in the Baltic states are lower than the European mean; in the Nordic countries they are higher than the mean. This study investigated the likelihood of General Practitioners (GPs) investigating or referring patients with a low but significant risk of cancer in these two regions, and how this was affected by GP demographics. Design A survey of GPs using clinical vignettes. Setting General Practice in Denmark, Estonia, Finland, Latvia, Lithuania, Norway, and Sweden. Subjects General Practitioners. Outcome measures A regional comparison of GPs’ stated immediate diagnostic actions (whether or not they would perform a key diagnostic test and/or refer to a specialist) for patients with a low but significant risk of cancer (between 1.2 and 3.6%). Results Of the 427 GPs that completed the questionnaire, those in the Baltic states, and GPs that were more experienced, were more likely to arrange a key diagnostic test and/or refer their patient to a specialist than those in Nordic Countries or who were less experienced (p < 0.001 for both measures). Neither GP sex nor practice location within a country showed a significant association with these measures. Conclusion While relative one-year cancer survival rates are lower in the Baltic states than in four Nordic countries, we found no evidence that this is due to their GPs’ reluctance to take immediate diagnostic action, as GPs in the Baltic states were more likely to investigate and/or refer at the first consultation. Research on patient and secondary care factors is needed to explain the survival differences.

Evaluation of the personality disorder positive outcomes programme (PDPOP) in general practice.

GPs and primary care services have been identified as crucial to the care of people with personality disorder. Individuals living with personality disorder frequently face stigma and difficulties when accessing healthcare. Primary care staff often describe feeling demoralised, incompetent, hurt or angry after difficult interactions with patients. To evaluate the effect of PDPOP training delivered to 10 GP practices in 2022-23. PDPOP is a co-produced training course aimed at all staff within GP surgeries to help teams, including administrative, reception and clinical staff, to feel confident and skilled when interacting with patients who may have personality disorder. The New World Kirkpatrick Model was used to evaluate the training, through questionnaires pre- training, post-training, at follow-up, and semi-structured interviews. Evaluation found that practice teams were highly satisfied with PDPOP training and found it relevant, engaging and useful. Results demonstrated that staff felt more confident and skilled when interacting with patients who may have personality disorder through use of the training's core concepts. Increased confidence in managing distress, crisis and participant's own emotions, was associated with reduced impact on staff at interview. Practices also demonstrated action taken post-training to reduce dependency on primary care services. By including lived-experience trainers and introducing core concepts, PDPOP has demonstrated a sustained positive impact on primary care teams. Further expansion of this type of training may help to increase the confidence of healthcare staff in delivering care to patients with personality disorder and similar complex emotional needs.

Estimating the burden of underdiagnosis within England: A modelling study of linked primary care data.

Undiagnosed chronic disease has serious health consequences, and variation in rates of underdiagnosis between populations can contribute to health inequalities. We aimed to estimate the level of undiagnosed disease of 11 common conditions and its variation across sociodemographic characteristics and regions in England. We used linked primary care, hospital and mortality data on approximately 1.3 million patients registered at a GP practice for more than one year from 01/04/2008-31/03/2020 from Clinical Practice Research Datalink. We created a dynamic state model with six states based on the diagnosis and mortality of 11 conditions: coronary heart disease (CHD), stroke, hypertension, chronic obstructive pulmonary disease, type 2 diabetes, dementia, breast cancer, prostate cancer, lung cancer, colorectal cancer, and depression/anxiety. Undiagnosed disease was conceptualised as those who died with a condition but were not previously diagnosed. This was combined with observed data on the incidence of diagnosis, the case fatality rate in the diagnosed, and an assumption about how that rate varies with diagnosis to estimate the number of undiagnosed disease cases over the total number of disease cases (underdiagnosis) in each population group. We estimated underdiagnosis by year, sex, 10-year age group, relative deprivation, and administrative region. We then applied small-area estimation techniques to derive underdiagnosis estimates for health planning areas (CCGs). Levels of underdiagnosis varied between 16% for stroke and 69% for prostate cancer in 2018. For all diseases, the level of underdiagnosis declined over time. Underdiagnosis was not consistently concentrated in areas with high deprivation. For depression/anxiety and stroke, underdiagnosis was estimated to be higher in less deprived CCGs, whilst for CHD and T2DM, it was estimated to be higher in more deprived CCGs, with no apparent relationships for other conditions. We found no uniform spatial patterns of underdiagnosis across all diseases, and the relationship between age, deprivation and the probability of being undiagnosed varied greatly between diseases. Our findings suggest that underdiagnosis is not consistently concentrated in areas with high deprivation, nor is there a uniform spatial underdiagnosis pattern across diseases. This novel method for estimating the burden of underdiagnosis within England depends on the quality of routinely collected data, but it suggests that more research is needed to understand the key drivers of underdiagnosis.

Current drawbacks and future perspectives in the diagnosis and treatment of male factor infertility, with a focus on FSH treatment: an expert opinion.

Infertility is defined as the inability to conceive after 1year of unprotected intercourse, affecting approximately 15-20% of couples in Western countries. It is a shared problem within the couple; when the main issue lies with one of the partners, it is preferable to refer to "male factor" or "female factor" infertility rather than simply male or female infertility. Despite male factor infertility accounting for half of all couple infertility cases, the clinical approach to the male partner is not uniformly standardized across international guidelines. To provide an expert overview, we have comprehensively reviewed and critically analyzed the most up-to-date literature on this sensitive topic, leading to the development of a proposal for tailored assessment of the diagnostic-therapeutic pathway and preventive strategies. The diagnostic approach also considers that infertile men are objectively less healthy than their fertile counterparts of the same age and ethnicity. This article discusses the diagnostic flow, the classification of male factor infertility, the definition of idiopathic infertility, the involvement of general health, and treatment recommendations, emphasizing follicle-stimulating hormone treatment in selected groups of patients. We provide expert opinion on current drawbacks and future perspectives in this field, with practical advice for the clinical practice of general practitioners and expert in reproductive medicine.

Association between video consultation use and general practitioner and practice characteristics: a cross-sectional survey in Denmark.

Video consultations (VC) disrupt how general practice provides care and how patients receive it. A step towards understanding the use of VC is to study the association between user-status and general practitioner and practice characteristics. To study the association between general practitioner and general practice characteristics and VC user-status (users, never users, and former users). An anonymous, web-based, cross-sectional survey was distributed to all 1674 Danish general practices (singlehanded, collaborative, and partnership forms) contracting with and working on a collective agreement with the public funder. Multinomial logistic regression was used to correlate VC user-status and (1) general practice characteristics, and general practitioners' (2a) objective characteristics and (2b) subjective attitudes towards VC and organizational change. The study sample included 416 general practitioners. Users of VC compared to never-users: partnership practices (RRR=0.22; 95% CI 0.06-0.85) and practices with six or more practice staff (RRR=0.05; 95% CI 0.01-0.28) were significantly more likely to be users. The same was found for general practitioners with a high degree of tech savviness (RRR=0.02; 95% CI 0.001-0.17) and openness to organisational change (RRR=0.26; 95% CI 0.08-0.85). Characteristics of general practice and general practitioners are associated with VC user-status (being a user, never user or former user). Future research should use a Difference-in-Difference study design and register data to make causality claims.

Pharmacist-led DE-eSCALation of opioids post-surgical dischargE (DESCALE) - A multi-centre, non-randomised, feasibility study protocol.

Opioids are frequently prescribed for short-term acute pain following surgery. Used appropriately, opioids deliver extremely favourable pain relief. Used longer than 90-days, however, can result in health complications, including unintentional overdose and addiction. Globally, >40 million people are dependent on opioids and annually >100,000 die from opioid misuse. With >4.7 million surgical procedures occurring annually in the United Kingdom it is imperative that opioid-use is managed upon discharge. A declining General Practitioner (GP) workforce and increased patient numbers, however, means gaps in healthcare during transfer of care. Here we report a mixed-methods protocol to understand the feasibility, and acceptability of a clinical pharmacist (CP)-led early opioid deprescribing intervention for discharged surgical patients. DESCALE is a multicentre, non-randomised, pragmatic feasibility study. Participants aged ≥18 years who have undergone a surgical procedure at a single NHS trust in Southeast England and discharged with opioids and without a history of long-term opioid use, cancer diagnosis or study contraindications will be offered a Medicines Use Review (MUR) within 7-10 days of discharge. The MUR will be delivered by CPs at participating GP practices. Feasibility outcomes will focus on recruitment, fidelity of CPs to deliver the MUR, and barriers within primary care that affect delivery of the intervention, with a maximum sample size of 100. Clinical outcomes will focus on the number of participants that reduce or stop opioid use within 91 days. Prescribing, medical, surgical, and demographic data for individual participants will be collected and analysed to inform future trial design. Qualitative interviews with participants and associated healthcare professionals will explore acceptability and implementation of the intervention. Data collected with respect to opioid use post-surgery, feasibility and acceptability of the intervention, patient experience and outcome data will inform the design of future research and larger clinical trials.

Disease burden, healthcare resource utilisation, and treatment patterns in patients with newly diagnosed myasthenia gravis in England: A retrospective cohort study

Background: Myasthenia gravis (MG), a chronic and unpredictable autoimmune disease, is associated with multiple comorbidities and high disease burden. Objective: To assess the disease burden, healthcare resource utilisation (HCRU), and treatment patterns of patients with newly diagnosed MG in England. Methods: Data from Clinical Practice Research Datalink GP practices linked to the Hospital Episode Statistics database were used. Eligible patients had ≥1 diagnostic code for MG, with the first MG diagnostic code recorded between 01 January 2010 and 31 December 2019. Non-MG controls were selected if they had no recorded MG diagnosis and ≥12 months of data. Controls were matched for age, sex and GP practice in a maximum ratio of 5:1. Results: Mean follow-up duration was 2.8 and 3.1 years for the MG and non-MG cohorts, respectively. In the MG cohort, 56% of patients were male, with a mean age of 67 years at baseline. Incidence rates of all comorbidities assessed during follow-up were higher in the MG cohort than in controls. Almost two-thirds of MG patients experienced ≥1 myasthenic exacerbation during follow-up; incidence rates (95% confidence interval) of MG exacerbations and crises were 50.0 (44.7–55.9) and 1.3 (0.8–2.0) per 100 person-years, respectively. Visits to non-neurology specialists and outpatient clinics were the most common instances of HCRU overall, each being more frequent in the MG cohort than for controls. In the first year of follow-up, acetylcholinesterase inhibitors (AChEIs) and corticosteroids were used by 56.0% and 50.2% of MG patients, respectively; the use of AChEIs declined thereafter. Conclusions: Despite treatment, there is a high disease burden for patients with newly diagnosed MG in England, with high rates of MG exacerbation and HCRU use. Thus, there is a need for targeted treatments with sustained efficacy and improved safety to adequately manage MG symptoms and reduce MG-related disease burden.

Headache assessment in the GP practice

Headache assessment in the GP practice

Insights into general practitioners’ self-care across 38 countries during the pandemic: a cross-sectional study

BackgroundThe adoption of healthy self-care practices has proven necessary for professional life, as they often serve as a shield against stressors in the workplace. The COVID-19 pandemic created a high strain on general practitioners (GPs), contributing to increased workload, burnout, and anxiety. The present study aimed to identify self-care practices adopted by GPs amid the COVID-19 pandemic; and to explore the relationships between self-care practices and risk of distress.MethodsThe current study utilized an online questionnaire arriving from the PRICOV-19 study, which was distributed among GP practices across 38 countries. The main focus was on the open-text responses where participants disclosed self-care practices employed to maintain mental health during COVID-19. The Six Domains of Self-Care theoretical framework was applied to investigate GP self-care practices across 6 domains including Physical, Professional, Relational, Emotional, Psychological, and Spiritual. The Mayo Clinic Well-Being Index (eWBI) was applied to assess mental well-being and risk of distress among GPs. The analysis was carried out using SPSS Statistics software.ResultsIn total, 2,949 GPs provided open-text responses on maintaining their mental health. 65.5% of GPs had an eWBI score of ≥ 2 and were considered at risk of distress. The majority of the participants prioritised physical (61.7%), followed by relational (38.0%) and psychological (34.6%) self-care practices to maintain their mental health during the pandemic. GPs who applied relational, physical, and professional self-care were significantly less likely to experience depression, stress, and emotional exhaustion, in comparison with the ones who did not apply these practices. GPs who practiced professional self-care practices had the lowest distress risk (eWBI = 1.99). Overall, 5% of GPs disclosed not applying any practices to maintain their mental health during the pandemic and were the most prone to mental health distress.ConclusionsGPs have navigated the pandemic uniquely, and despite applying self-care practices they faced some level of impact, hence self-care interventions for healthcare professionals should be regarded as essential rather than optional. A long-term investment in strategies focused on improving GPs’ self-care is necessary to increase resilience among GPs and ensure their optimal well-being levels are achieved.

Effects of timely case conferencing between general practitioners and specialist palliative care services on symptom burden in patients with advanced chronic disease: results of the cluster-randomised controlled KOPAL trial

BackgroundPatients with advanced chronic non-malignant conditions often experience significant symptom burden. Therefore, overcoming barriers to interprofessional collaboration between general practitioners (GPs) and specialist palliative home care (SPHC) teams is essential to facilitate the timely integration of palliative care elements. The KOPAL trial aimed to examine the impact of case conferences between GPs and SPHC teams on symptom burden and pain in patients with advanced chronic heart failure, chronic obstructive pulmonary disease, and dementia.MethodsThe cluster-randomised controlled trial compared a structured palliative care nurse visit followed by an interprofessional case conference to usual care. Data were collected from GPs at baseline and 48 weeks, while standardised patient interviews were conducted at baseline, 6, 12, 24, and 48 weeks.ResultsWe analysed 172 patients from 49 German GP practices. Both groups showed marginal improvement in symptom burden; however, no statistically significant between-group difference was found (=-0.561, 95% CI: -3.201–2.079, p = .68). Patients with dementia experienced a significant pain reduction (=2.187, 95% CI: 0.563–3.812, p = .009). Conversely, the intervention did not have a significant effect on pain severity (=-0.711, 95% CI: -1.430 − 0.008, p=.053) or pain interference (=-0.036, 95% CI:-0.797 − 0.725, p=.926) in other patient groups.ConclusionsThe intervention showed promise in the timely introduction of palliative care elements to address pain management in patients with dementia. Further studies are needed to identify and effectively address symptom burden and pain in other patient groups.Trial registrationGerman Clinical Trials Register: https://www.drks.de/DRKS00017795 (Registration date: 9th January 2020).

Improving event prediction using general practitioner clinical judgement in a digital risk stratification model: a pilot study

BackgroundNumerous tools based on electronic health record (EHR) data that predict risk of unscheduled care and mortality exist. These are often criticised due to lack of external validation, potential for low predictive ability and the use of thresholds that can lead to large numbers being escalated for assessment that would not have an adverse outcome leading to unsuccessful active case management. Evidence supports the importance of clinical judgement in risk prediction particularly when ruling out disease. The aim of this pilot study was to explore performance analysis of a digitally driven risk stratification model combined with GP clinical judgement to identify patients with escalating urgent care and mortality events.MethodsClinically risk stratified cohort study of 6 GP practices in a deprived, multi-ethnic UK city. Initial digital driven risk stratification into Escalated and Non-escalated groups used 7 risk factors. The Escalated group underwent stratification using GP global clinical judgement (GCJ) into Concern and No concern groupings.Results3968 out of 31,392 patients were data stratified into the Escalated group and further categorised into No concern (n = 3450 (10.9%)) or Concern (n = 518 (1.7%)) by GPs. The 30-day combined event rate (unscheduled care or death) per 1,000 was 19.0 in the whole population, 67.8 in the Escalated group and 168.0 in the Concern group (p < 0.001). The de-escalation effect of GP assessment into No Concern versus Concern was strongly negatively predictive (OR 0.25 (95%CI 0.19–0.33; p < 0.001)).The whole population ROC for the global approach (Non-escalated, GP No Concern, GP Concern) was 0.614 (0.592—0.637), p < 0.001, and the increase in the ROC area under the curve for 30-day events was all focused here (+ 0.4% (0.3–0.6%, p < 0.001), translating into a specific ROC c-statistic for GP GCJ of 0.603 ((0.565—0.642), p < 0.001).ConclusionsThe digital only component of the model performed well but adding GP clinical judgement significantly improved risk prediction, particularly by adding negative predictive value.

The Impact and Wider Implications of Remote Consultations for General Practice in Norway: Qualitative Study Among Norwegian Contract General Practitioners.

The digital shift toward remote consultations in general practice needs ongoing monitoring to understand its impact on general practice organizations and the wider health care system. This study aimed to explore how remote consultations impact on contracted general practitioner (GP) practices and how GPs perceive the implications of this uptake for the overall health care system. In total, 5 focus groups were conducted with a total of 18 GPs from all 4 health regions of Norway in 2022. The material was subjected to Braun and Clarke's thematic analysis. The analysis yielded six themes: (1) the design of novel effective clinical pathways: remote consultations empower GPs to tailor new effective clinical trajectories, blending modalities to address diverse needs across clinical episodes-from initial triage, through investigations to case closure; (2) increased workday flexibility: remote consultations introduce variability into daily work, allowing GPs to adjust patient contact intensity, and leading to a less stressful work-home balance; (3) erosion of organizational boundaries: easy remote access to GPs appears to reduce patients' tolerance for minor illness and self-care, hindering effective gatekeeping and shifting GPs' focus from proactive to more reactive work, increasing work-related stress; (4) degradation of clinical shrewdness: confronted with an increasing amount of unsorted and trivial remote inquiries, GPs observe challenges in detecting and prioritizing serious cases; (5) dilemmas related to responsibility, ethics, and legislation: remote consultations highlight a tension for contract GPs between legal responsibilities and ethical obligations, with implications for patients with limited health literacy; this may entail suboptimal evaluation or delayed treatment-potentially contributing to increased health care inequity; and (6) retaining clinical core values in a changing world. Overall, GPs affirm that remote consultations have come to stay and describe efforts to effectively manage the advantages and disadvantages inherent in such interactions to safeguard clinical effectiveness and organizational sustainability of primary health care. The widespread adoption of remote consultations in the Norwegian contract GP scheme fundamentally reshapes the dynamics of GP work and the overall health care system. Awareness and proactive management of these changes are essential for maintaining sustainable, high-quality primary health care.

Primary Care Referral Delays in Oral Cancer Diagnosis: A Meta-Analysis.

To measure the primary care interval (PCI) in the diagnostic delay of oral cancer and to assess the relation of the referring physician's specialty with disease stage at diagnosis. We meta-analyzed reports of oral/oropharyngeal carcinomas detailing PCI start- and endpoints, i.e., the time needed by a primary care physician to refer a suspected oral cancer patient to a specialist. 17 studies with a total of 2530 patients were eligible; nine provided data on the relative length of PCI, and 10 reported on the impact of the referring professional's specialty on oral cancer diagnostic delay. The average PCI length was slightly longer for general practitioners (GPs) (30.5 days) than for general dental practitioners (GDPs) (27.6 days), while that for the total group was 28.7 days. One-third of the total pre-hospital time spent on diagnosis elapses in GP practices (PCI%: 0.31 [95% CI: 0.23, 0.40]). GDPs refer their patients for treatment at earlier disease stages (TNM I-II) than GPs (Odds Ratio: 0.58; 95% CI: 0.34-0.98). Primary care accounts for a considerable pre-hospital amount of time of what is necessary for reaching a diagnosis of oral cancer patients. This calls for enhancing early oral cancer recognition in primary care settings.

So you think you are safe from litigation?

Mrs J is a 45-year-old mother of three teenagers who developed a leg ulcer after a minor injury because of underlying venous issues from years of standing as a hairdresser. Despite regular visits to her GP practice nurse, her ulcer worsened over three years. A turning point came when she joined a local Leg Club, where her ulcer healed rapidly. Mrs J later sought specialised treatment and pursued legal action against her GP for inadequate care, highlighting the critical need for proper training and adherence to guidelines in ulcer management.

Utilisation and trends of laboratory testing and point-of-care testing in primary care in Germany: an analysis of claims data

ObjectivesGerman general practitioners (GPs) either order laboratory tests from external laboratories (initiated laboratory services (ILS)) or perform point-of-care tests (POCTs) within the GP practice. This study investigated the current use...