Primary Care General Practitioners Research Articles

The experiences of physiotherapy independent prescribing in primary care: implications for practice.

To explore the experiences of musculoskeletal (MSk) physiotherapy independent prescribing in primary care from the perspectives of physiotherapists and General Practitioners (GPs) and identify the implications these have for contemporary physiotherapy practice in primary care. Legislative change in the United Kingdom (UK) in 2013 enabled physiotherapists holding a postgraduate non-medicalprescribing qualification to independently prescribe certain drugs that assist in patient management. Independent prescribing by physiotherapists is a relatively contemporary development in role change and purpose, occurring alongside the development of physiotherapy first contact practitioner (FCP) roles in primary care. A critical realist approach was used, with qualitative data collected via 15 semi-structured interviews with physiotherapists and GPs in primary care. Thematic analysis was applied. Fifteen participants were interviewed (13 physiotherapists, 2 GPs). Of the 13 physiotherapists, 8 were physiotherapy independent prescribers, 3 were MSk service leads, and 3 were physiotherapy consultants. Participants worked across 15 sites and 12 organisations. Whilst physiotherapists were empowered by their independent prescribing qualification, they were frustrated by current UK Controlled Drugs legislation. Physiotherapists reported vulnerability, isolation, and risk as potential challenges to independent prescribing, but noted clinical experience and 'patient mileage' as vital to mitigate these. Participants identified the need to establish prescribing impact, particularly around difficult to measure aspects such as more holistic conversations and enhanced practice directly attributed to prescribing knowledge. GPs were supportive of physiotherapists prescribing. Establishment of physiotherapy independent prescribing value and impact is required to evaluate the role of, and requirement for, physiotherapy independent prescribers within primary care physiotherapy FCP roles. Additionally, there is a need for a review of physiotherapy prescribing permitted formulary, and development of support mechanisms for physiotherapists at individual and system levels to build prescribing self-efficacy and autonomy, and to advance and sustain physiotherapy independent prescribing in primary care.

Self-Perceived Competence of Primary Healthcare Physicians in Managing Medical Emergencies in Health Centers; Kingdom of Bahrain: A Cross-Sectional Study

Background: Primary care physicians (PCPs) are the first point of contact for individuals when seeking healthcare and the cornerstone for providing a wide variety of preventive and curative services. Family physicians and general practitioners in primary care often encounter medical emergencies and their role in dealing with emergencies is essential to improve the patient’s outcome. Data about self-perceived competence of primary care physicians in dealing with emergencies in primary care in the Kingdom of Bahrain are lacking. This study aims at assessing the self-perceived competence of primary healthcare physicians in dealing with emergencies in primary care settings. Methods: A descriptive questionnaire-based cross-sectional study of primary healthcare family physicians and general practitioners in the Kingdom of Bahrain was conducted in January to February 2022. A total of 375 family physicians and general practitioners working in health centers were identified from Ministry of health database and 7 element anonymous self-administered electronic questionnaires were sent to their email to evaluate their level of competence in managing emergencies. Results: out of 375 PCPs; 184 (45.5%) participated and returned answered questionnaires. Most of the PCPs were females 117 (83.6%) with median age of 35 years. Regarding the level of competency in managing emergencies the majority either agreed feeling competent (37.5%) or were not sure if they feel competent in managing emergencies in primary care(37.5%).The study did not find any statistical significance or correlation between the reported competency among primary care physicians(PCPs) and age (P=0.486), years of practice(P=0.462), specialty(P=0.053), or the attended course; basic life support (BLS)(p=0.334),advanced cardiovascular life support (ACLS) (P=0.156), advanced trauma life support (ATLS)(P=0.691), pediatric advanced life support (PALS) (P=0.920).Study revealed that highest number of participants reported not feeling comfortable in dealing with major and multiple traumas in adults (n= 67, 47.86%) and pediatrics (n= 63, 45%) . The lowest level of competence in performing emergency skills was found in transcutaneous pacing, cardioversion, and nasogastric tube (NGT) insertion at which PCPs reported that they wouldn’t know how to start transcutaneous pacing (n= 67, 47.9%), while (n= 51, 36.4%) would perform cardioversion and nasogastric tube insertion (n= 43, 30.7%) only if no-one else was available. Most PCPs (n= 137, 97.9%) think that they need training in emergencies and the preferred method is practical training in health center by qualified staff (n= 122, 87.1%). Conclusion: Based on study findings, more efforts should be directed towards practical training of healthcare physicians in dealing with emergencies and the barriers should be explored. More practical training sessions should be devoted to pediatric emergencies, transcutaneous pacing, and cardioversion.

Celiac disease: experience of general practitioners in Brianza Area- Monza- Milan-Italy.

The purpose of the study was to better investigate the degree of knowledge and the diagnostic approach concerning celiac disease and its extra-intestinal manifestations by general practitioners in Italy. Celiac Disease is a common chronic disease, but often goes undiagnosed because of atypical symptoms or silent disease. Currently there are non-definitive data about the disease management approach concerning celiac disease by general practitioners. To better investigate the degree of knowledge and the diagnostic approach concerning celiac disease and its extra-intestinal manifestations, questionnaire was used to assess the daily practice of diagnosis, treatment, and follow-up of this condition by general practitioners in two densely populated area in Italy: Monza-Brianza Area and Milan City. The questionnaire was composed of 18 questions that explored 3 precise domains: diagnosis criteria, correct management of celiac disease and availability for training. The frequencies of the domains explored were analyzed, analyzes were carried out to identify differences between the groups of general practitioners interviewed. Analysis of the questionnaires showed a degree of knowledge and preparation comparable to that of other countries, even though not sufficient to guarantee access to early diagnosis for all patients with celiac disease. The knowledge was not influenced by the years of experience or specific curriculum of health professionals. General practitioners under 40 were much more in favor of continuous training and were aware of its importance (OR=10.55; CI95%: 1.62-445.39), although this need was a high priority in the whole group interviewed (84.7%). Continuous specific training aimed at primary care physicians and general practitioners is the first tool to improve early diagnosis. A second opportunity is represented by the continuous dialogue between general practitioners and tertiary level hospitals and universities.

Improving access to primary care and annual health checks for people who have a learning disability: a multistakeholder qualitative study

ObjectivesTo investigate key stakeholders’ views on how to improve access to primary care in general practice settings for people with learning disabilities (or intellectual disabilities). Further to explore how inequalities...

Prescribing buprenorphine for opioid use disorder in primary care: A survey of French general practitioners in the Sentinelles network

IntroductionAlthough opioid substitution coverage in France is high and patient care with buprenorphine is mainly managed by general practitioners (GPs), buprenorphine sales have been decreasing since 2011, suggesting that French GPs are prescribing less buprenorphine. Yet this possible change in GP practices has not yet been investigated. This study aimed to examine primary care GPs' opinions about buprenorphine and habits related to prescribing buprenorphine. MethodsThe study team conducted a cross-sectional survey from March 2021 to July 2021 among a sample of GPs in the Sentinelles network, a French epidemiologic surveillance system based on primary care practitioners. The study collected information about substance use disorder (SUD) training, opinions on buprenorphine, and habits related to buprenorphine prescription were collected (initiation and renewal within the past two years). FindingsAmong the 237 participants (34 % response rate), 15.2 % reported having had specific training for SUD management. A majority reported a very positive (16 %) or positive (63.7 %) opinion of buprenorphine. Most participants agreed (61.2 %) or strongly agreed (31.2 %) that buprenorphine was efficacious in the treatment of illicit opioid use disorder. Of the 206 GPs who reported having treated patients with opioid use disorder in the past two years, 47 (22.8 %) had initiated a buprenorphine prescription, whereas 177 (85.9 %) had renewed a buprenorphine prescription. Previous SUD training was associated with initiating buprenorphine (OR 4.66; 95 % CI [2.15–10.08]), while female gender was associated with not initiating buprenorphine prescribing (OR 0.46; 95 % CI [0.22–0.98]). ConclusionA sample of French GPs who work in primary care has a positive view of buprenorphine, but the absence of SUD training among this population may be a barrier to their prescribing buprenorphine.

The one-year clinical course of back-related disability and the prognostic value of comorbidity among older adults with back pain in primary care.

Back pain and comorbidity are common in older adults. Comorbidity is a promising prognostic factor for the clinical course of back-related disability, but confirmatory studies assessing its prognostic value are needed. Thus, the aims of this study were to describe the clinical course of back-related disability during 1-year follow-up in patients aged ≥55 years visiting primary care (general practitioner, physiotherapist, or chiropractor) with a new episode of back pain and assess the prognostic value of comorbidity on back-related disability during 1-year follow-up. A prospective cohort study was conducted, including 452 patients. The outcome measure was Roland-Morris Disability Questionnaire (RMDQ, range 0-24) measured at baseline and at 3-, 6-, and 12-month follow-up. The Self-Administered Comorbidity Questionnaire was used to assess comorbidity count (CC, range 0-15) and comorbidity burden (CB, range 0-45). The RMDQ scores improved from median (interquartile range) 9 (4-13) at baseline to 4 (1-9), 4 (0-9), and 3 (0-9) at 3, 6, and 12 months, respectively. Using linear mixed-effects models, we found that CC and CB were independently associated with RMDQ scores. A 1-point increase in CC was associated with an increase in RMDQ score of 0.76 points (95% confidence interval [0.48-1.04]) over the follow-up year, adjusted for known prognostic factors. A 1-point increase in CB was associated with an increased RMDQ score of 0.47 points (95% confidence interval [0.33-0.61]). In conclusion, the clinical course of back-related disability for older adults presenting in primary care was favorable, and increased comorbidity was an independent prognostic factor for increased disability levels.

Clinical leadership training in integrated primary care networks: a qualitative evaluation

ObjectiveTo explore how a clinical leadership training programme contributes to successful implementation of integrated dementia care in local primary care networks.Methods and analysisA qualitative design was used in local primary...

The impact of family doctor system on patients' utilisation of general practitioner in primary care facilities-Evidence from Hangzhou, China.

This study aims to examine whether participating in the contracted family doctor system increases patients' utilisation of primary care general practitioner for multiple disease outcomes in China. Binary logistic regression models were estimated using data collected from 372 community residents in nine selected districts of Hangzhou, China. Findings revealed that (1) for patients with influenza, diabetes, upper respiratory infection, and gingivitis, those who participated in the contracted family doctor system were approximately 4.3 times, 98.4%, 92.5%, and 52.8% more likely to choose primary care general practitioners (GP) for their initial diagnosis, respectively, as compared with their counterparts who did not have contracted family doctors; (2) For patients with stroke or cerebrovascular disease and cholecystitis or cholelithiasis, those who had contracted family doctors were 1.111 times and 80.6% more likely to choose primary care GP for their subsequent disease maintenance, respectively, as compared to their counterparts without contracted family doctors. Our findings indicate that the contracted family doctor system not only increases the utilisation of primary care GP for patients with many chronic conditions but also promotes the overall completion of China's hierarchical medical system in the long run. Policy implications were provided to help policymakers actively construct and develop the contracted family doctor system to promote the hierarchical medical system in China.

Work Content of General Practitioners in Beijing, China: A Multi-method Study.

BackgroundDespite the dramatic growth of primary care in China, little evidence showed what general practitioner (GP) do and how GP provided medical service in Beijing.ObjectiveThis study aimed to explore the work content of GPs in primary care in Beijing.MethodsA multi-method study was conducted in five community health service institutions using non-participant observation and critical incident technique interview. Eleven GPs was recruited by purpose sampling, with each GP recording details of 100 patient encounters. Health problems of patients and activities of GPs were observed in consultations. Then, critical incident technique interviews were conducted focusing on GPs' works out of clinics and challenge.ResultsA total of 1, 100 patients encounters and 1,897 reasons for encounter (RFEs) were recorded from 11 GPs. There were 1897 RFEs (1.72 per encounter) and 2,762 health problems (2.51 per encounter) from 1,100 encounters during our observation. GPs' work related to consultation was focus on disease diagnoses and treatment. Physical examination and investigations were performed in only 15.5 and 17.1% consultations, respectively. Procedures for chronic disease management were infrequently provided to patients (0.4–26.6%). Time spent in each work process in consultations ranged from 0.68 ± 0.27 min for reservation to 4.00 ± 2.45 min for surgical treatment. In addition to clinical work, there were tasks about health files, contracted family doctor services, health education, teaching students, and scientific research.ConclusionThis study illustrated the complexity of GPs' work and heavy workload in Beijing, China. More attention and effort are needed to develop GPs performance and release GPs' work workload in primary care.

A feasibility study of a pharmacist led proton pump inhibitor deprescribing intervention in older patients in an Irish hospital

Abstract Introduction Proton pump inhibitors (PPIs) are over-prescribed and prescribed inappropriately in the older population and have the potential for long-term adverse effects e.g. increased fracture risk, C. difficile infection, chronic kidney disease and drug interactions (1). Hospitalisation of older patients presents an opportunity for review of the PPI indication and potential for deprescribing. Aim The study aimed to assess the feasibility of a pharmacist led intervention to deprescribe inappropriately prescribed PPIs in patients ≥65 years in an Irish teaching hospital. Methods A multi-component feasibility intervention consisting of an education session for the medical team, followed by pharmacist-led screening of patients for potential PPI deprescribing, was conducted. The education session was delivered by the pharmacist to a geriatric medical team and the content outlined the prevalence of PPI prescribing, potential long-term effects of PPIs, and implementation of a PPI deprescribing algorithm. Over an eight-week period (May-June 2021), new admissions to the geriatric team were screened daily by the pharmacist and PPI prescribing patterns and indications were recorded. Patients ≥65 years were reviewed for PPI appropriateness based on their medical history and use of a PPI deprescribing algorithm (2). If the PPI was eligible for deprescribing (i.e. dose reduction or discontinuation) this was discussed with the geriatric team and the patient’s primary care general practitioner (GP) and the patient. Patients were counselled and educated on this by the pharmacist. Patients whose PPI was deprescribed were followed up at 4- and 12- weeks post deprescribing to assess their symptoms and satisfaction with deprescribing in the interim period. An online survey was sent to the geriatric team doctors evaluating their views on the study process and implementation of PPI deprescribing in practice; data was analysed descriptively using Microsoft Excel®. Written, informed consent was obtained from all patients and doctors involved. Results Of a total of 133 patient charts reviewed over the 8-week period, 94 patients were prescribed a PPI, with esomeprazole 40mg (43/94, 45.7%) being most commonly prescribed PPI, followed by pantoprazole 40mg (17/94, 18.1%). PPIs were inappropriately prescribed as per the indication in 36 cases (36/94, 38.3%). Following GP and Geriatric team discussion, 7/94 (7.4%) of patients were eligible for deprescribing, of which 5 had their PPI dose reduced (5/94, 5.3%). One patient declined the deprescribing, in another case the GP declined the deprescribing recommendation. The 5 patients deprescribed had their esomeprazole 40mg daily dose reduced to 20mg daily. This was sustained at the 12-week follow up and patients reported satisfaction with the change with no negative outcomes reported. Of the 12 geriatric doctors in the study, 6 completed the online survey. The majority reported barriers to PPI deprescribing being uncertainty regarding the indication (5/6) and being unable to monitor the patient after hospital discharge (5/6). All doctors agreed that pharmacists have a positive role to play in implementing PPI deprescribing. Conclusion This study found that esomeprazole 40mg daily was the most commonly prescribing PPI in this hospital cohort, with the majority of PPI prescribing found to be inappropriate according to the indication. The feasibility study resulted in a number of patients having their PPI safely deprescribed with a dose reduction. Despite the limitation of a small sample size and small rates of deprescribing, a strength of the study was that a pharmacist led PPI deprescribing initiative resulted in reducing inappropriate PPI prescribing in older patients, with positive engagement from the geriatric medical team. Further resources and research are required to implement this initiative on a wider scale. References (1) Wilsdon TD, Hendrix I, Thynne TR, Mangoni AA. Effectiveness of Interventions to Deprescribe Inappropriate Proton Pump Inhibitors in Older Adults. Drugs Aging. 2017 Apr;34(4):265-287. doi: 10.1007/s40266-017-0442-1. PMID: 28220380. (2) National Health Service. Proton Pump Inhibitor (PPI): Deprescribing algorithm (adult) [Internet]. [cited 2021 Aug 6]. Available from: https://www.dorsetccg.nhs.uk/Downloads/aboutus/medicines-management/Other Guidelines/prescqipp proton-pump-inhibitor-desprescribing-algorithm.pdf

Supportive interactions with primary care doctors are associated with better mental health among transgender people: results of a nationwide survey in Aotearoa/New Zealand.

BackgroundPast research has established that transgender people experience significant disparities in mental health outcomes and healthcare dissatisfaction compared with cisgender people, but more research is needed on how supportive healthcare interactions relate to the mental health of transgender people.ObjectivesThe 2 main aims of our analyses were: (i) to establish the most common negative experiences in healthcare and the most common supportive experiences specifically with primary care doctors for transgender people; and (ii) to examine the association of supportive experiences with mental health variables after controlling for demographic factors.MethodsData from the 2018 Counting Ourselves nationwide survey of transgender people were analysed using regression modelling. The 948 participants with a primary care doctor or general practitioner were included in analyses. Participants were aged 14–83 years old (mean 30.20).ResultsThe most common supportive experiences involved primary care doctors treating transgender people equitably, with competence, and with respect. Participants with more negative healthcare experiences had higher psychological distress as well as higher likelihood of reporting nonsuicidal self-injury and suicidality. Conversely, participants with more experiences of supportive primary care doctors had lower psychological distress and were less likely to have attempted suicide in the past 12 months.ConclusionWhen transgender people receive supportive care from their primary care providers they experience better mental health, despite ongoing negative healthcare experiences. Future research is needed to confirm ways of supporting positive trajectories of mental health for transgender people but these findings demonstrate the importance of positive aspects of care.

Development of office-hours use of primary health centers in the early years of the 21st century: a 13-year longitudinal follow-up study

ABSTRACT This study, conducted in a Finnish city, examined whether a long-lasting observed trend in Finnish primary health care, namely, a decreasing rate of office-hour visits to general practitioners (GPs), would lead to reduced services for specific gender, diagnosis or age groups. This was an observational retrospective follow-up study. The annual number of visits to office-hour primary care GPs in different gender, diagnosis and age groups was recorded during a 13-year follow-up period. The effect of the decreasing visit rate on the annual mortality rate in different age and gender groups was also studied. The total number of monthly visits to office-hour GPs decreased slowly over the whole study period. This decrease was stronger in women and older people. The proportion of recorded infectious diseases (Groups A and J and especially diagnoses related to infections of respiratory airways) decreased. Proportions of recorded chronic diseases increased (Group I, cardiovascular diseases, diabetes and osteoarthrosis) during the follow-up. The annual rate of visits to office-hour GP/per GP decreased. There was a decrease in the mortality in two of the age groups (20–64, 65+ years) and no change in the youngest population (0–19 years). The decrease in the office-hours GP activity does not seem to increase mortality either.

How to improve preconception care in a local setting? Views from Dutch multidisciplinary healthcare providers

ObjectiveTo explore healthcare providers’ views on improving preconception care in their region. DesignMixed-methods study. SettingWorking conferences aimed to educate healthcare providers on preconceptional risk factors and conduct a region-specific analysis of barriers and facilitators for implementing preconception care, were organised in ten municipalities in the Netherlands. Participants250 healthcare providers of various disciplines attended a working conference and participated in the study. Measurements and findingsParticipants were asked to both fill out a questionnaire concerning statements and experiences with preconception care and to participate in a workshop, to identify barriers and facilitators for the implementation of a local preconception care program. Almost all healthcare providers suggested that the responsibility for providing preconception care consultations lies within primary care (general practitioners (n = 239; 95.6%) and midwives (n = 236; 94.4%)). Professionals other than midwives found it significantly more difficult to start a conversation about a wish to conceive compared to midwives (26.8% versus 20.2%, p-value = 0.006) and felt less competent to provide preconceptional information (32.3% versus 15.1%, p-value = <0.001). Innovative facilitators were mentioned to improve reaching the target population with preconceptional information, i.e. the use of social media and local ambassadors. Key conclusionWhile the responsibility for providing preconception care consultations is best suited with primary care, many other healthcare providers involved may act as referrers towards preconception care. Still, approximately 1 in 7 midwives (strongly) disagree with the statement that it is part of their job to provide preconceptional information to couples with a wish to conceive. Implications for practiceThere is a need for integrating preconception care in many curricula and postgraduate courses, especially for non-midwives, to improve the delivery of preconception care. Insights in the suggested barriers and facilitators can improve the implementation of (local) preconception care programs.

Views, facilitators, barriers and strategies associated with detoxification in patients with opioid use disorder: A qualitative study on primary care general practitioners

IntroductionOpioid Use Disorder (OUD) affects 16 million people worldwide and stems from the repeated use of opioids. Although standard care for OUD is based on harm reduction policy and relies on Opioid Maintenance Treatment, opioid detoxification still has some advantages over OMT. However, little is known about the medical community's views on this specific topic of the current advantages of detoxification. ObjectiveThe objective of this study is to collect the views of GPs on detoxification and identify the facilitators, barriers and strategies associated with detoxification. MethodsWe conducted a qualitative study using semi-structured in-person interviews with fifteen French GPs. After a triple-blind thematic analysis, main themes and sub-themes were selected after consensual agreement. We conducted an in-depth analysis of the discourse favouring an interdisciplinary approach. ResultsThe main themes are: GPs' views on detoxification, facilitators, barriers and strategies associated with detoxification. Detoxification is seen through OMT tapering or inpatient detoxification. Facilitators of detoxification include a steady environment, sufficient motivation and trust. Barriers to detoxification include abuse of OMT, polydrug use, long periods of drug use and pregnancy. Alleged obstacles include lack of availability/knowledge and difficulty having access to specialised care. Strategies facilitating detoxification include a coordinated healthcare circuit involving multiple providers in a dedicated healthcare facility and the practice of physical activity. ConclusionDetoxification is perceived through OMT tapering or inpatient detoxification. The conditions of practice influence the implementation of detoxification. This study shows that detoxification is possible in primary care in dedicated outpatient practices coordinated by GPs.

Potentials and current shortcomings in the cooperation between German centers for rare diseases and primary care physicians: results from the project TRANSLATE-NAMSE

BackgroundThe TRANSLATE-NAMSE project with the strengthening of the centers for rare diseases with their affiliation to the European Reference Networks was a major step towards the implementation of the German National Plan of Action for People with Rare Diseases establishing better care structures. As primary care physicians, general practitioners and pediatricians play a central role in the diagnosis of patients with rare disease, as it is usually them referring to specialists and rare disease centers. Therefore, the interface management between primary care physicians and the centers for rare diseases is of particular importance.MethodsIn a mixed-method-approach an anonymous postal survey of 1,500 randomly selected primary care physicians in Germany was conducted with focus on (1) knowledge about a center for rare diseases and how it works, (2) in case of cooperation, satisfaction with the services provided by centers, and (3) expectations and needs they have with regard to the centers. In addition, in-depth telephone interviews were conducted with physicians who had already referred patients to a center.ResultsIn total, 248 physicians responded to the survey, and 15 primary care physicians were interviewed. We observed a wide lack of knowledge about the existence of (45.6% confirmed to know at least one center) about how to access rare disease centers (50.4% of those who know a center confirmed knowledge) and what the center specializes in. In case of cooperation the evaluation was mostly positive.ConclusionTo improve medical care, the interplay between primary care physicians and rare disease centers needs to be strengthened. (1) To improve the communication, the objectives and functioning of the rare disease centers should become more visible. (2) Other projects dealing with the analysis and improvement of interface management between centers and primary care physicians, as described in the National Plan of Action for People with Rare Diseases, need to be implemented immediately. (3) If the project is evaluated positively, the structures of TRANSLATE-NAMSE should be introduced nationwide into the German health care system to ensure comprehensive, quality-assured care for people with rare diseases with special consideration of the key role of primary care physicians—also taking into account the financial expenditures of this new care model.

Management of Pediatric Atopic Dermatitis by Primary Care Providers: A Systematic Review

Primary care providers (PCPs), including pediatricians and general practitioners, are often the first to see children with eczema/atopic dermatitis (AD). Little is known about management of pediatric AD by PCPs and adherence to national guidelines. To review existing literature examining management components of pediatric AD (topical corticosteroids [TCS], topical calcineurin inhibitors [TCIs], antihistamines, bathing, emollients, and diet) by PCPs. PubMed/Medline and Embase. English-language articles dated 2015 to 2020 reporting outcomes addressing management of pediatric AD by PCPs. Two authors independently screened titles/abstracts, reviewed full-text articles, extracted relevant data, and evaluated study quality. Disagreements were resolved by a third author. Twenty articles were included. Surveys and national database analyses were the most common methodologies (n=7 each). PCPs commonly prescribed TCS but had a preference for low-potency agents, overprescribed nonsedating antihistamines, and avoided TCIs. PCPs commonly recommended emollients, although this was not universal. Data characterizing nonmedication management were limited. Most studies did not examine individual patient encounters, but rather relied on providers reporting their general behaviors. Provider behavior may vary based on country of practice. Knowledge and management gaps exist among PCPs in treating pediatric AD in key areas including knowledge of TCS safety profiles and prescribing of TCIs. The current literature is largely limited to small studies that evaluate prescribing behaviors with limited data characterizing nonmedication management, highlighting the need for future research in this area.

Association Between Characteristics of Danish Chiropractors and Number of Referred Patients From General Practitioners: A Cross-sectional Study

ObjectiveThe purposes of this study were to quantify the number of patients referred weekly from primary health care general practitioners (GPs) to chiropractors and to identify chiropractor characteristics associated with the number of referrals. MethodsAn online, cross-sectional survey was sent to the 600 active members of the Danish Chiropractic Association. Of those, 364 completed the survey and 286 met our inclusion criteria. We used bivariable analyses and negative binomial multivariable regression to evaluate the association between predetermined characteristics and the weekly number of patients referred by GPs. ResultsOn average, chiropractors reported that they received 2.5 (standard deviation, 2.2) referrals from GPs per week, representing 31% of all new patients received by chiropractors. Clinics with more than 1 chiropractor and access to diagnostic ultrasound received more GP referrals. Chiropractors reporting expertise in geriatrics and a higher number of new patients per week reported more referrals. Chiropractors who reported referring more patients to GPs also reported receiving more referrals from them. ConclusionVariables related to access to chiropractic care, the type of care provided, and interprofessional communication were positively associated with the number of GP referrals that chiropractors self-reported. This is the first study to report on factors associated with GP referrals to Danish chiropractors.

Incidence and treatment of hand and wrist injuries in Dutch emergency departments

PurposeThe purpose of this study was to describe the epidemiology, treatment and costs of hand and wrist injuries presenting to the Dutch ED. With increasing medical costs and crowding of emergency departments (ED), a more detailed description of emergency department attendance of hand and wrist injuries and their treatment may help to facilitate more adequate allocation of health care services.MethodsThe Dutch Injury Surveillance System obtained a total of 160,250 hand and wrist injuries. Patient characteristics, incidence rates, type of injury, treatment, and costs were described.ResultsThe incidence of hand and wrist injuries in the Netherlands in 2016 was 11 per 1000 in males and 8 per 1000 in females. This is about 25% of all injuries presented at the ED. Of all hand injuries, only 3% was directly admitted to the hospital or received emergency surgery. Thirty percent did not need further treatment in the hospital.ConclusionThe current data suggest that a substantial proportion of the hand and wrist injuries needed no subsequent specialized treatment. Although the severity of the injury could not be deduced from our data, the data suggest a ground for a more extensive role of primary health care (general) practitioners in the primary triage and treatment of hand and wrist injuries. This may reduce health care cost and help decongest the ED departments. Prospective studies are needed to confirm these preliminary conclusions.Level of evidenceIII.

The prevalence and risk factors of urinary incontinence among women with type 2 diabetes in the north West Bank: a cross-sectional study

BackgroundDiabetes is one of the most common chronic illnesses worldwide, and it is increasing in prevalence. Urinary incontinence is another worldwide health problem, with a reported prevalence that ranges from 9% to 67%. It decreases quality of life for men and women and has been associated with many poor outcomes, such as longer hospital stays, recurrent or persistent urinary tract infection, and a higher mortality rate. Previous studies have suggested that diabetes is an independent risk factor for urinary incontinence. In addition, the patients’ background and clinical characteristics such as age, obesity, and child-bearing history have been found to increase the risk. The aim of this study was to determine the prevalence of urinary incontinence in women with type 2 diabetes in the north West Bank and to assess the role of potential risk factors, including age, marital status, weight, and diabetes control. MethodsWomen with diabetes attending the six governmental primary health care centres in the north West Bank (Jenin, Tubas, Tulkarem, Nablus, Qalqilya, and Salfit) were interviewed using the CDC National Health and Nutrition Examination Survey (NHANES) standardised incontinence questionnaire. SPSS version 22 was used for data entry and analysis. The prevalence of urinary incontinence was estimated and differences between groups (variables of interest) were evaluated using the chi squared test. The study was approved by the Institutional Review Board of An-Najah National University, and permission to conduct the study was obtained from the Ministry of Health. Findings400 Palestinian women with diabetes were invited to participate in the study by convenience sampling, of whom 381 were recruited (a sample size that was chosen with a sample size formula, based on the population of the north West Bank). The participants were aged 30–83 years, and 44% (165 of 381; 95% CI 39–49) reported incontinence, regardless of the type. The prevalence of stress and urge incontinence were 34% (128) and 35% (133), respectively. 30% of women with urinary incontinence (49 of 165) reported that it did not affect their quality of life, and 34% (56 of 165) stated that it did not affect their daily activity. The presence or absence of urinary incontinence was studied in relation to the background and clinical variables by use of the chi squared test. The analysis showed a significant relationship between urinary incontinence status and age (p=0·0011), previous abdominal and genitourinary surgeries (p=0·0037), and caffeine consumption (p=0·041). There was no relationship between urinary incontinence and the duration, type of treatment, or complications of diabetes. InterpretationThe prevalence of urinary incontinence (regardless of the type) is high among Palestinian women with diabetes. This is similar to reported prevalence in women with diabetes in neighbouring countries, such as Jordan (44%) and Qatar (21%). The majority of participants in this study (70%) reported that urinary incontinence did not affect their quality of life. This may suggest that patients consider the problem to be ordinary, that it does not require medical advice, or that the symptoms are mild. The findings highlight the importance of educating women with diabetes about urinary incontinence. The primary health care medical teams, general practitioners, and nurses who care for patients with diabetes should focus on this neglected problem, and physicians should be alert to urinary incontinence as it may often go unreported and therefore undertreated. To understand whether non-reporting of urinary incontinence reflects mild symptoms, investigating a potential association between non-reporting and the severity or frequency of urinary incontinence may be of interest for future study. FundingNone.

Prevalence, healthcare resource utilization and mortality of Lennox-Gastaut syndrome: retrospective linkage cohort study

PurposeTo retrospectively investigate the prevalence, demography, antiseizure medication (ASM) usage, healthcare resource utilization (HCRU), and mortality of patients with Lennox-Gastaut syndrome (LGS) in primary and secondary care in the UK. MethodsPatients with confirmed LGS were anonymously identified from the UK Clinical Practice Research Datalink (CPRD) GOLD database (01/01/1987–31/1b0/2018) using the LGS Read Code (F250500). Probable LGS was identified using the International Classification of Diseases-10/Read Code for epilepsy (Hospital Episode Statistics [HES]/CPRD) plus rufinamide prescription. Period prevalence was calculated based on patients enrolled in CPRD GOLD and alive in 2017. CPRD data were linked to HES to calculate HCRU, and to the Office for National Statistics mortality registry. ResultsPeriod prevalence of LGS was 0.578/10,000 (n = 180), with 74 and 106 patients identified with confirmed (0.289/10,000) and probable LGS (0.420/10,000). Mean (max) ASM usage was ~1 (3) per year. In confirmed LGS, valproate (72%), lamotrigine (69%), and clobazam (66%) were the most commonly prescribed ASMs. HCRU (per patient-year) was similar in confirmed and probable LGS and mostly consisted of primary care general practitioner consultations (4–6), outpatient visits (5–10), inpatient admissions (1–4), and A&E visits (1). During the follow-up period, 18 patients died with crude mortality rates of 6.12 (confirmed LGS) and 4.17 (probable LGS) deaths per 1000 person-years. ConclusionPrevalence of LGS appears low in the UK. The similarly high HCRU and mortality rates in confirmed and probable LGS support the validity and specificity of the probable LGS algorithm and high burden of LGS.