Routine Primary Care Consultations Research Articles

Use of the FebriDx point-of-care test for lower respiratory tract infections in primary care: a qualitative interview study.

FebriDx is a single-use, analyser-free, point-of-care test with markers for bacterial (C-reactive protein [CRP]) and viral (myxovirus resistance protein A [MxA]) infection, measured on a finger-prick blood sample. As part of a larger feasibility study, we explored the views of healthcare professionals (HCPs) and patients on the use of FebriDx to safely reduce antibiotic prescriptions for lower respiratory tract infections (LRTIs) in primary care. Remote semi-structured qualitative interviews were conducted in South England. In total, 22 individuals (12 patients who underwent FebriDx testing and 10 HCPs from general practices that conducted testing) participated in interviews, which were analysed thematically. Patients and HCPs expressed positive views about use of the test. They felt FebriDx was a useful tool to inform prescribing decisions and provided a visual aid to support shared decision making and appropriate antibiotic use. Most felt it would be feasible to integrate use into routine primary care consultations. Some practical difficulties with blood collection and interpreting results, which impacted on usability, were identified. Some patients' reactions to negative test results suggested the need for better communication alongside use of the test. FebriDx was perceived as a useful tool to guide antibiotic prescribing and support shared decision making. Initial practical problems with testing and communicating results are potential barriers to use. Training and practice on using the test and effective communication are likely to be important elements in ensuring patient understanding and satisfaction, and successful adoption.

Perspectives on sexual history taking in routine primary care consultations in North West, South Africa: Disconnect between patients and doctors.

BackgroundSexual history is rarely taken in routine consultations and research reported on common barriers that doctors experience, such as gender, age and cultural differences. This article focuses on how patients and doctors view sexual history taking during a consultation and their perspectives on barriers to and facilitators of sexual history taking.AimThis study aimed to explore doctors’ and patients’ perspectives on sexual history taking during routine primary care consultations with patients at risk of sexual dysfunction.SettingThe research was conducted in primary care facilities in the Dr Kenneth Kaunda Health District, North West province.MethodsThis was part of grounded theory research, involving 151 adult patients living with hypertension and diabetes and 21 doctors they consulted. Following recording of routine consultations, open-ended questions on the demographic questionnaire and brief interactions with patients and doctors were documented and analysed using open inductive coding. The code matrix and relations browsers in MaxQDA software were used.ResultsThere was a disconnect between patients and doctors regarding their expectations on initiating the discussion on sexual challenges and relational and clinical priorities in the consultation. Patients wanted a doctor who listens. Doctors wanted patients to tell them about sexual dysfunction. Other minor barriers included gender, age and cultural differences and time constraints.ConclusionA disconnect between patients and doctors caused by the doctors’ perceived clinical priorities and screening expectations inhibited sexual history taking in a routine consultation in primary care.

Complexity of sexual history taking in patients with diabetes and hypertension in routine primary care consultations in South Africa

ABSTRACT Background Research globally confirmed the lack of screening for sexual dysfunction in routine consultations by primary care doctors. Various barriers to sexual history taking were identified, such as differences in age, sex, and culture. Doctors justified the lack of sexual history taking also on their lack of knowledge and skill. As sexual wellbeing also influences the quality of life, patients want to talk to doctors about their sexual health needs but are often shy, or they fear they will embarrass their doctors. Unfortunately, they also find that their complaints are often ignored. Aim The aim of the study was to observe and describe the patient-doctor interaction dynamics of routine consultations in primary health care settings in North-West province South Africa, to improve sexual history taking. Methods The study design was a grounded theory approach. One hundred and fifty-one consecutive consultations with adult patients at risk of sexual dysfunction due to diabetes and hypertension, were video recorded. All the doctors working at 10 primary care facilities were recruited. Doctor-patient interactions were recorded during a normal working day using a discreet camera and laptop. Following the consultations, patients completed demographic questionnaires and sexual dysfunction questionnaires (IIEF and FSFI). After completion of consultation and patient data collection, doctors completed a vignette study with hypothetical scenarios. At the end of the recordings, doctors reflected on their consultations and sexual history taking. Analysis entailed open coding followed by focused and verbatim coding using MaxQDA 2018 software. Some information was quantified using descriptive statistics and Fischer Exact test for associations. Results No history taking for sexual dysfunction took place. Ninety-four percent of the 81 sexually active women had sexual dysfunction symptoms and only 2% of 48 men reported no erectile dysfunction. One patient presented with pain after sexual intercourse. There was no evidence of help seeking for sexual challenges which could be contributed to low education, passive, or low engagement in the health setting or the disconnect between doctors and patients. Patients wanted receptive doctors to ask about their sexual health, whilst doctors expected patients to tell. Doctors admitted that they did not even think about sexual dysfunction and did not consider it a priority. A vignette study with hypothetical scenarios showed that the doctors’ clinical reasoning was generally poor and did not incorporate sexual functioning as a differential diagnosis. The consultations revealed inadequate communication and consultation skill competence. The patient-doctor interaction was doctor centered. Doctors and patients blamed an influx of patients and long waiting times for sub-standard consultations. Consultation time was lost on poorly organized patient files and laboratory results that were retrieved on the doctors’ personal mobile phones. Conclusion Sexual history was inhibited by patient, doctor, and health system factors. Although sexual history is an integral part of comprehensive history taking during a routine consultation, patient-doctor-system engagement need to change to facilitate sexual history taking. Disclosure Work supported by industry: no.

What Matters to Patients and Families: A Content and Process Framework for Clarifying Preferences, Concerns, and Values.

Background. Values clarification, or sorting out what matters to a patient or family relevant to a health decision, is a fundamental part of shared decision making. We aimed to describe how values clarification occurs in routine primary care. Methods. Using framework analysis and an established taxonomy, 2 independent researchers analyzed 260 consultations in 5 family medicine clinics across Quebec. Two questions guided our analyses: 1) What categories exist regarding what matters to patients? 2) What patterns exist in discussions of what matters to patients? Results. 1) Five distinct categories of what matters to patients and families were discussed during values clarification: preferences, concerns, treatment-specific values, life goals or philosophies, and broader contextual or sociocultural values. Preferences and concerns were the matters most commonly raised. 2) Diverse patterns of values clarification emerged based on 3 analytical questions: Who initiates the discussion about what matters to patients? When? What information is discussed? The most frequent pattern was clinicians soliciting patients' concerns and preferences during the information-gathering phase. The second most common pattern was similar, except that patients' spontaneously raised what matters to them. Limitations. The study was descriptive and based on audio-recorded visits. We did not interview patients and clinicians to elicit their perspectives. Conclusions. There are 5 distinct categories of what matters to patients and families as well as clear patterns of how values clarification occurs in routine primary care consultations. Clinicians could be sensitive to these categories when engaging in the process of values clarification and may wish to pay particular attention to the opening minutes of a consultation. This study provides a structure for future identification of best practices in values clarification.

Shared decision making about blood tests: secondary analysis of video-recorded primary care consultations.

Awareness of the importance of shared decision making (SDM) is widespread; however, little research has focused on discussions surrounding investigations, despite increasing laboratory testing in primary care. To explore the discussion of blood tests in routine primary care consultations. A secondary analysis of 50 video-recorded routine primary care consultations, linked surveys, and records data (all from the One in a Million [OiaM] archive). The consultations were taken by 22 GPs across 12 practices. A coding scheme was developed, using qualitative content analysis, to explore discussion of blood tests in transcripts of recorded consultations. Codes focused on instigating testing, the extent of SDM, and how results were explained. Survey data were used to compare patients' pre-visit expectations with consultation content. Medical records were reviewed to compare tests discussed with those ordered. In 36 out of 50 consultations that discussed ordering blood tests, 11 patients (31%) hinted that they wanted a blood test; however, none asked explicitly. Only four patients (11%) were offered alternative options. In 29 cases (81%) the GP gave some explanation of the indication, but only in six cases (17%) were the limitations of testing explained. Only 10 out of 31 patients (32%) were informed about all blood tests ordered. Of the 23 out of 50 consultations in which results were conveyed, the GP gave no explanation of the results in six cases (26%). Thirteen patients (57%) were only informed of an assessment of the results (for example, 'normal'), rather than the actual results. A lack of information dissemination and SDM exists around ordering tests and conveying results. Promoting SDM could reduce unnecessary testing and improve patient-centred care.

Safety netting in routine primary care consultations: an observational study using video-recorded UK consultations.

BackgroundSafety-netting advice is information shared with a patient or their carer designed to help them identify the need to seek further medical help if their condition fails to improve, changes, or if they have concerns about their health.AimTo assess when and how safety-netting advice is delivered in routine GP consultations.Design and settingThis was an observational study using 318 recorded GP consultations with adult patients in the UK.MethodA safety-netting coding tool was applied to all consultations. Logistic regression for the presence or absence of safety-netting advice was compared between patient, clinician, and problem variables.ResultsA total of 390 episodes of safety-netting advice were observed in 205/318 (64.5%) consultations for 257/555 (46.3%) problems. Most advice was initiated by the GP (94.9%) and delivered in the treatment planning (52.1%) or closing (31.5%) consultation phases. Specific advice was delivered in almost half (47.2%) of episodes. Safety-netting advice was more likely to be present for problems that were acute (odds ratio [OR] 2.18, 95% confidence interval [CI] = 1.30 to 3.64), assessed first in the consultation (OR 2.94, 95% CI = 1.85 to 4.68) or assessed by GPs aged ≤49 years (OR 2.56, 95% CI = 1.45 to 4.51). Safety-netting advice was documented for only 109/242 (45.0%) problems.ConclusionGPs appear to commonly give safety-netting advice, but the contingencies or actions required on the patient’s part may not always be specific or documented. The likelihood of safety-netting advice being delivered may vary according to characteristics of the problem or the GP. How to assess safety-netting outcomes in terms of patient benefits and harms does warrant further exploration.

Test Talk: an observational study exploring the discussion of blood tests in routine primary care consultations

BackgroundClinicians are encouraged to share decisions about treatment options with their patients, however to-date there has been little research attention focusing on the discussion of investigations.AimThis study explored shared decision making (SDM) regarding blood testing during routine primary care consultations.MethodThis observational study used inductive and deductive qualitative content analysis to examine 50 consultations. Data were sampled from the One in a Million archive, which contains video-recordings of 300 primary care consultations and linked data between GPs and adult patients with permissions for reuse. The discussion surrounding both ordering blood tests and conveying results was coded, including who instigated testing, whether there was SDM, and how results were explained to patients.ResultsDuring 36/50 consultations in which ordering blood tests was discussed, 31% of patients hinted they wanted a blood test, however none explicitly asked: 32% of patients were informed about all blood tests ordered. Only 11% were offered any alternative options. In 81% of cases the GP gave some explanation of why the test was indicated, but only 17% explained any limitations of testing. Of 23/50 consultations in which results were conveyed, the GP gave no explanation of the results in 26% of cases: 57% of patients were only informed of an ‘assessment’ of the result, not the actual result.ConclusionThis study identifies numerous areas for improvement in terms of patient information and SDM surrounding blood testing. Promoting SDM has been hypothesised to reduce rates of unnecessary testing and could potentially improve patient-centred care and efficiency.

Exploring lifestyle counselling in routine primary care consultations: the professionals' role

It is generally acknowledged that GPs and practice nurses (PNs) may significantly contribute to a patient's healthy lifestyle behaviour. Two counselling techniques are known to strengthen this process: tailoring information and advice about lifestyle behaviour to a patient and motivational interviewing (MI). It is not clear to what extent GPs and PNs actually apply these techniques during routine consultations. To examine how GPs and PNs discuss patients' lifestyle behaviour, in terms of the level of tailoring of information and advice and their application of MI. We randomly videotaped GP-patient and PN-patient consultations within Dutch general practices and selected 124 and 141 consultations, respectively, that included any discussion about the patient's lifestyle. These were analysed, using the 'Behaviour Change Counselling Index', level of tailoring and content of lifestyle counselling. Information about lifestyle is mainly given in generic terms by GPs and PNs. In contrast, advice about smoking behaviour more often seems to be tailored to the patient. GPs hardly ever applied MI in their consultations about patient's lifestyle behaviour. PNs trained in MI did apply this technique, but to some extent only. Both GPs and PNs somehow perform lifestyle counselling according to generally acknowledged criteria. However, for both, there is room for improvement in the application of MI skills and in tailoring of information and advice about lifestyle behaviour. Effort needs to be put into integrating such techniques into busy daily practice while simultaneously complying with the many other clinical demands.

Verbal and non-verbal behavior of doctors and patients in primary care consultations – How this relates to patient enablement

ObjectiveTo assess the relationship between observable patient and doctor verbal and non-verbal behaviors and the degree of enablement in consultations according to the Patient Enablement Instrument (PEI) (a patient-reported consultation outcome measure). MethodsWe analyzed 88 recorded routine primary care consultations. Verbal and non-verbal communications were analyzed using the Roter Interaction Analysis System (RIAS) and the Medical Interaction Process System, respectively. Consultations were categorized as patient- or doctor-centered and by whether the patient or doctor was verbally dominant using the RIAS categorizations. ResultsConsultations that were regarded as patient-centered or verbally dominated by the patient on RIAS coding were considered enabling. Socio-emotional interchange (agreements, approvals, laughter, legitimization) was associated with enablement. These features, together with task-related behavior explain up to 33% of the variance of enablement, leaving 67% unexplained. Thus, enablement appears to include aspects beyond those expressed as observable behavior. ConclusionFor enablement consultations should be patient-centered and doctors should facilitate socio-emotional interchange. Observable behavior included in communication skills training probably contributes to only about a third of the factors that engender enablement in consultations. Practice implicationsTo support patient enablement in consultations, clinicians should focus on agreements, approvals and legitimization whilst attending to patient agendas.

A comparison of patient recall of smoking cessation advice with advice recorded in electronic medical records

BackgroundBrief cessation advice delivered to smokers during routine primary care consultations increases smoking cessation rates. However, in previous studies investigating recall of smoking cessation advice, smokers have reported more advice being received than is actually documented in their medical records. Recording of smoking cessation advice in UK primary care medical records has increased since the introduction of the Quality and Outcomes Framework (QOF) in 2004, and so we compare recall and recording of cessation advice since this time to assess whether or not agreement between these two data sources has improved.MethodsFor each year from 2000 to 2009, the proportion of patients in The Health Improvement Network Database (THIN) with a recording of cessation advice in their notes in the last 12 months was calculated. In 2004, 2005 and 2008, these figures were compared to rates of patients recalling having received cessation advice in the last 12 months in the Primary Care Trust (PCT) Patient Surveys, with adjustment for age, sex and regional differences between the populations.ResultsIn 2004 there was good agreement between the proportion of THIN patients who had cessation advice recorded in their medical records and the proportion recalling advice in the Patient Survey. However, in both 2005 and 2008, more patients had cessation advice recorded in their medical records than recalled receiving advice.ConclusionsSince the introduction of the QOF, the rate of recording of cessation advice in primary care medical records has exceeded that of patient recall. Whilst both data sources have limitations, our study suggests that, in recent years, the proportion of smokers being advised to quit by primary care health professionals may not have improved as much as the improved recording rates imply.

Death, depression and ‘defensive expansion’: Closing down smoking as an issue for discussion in GP consultations

This paper examines routine primary care consultations in the UK where smoking is discussed using data from a larger study of the factors influencing discussion of smoking between general practitioners (GPs) and patients. In this study, consultations have been analysed with a focus on the termination of discussion about smoking, using an approach that is informed by the conversation analytic (CA) literature on professional/client interaction. In interviews from the previous larger study, GPs suggested two main reasons for not pursuing discussion of smoking in consultations. One reason was an overarching fear of damaging the GP/patient relationship. The second reason related to clinical judgement, where it was feared that an attempt to stop smoking might exacerbate a patient's existing condition, particularly their mental health. This paper suggests that, while this latter scenario of clinical judgement is borne out by the consultation data, there are two more subtle patient behaviours which are associated with GPs abandoning further discussion of smoking: patients’ ‘troubles telling’, where the issue of smoking is de-emphasised in the face of other ‘troubles’, and ‘defensive expansion’, where the patient over-emphasises deficiencies to curtail discussion. Greater awareness of the situations in which doctors end discussion of smoking will help GPs to develop ideas for alternative approaches in these circumstances which could result in more meaningful, effective engagement between doctors and their patients who smoke when smoking is discussed.

The OPTION scale: measuring the extent that clinicians involve patients in decision‐making tasks

To examine the psychometric properties of a revised scale, named 'observing patient involvement in decision making' (OPTION), by analysing its reapplication to a sample of routine primary care consultations. The OPTION instrument assesses to what degree clinicians involve patients in decision making. Cross-sectional assessment of medical interaction by two calibrated raters. Primary care. Twenty-one general practitioners provided 186 consultations for assessment. Observational score using the OPTION instrument. Compared with the first version of the OPTION scale, the revised scale that uses a magnitude instead of an attitude scale, when applied to the same data set, resulted in improvement in the scale's reliability and to lower scores for the levels of involvement achieved by the practitioners. Factor analysis confirms that it is acceptable to regard the scale as a single construct. Although there is moderate variability when raters are assessed on an item by item basis, the agreements between raters at the level of the overall OPTION score is high (the intraclass correlation coefficient scores for total OPTION score was 0.77), a level that is acceptable for the evaluation of a set of consultations per practitioner (e.g. between 5 and 10 consultations), where aggregate scores would be used for determining overall performance. We conclude that OPTION is sufficiently reliable to be used for formal assessment at the level of the whole instrument (all 12 items).

The effect of physical activity advice given in routine primary care consultations: a systematic review.

Recent evidence and recommendations suggest that physical activity health promotion should be aimed at persuading the whole population to adopt an active lifestyle. Intensive medical programmes aimed at promoting physical activity amongst those at risk are not effective at achieving this aim. Brief advice from primary care professionals to quit smoking has a small but, at a population level, important effect. Brief advice in primary care to adopt a more active lifestyle may be similarly effective. The aim of this review is to determine the effect of advice given in routine primary care consultations on levels of physical activity. A systematic review was carried out of trials assessing the effectiveness of advice given in routine primary care consultations. Data sources were four electronic databases (MEDLINE, EMBASE, Sport discus, Cochrane Library), and bibliographies of retrieved papers were searched. Experts were contacted. Eight trials, with a total of 4747 participants, were identified; the majority were from the United States. Outcome measures varied considerably between trials, including continuous measures (e.g. duration of exercise) and dichotomous measures (e.g. being active), therefore statistical pooling was inappropriate. Two of the trials were cluster randomized controlled trials, the remainder were quasi-experimental. None of the trials fulfilled all of the predetermined quality criteria and selection bias in the nonrandomized studies may have exaggerated results. Four of the six trials that presented short-term (up to 8 weeks) results found advice to be effective; only one of the four trials with long-term follow-up (4-12 months) found a sustained effect. The two randomized controlled trials had negative short- and long-term results. From the available evidence it appears that advice in routine primary care consultations is not an effective means of producing sustained increases in physical activity. However, these results may not be applicable to the United Kingdom, where the structure of primary care is unique. Quality research in UK primary care would be valuable.