Quality care provision for older people: an interview study with patients and primary healthcare professionals

Background

In recent years, primary health care for the ageing population has become increasingly complex.

Aim

This study sought to explore the views and needs of healthcare professionals and older patients relating to primary care in order to identify focal areas for improving primary health care for older people.

Design and setting

This research was structured as a mixed interview study with focus groups and individual interviews. Participants were made up of primary healthcare professionals and older patients. Patients were recruited from five elderly care homes in a small city in the southern part of the Netherlands.

Method

All interviews were transcribed verbatim and analysed by two individual researchers applying constant comparative analysis. Data collection proceeded until saturation was reached.

Results

Participants in the study agreed about the need for primary care for older patients, and showed sympathy with one another’s perspectives. They did note, however, a number of obstacles hindering good healthcare provision. The major themes that arose were: ‘autonomy and independence’, ‘organisational barriers’, and ‘professional expertise’. Participants generally noted that it is important to clarify differences in perspectives about good care between patients and healthcare professionals.

Conclusion

Effective primary care intervention for older patients requires mutual understanding of the expectations and goals of all parties involved. There are a number of important requirements, especially accessible patient information in the form of care plans; specialist training for nurses and GPs on complex care and multimorbidity; and training on discussing autonomy, goal setting, and shared care. Further improvement in health care for older people and its evaluation research should focus on these requirements.     

Measuring preventive procedures by French GPs: an observational survey

Background

Prevention has become a legal obligation for French GPs, since a law was passed in March 2002.

Aim

Measurement and analysis of preventive procedures performed by French GPs.

Design of study

Observational survey.

Setting

GP surgeries in Puy-de-Dôme, France.

Method

Doctors completed a questionnaire about their socioprofessional characteristics, and a researcher completed another questionnaire about preventive procedures performed on the last 15 patients seen by each GP. Twenty preventive services were evaluated and, for each service, medical records, targets, and objectives were defined according to the national preventive care guidelines. The gap between guidelines and practice was explained by doctor characteristics. Statistical analyses were performed using χ² and logistic regression.

Results

Representative samples of 179 doctors and 2453 medical records were randomised. Four preventive services were performed in more than 75% of cases, and the gap was explained by the salaried job the doctors had. Ten preventive services were performed in 25% to 75% of cases and the gap was explained by the medical software used. The six remaining services were performed in less than 25% of cases and no explanatory variable was identified.

Conclusion

Sixteen preventive procedures were insufficiently performed. The more a preventive service is performed the more the gap will be explained by GPs'' socioprofessional characteristics. The gap for a preventive procedure performed in 25% to 75% of cases was mainly explained by management of the medical records. A nationwide policy to improve prevention performance in general practice seems to be essential.     

Practitioners' views on managing childhood obesity in primary care: a qualitative study

Background

In 2006 the Department of Health and the National Institute for Health and Clinical Excellence (NICE) published guidance on the management of childhood obesity, for use by primary care practitioners. Little is known, however, about practitioners'' views and experiences of managing childhood obesity in primary care.

Aim

To explore practitioners'' views of primary care as a setting in which to treat childhood obesity.

Design of study

Qualitative interview study.

Setting

Primary care and other community settings based in Bristol, England.

Method

Interviews explored practitioners'' views and experiences of managing childhood obesity and their knowledge of the recent guidance provided by the Department of Health and NICE. Interviews were audiotaped and transcribed verbatim. Analysis was thematic and comparisons made both within and across the interviews.

Results

Thirty practitioners were interviewed: 12 GPs, 10 practice nurses, four school nurses, and four health visitors. Participants varied in their views about whether primary care is an appropriate treatment setting for childhood obesity. However, all described factors that limited the extent to which they could intervene effectively: a lack of expertise, resources, and contact with primary school children; the causes of childhood obesity; and the need to work with parents. It was also apparent that very few participants had knowledge of the recent guidance.

Conclusion

Practitioners do not currently view primary care as an effective treatment setting for childhood obesity and it is unlikely that the guidance from the Department of Health and NICE will have a meaningful impact on their management of this condition.     

Barriers engaging families and GPs in childhood weight management strategies

Background

The rapid increase in the prevalence of childhood obesity in recent years has led to inconclusive debate about the most effective way to manage the condition and the most appropriate care setting. Primary care has been suggested as a key site to identify and treat obesity in children.

Aim

To identify children from general practice databases with a body mass index (BMI) categorised as ‘obese’, and invite them for a primary care consultation and possible referral to a specialist secondary care clinic.

Design and setting

Targeted screening of GP practice databases for obese children in 12 general practices in Bristol, UK.

Method

Participating GP practices searched databases for children''s BMIs which were then screened by the study team to identify obese children (≥98th centile). Practices invited families of obese children to consult their GP with the potential for referral to a specialist clinic. Follow-up data was recorded with respect to: consultations; consultations about child''s weight; and referrals to specialist clinic; and other referrals.

Results

A total of 285 letters inviting families to consult their GP were sent; 134 patients consulted their GP in the follow-up period (minimum 3 months), and 42 of these consultations discussed the child''s weight. Nineteen patients received a secondary care referral and six received an alternative weight-management referral.

Conclusion

The low take-up following the mail-out of an invitation to consult highlights the inherent difficulties of engaging families and their obese children in care pathways that facilitate long-term weight management.     

Australian GPs'' perceptions about child and adolescent overweight and obesity the Weight of Opinion study

BACKGROUND: GPs can potentially play a significant role in assessing weight status, providing advice, and making referrals to address overweight and obesity and its consequences among children and adolescents. AIM: To investigate the perceptions of GPs about overweight and obesity in children and adolescents, including the extent to which they perceive it as a concern, the factors they see as causal, what actions they consider might be needed, and their sense of responsibility and self-efficacy. DESIGN OF STUDY: A cross-sectional qualitative study of GPs' perceptions. SETTING: General practice and primary health care services in the state of New South Wales, Australia. METHOD: Focus groups using a structured protocol were conducted with samples of GPs. Groups comprised a mix of male and female GPs from a range of cultural backgrounds and working in practices in low, medium and high socioeconomic areas. Data were recorded and transcribed. Content analysis was used to identify key themes. RESULTS: Many GPs are concerned about the increasing prevalence of childhood overweight and obesity. They are committed to dealing with the medical consequences, but are aware of the broad range of social causes. GPs perceived that parents are sensitive about this topic, making it difficult for them to raise the issue directly in clinical practice, unless they use lateral strategies. GPs were confident about providing advice, with some managing the problem independently, while others preferred to refer to specialised services. GPs perceived that there were significant barriers to patient compliance with advice. CONCLUSION: Whereas some GPs manage patients' lifestyle change directly, including children's weight management, others prefer to refer. Programmes, service delivery systems, and resources to support both approaches are required.     

Evaluating the transferability of a hospital-based childhood obesity clinic to primary care: a randomised controlled trial

Background

The Care Of Childhood Obesity (COCO) clinic at the Bristol Royal Hospital for Children (BRHC) uses a multidisciplinary approach comprising a consultant, dietitian, and exercise specialist. The clinic has demonstrated efficacy in managing children''s weight but similar clinics are scarce in the UK.

Aim

This pilot randomised controlled trial (RCT) aimed to examine the feasibility of undertaking a fully powered RCT and to gauge whether the COCO model could be effective as a nurse-led clinic in primary care settings.

Design and setting

Patients were randomised to a hospital-based childhood obesity clinic or a nurse-led clinic in a primary care setting in south-west England.

Method

Children aged 5–16 years with a body mass index (BMI) ≥98th centile were referred by GPs to the consultant in charge of the COCO clinic at BRHC. Referred children were clinically screened for suitability and invited into the study. Consenting families were randomised to BRHC or a primary care clinic (PCC) and offered five appointments over 12 months. Clinical effectiveness was measured by change in body mass index standard deviation score (BMI SDS) at 12 months. Other measures included: treatment adherence, quality of life (QOL), and satisfaction. Feasibility was examined by assessing referral, screening, and recruitment data.

Results

A total 152 patients were referred by GPs: 31 (20%) were screened out; 45 (30%) declined to participate. Seventy-six (50%) patients were randomised and 68 provided baseline data (PCC = 42; BRHC = 26); 52 provided outcome data (PCC = 29; BRHC = 23). Mean change in BMI SDS was PCC –0.17 (95% confidence interval [CI] = –0.27 to –0.07); BRHC –0.15 (95% CI = –0.26 to –0.05). QOL, adherence, and satisfaction data indicated similar positive patterns in both trial arms.

Conclusion

Screening and recruitment data indicate that primary care is a clinically appropriate setting and acceptable to families. The primary clinical outcome measure (reduction in BMI SDS), along with secondary outcome measures, indicate that primary care has the potential to be effective in providing weight management for children, using the COCO model.     

Prevalence of comorbid depression and obesity in general practice: a cross-sectional survey

Background

General practice is a common setting for the provision of weight-management advice, as well as the treatment of depression. While there is some evidence of a reciprocal relationship between obesity and depression, there are limited data about the rates of depression among general practice patients who are underweight, normal weight, overweight, and obese.

Aim

To explore the prevalence of depression among underweight, normal weight, overweight, and obese general practice patients.

Design and setting

A cross-sectional survey was conducted in 12 Australian general practices.

Method

Patients aged ≥18 years and older who were presenting for general practice care were eligible to participate. Consenting patients completed a touchscreen computer survey assessing self-reported weight and height. Depression was assessed by the Patient Health Questionnaire-9 (PHQ-9), with a score of ≥10 used to indicate possible depression.

Results

Data were obtained from 3361 participants. The prevalence of depression was 24% (95% confidence interval [CI] = 11.86 to 39.28) among underweight participants, 11% (95% CI = 8.5 to 14.0) among normal weight participants, 12% (95% CI = 0.9 to 15.2) among overweight participants, and 23% (95% CI = 17.8 to 29.0) among obese participants. The prevalence of depression was higher for women than for men across all weight categories except underweight.

Conclusion

Weight and depression demonstrated a U-shaped relationship, with higher prevalence of depression observed among underweight and obese general practice patients. These conditions may act as red flags for opportunistic screening of depression in the general practice setting.     

Inequalities in the uptake of weight management interventions in a pragmatic trial: an observational study in primary care

Background

Primary care referral to a commercial open-group behavioural weight-loss programme is a cost-effective intervention, but only 10% of patients receiving this intervention are male.

Aim

To explore whether observed biases in participation in these interventions reflect biases in the uptake of the invitation to participate.

Design and setting

Comparison of invited population and recruited participants in a multicentre randomised controlled trial of primary care referral to a commercial open-group behavioural weight-loss programme in England (WRAP [Weight loss Referrals for Adults in Primary care]).

Method

Between October 2012 and February 2014, participants were recruited through 23 primary care practices in England; 17 practices provided data on the characteristics of invited participants.

Results

Females were twice as likely as males to enrol in the trial (odds ratio [OR] 2.01, 95% confidence interval [CI] = 1.75 to 2.32). However, the proportion of males was threefold higher than seen in routine primary care referrals or similar trials that invited patients opportunistically. People from less deprived areas were more likely to enrol than those in more deprived areas (OR 1.77, 95% CI = 1.55 to 2.03). Older patients (≥40 years) were more likely to enrol than younger patients (OR 1.60, 95% CI = 1.34 to 1.91).

Conclusion

Males, younger people, and those from more deprived areas were less likely to take up the invitation to participate in this trial. The gender bias was smaller than observed in routine practice, suggesting that a substantial proportion of the inequity observed previously is a consequence of bias with regard to the offer of intervention. This study suggests that a simple way to overcome much of the gender bias is to write to patients who are overweight and offer referral. Uptake of the invitation to participate was lower in groups of lower socioeconomic status suggesting the need to preferentially offer referrals to this group to reduce health inequalities and for research to explore barriers to uptake.     

Prophylactic treatment of migraine by GPs: a qualitative study

Background

Despite the considerable impact of migraine, the use of preventive medication in primary care is limited. Only about 5% of migraine patients who qualify for prophylaxis actually receive it, and adherence is far from optimal.

Aim

To explore the opinions of GPs regarding preventive medication for migraine.

Design and setting

A qualitative focus group study in Dutch general practice.

Method

Four focus groups (six GPs each) were formed. GPs were purposively sampled to acquire a range of participants, reflecting the more general GP population.

Results

GPs perceived patients'' concerns about the impact of migraine and the potential benefits of prophylaxis. However, some were hesitant to start prescribing prophylaxis due to doubts about effectiveness, potential side effects, and the risk of developing drug dependency. GPs'' decisions were often based on considerations other than those presented in national guidelines, for example, the patient''s need to control their own problem. Many GPs placed responsibility for initiating prophylaxis with the patient.

Conclusion

Various considerations hamper GPs from managing migraine with preventive medication, and various patient-related concerns cause GPs to deviate from national headache guidelines.     

Which weight-loss programmes are as effective as Weight Watchers??: Non-inferiority analysis

Background

Three randomised controlled trials have provided strong evidence that Weight Watchers^® is an effective weight-loss programme but there is insufficient evidence to determine whether three other weight-loss programmes are also effective.

Aim

To examine whether other group-based weight-loss programmes were not inferior to Weight Watchers.

Design and setting

A prospective cohort study using a non-inferiority analysis of 3290 adults referred through primary care.

Method

Participants who met the eligibility criteria for primary care obesity management treatment chose a free programme (Weight Watchers, Rosemary Conley Diet and Fitness Clubs, Slimming World or a NHS group programme) lasting 3 months; they were weighed at 3 months (programme end) and self-reported their weight at 12 months.

Results

At 3 months, weight loss achieved through Rosemary Conley and Slimming World was not inferior to Weight Watchers. The NHS group programme was inferior. At 12 months Slimming World and Rosemary Conley were not inferior to Weight Watchers, although participants using Slimming World lost significantly more weight than those using Weight Watchers. Data on the NHS group programme were inconclusive.

Conclusion

In the short term all commercial weight-loss programmes appear to result in similar weight loss but the NHS alternative appears to produce less weight loss. At 12 months Slimming World led to greater weight loss but the differences between commercial programmes was small and of minor clinical importance.     

Identification of an updated set of prescribing-safety indicators for GPs

Background

Medication error is an important contributor to patient morbidity and mortality and is associated with inadequate patient safety measures. However, prescribing-safety tools specifically designed for use in general practice are lacking.

Aim

To identify and update a set of prescribing-safety indicators for assessing the safety of prescribing in general practice, and to estimate the risk of harm to patients associated with each indicator.

Design and setting

RAND/UCLA consensus development of indicators in UK general practice.

Method

Prescribing indicators were identified from a systematic review and previous consensus exercise. The RAND Appropriateness Method was used to further identify and develop the indicators with an electronic-Delphi method used to rate the risk associated with them. Twelve GPs from all the countries of the UK participated in the RAND exercise, with 11 GPs rating risk using the electronic-Delphi approach.

Results

Fifty-six prescribing-safety indicators were considered appropriate for inclusion (overall panel median rating of 7–9, with agreement). These indicators cover hazardous prescribing across a range of therapeutic indications, hazardous drug–drug combinations and inadequate laboratory test monitoring. Twenty-three (41%) of these indicators were considered high risk or extreme risk by 80% or more of the participants.

Conclusion

This study identified a set of 56 indicators that were considered, by a panel of GPs, to be appropriate for assessing the safety of GP prescribing. Twenty-three of these indicators were considered to be associated with high or extreme risk to patients and should be the focus of efforts to improve patient safety.     

Practice size and service provision in primary care: an observational study

Background

In 2004, primary care payments for basic services and enhanced services were separated. This change has greatly facilitated the evaluation of the breadth and volume of services.

Aim

To determine whether larger practices produce a higher volume and greater diversity of enhanced services.

Design of study

Cross-sectional observational study using practice data obtained under the Freedom of Information Act 2000.

Setting

A total of 384 practices in 14 English primary care trusts.

Method

Practice data for all practices were collated for enhanced services, practice size, and deprivation. Diversity and volume of enhanced services were used as dependent variables in a series of multiple regression models to ascertain the effect of practice size, and any relationship with deprivation.

Results

Larger practices provided a greater diversity of services (P = 0.002), although this effect was not present in practices with more than 6330 patients. Practice size seems to influence the volume of enhanced services in general medical services, but this effect disappeared when deprivation was taken into account. Deprivation had a negative influence on the volume of enhanced services provided (P = 0.019). The effect of deprivation on volume persisted in practices with more than 6330 patients.

Conclusion

Current average-sized practices provide similar volume and diversity of enhanced services as those in the largest quartile; therefore, there seems to be little merit in creating ‘supersurgeries’ if the aim is to transfer work from secondary to primary care. There does not seem to be an upper threshold above which practice size creates spare capacity and expertise to deliver a significantly greater volume or more diversity of extra services.     

Weight-management interventions in primary care: a pilot randomised controlled trial

Background

There is a paucity of randomised controlled trials of weight management in primary care.

Aim

To ascertain the feasibility of a full trial of a nurse-led weight-management programme in general practice.

Design of study

Factorial randomised control trial.

Setting

Primary care, UK.

Method

A total of 123 adults (80.3% women, mean age 47.2 years) with body mass index ≥27 kg/m², recruited from eight practices, were randomised to receive structured lifestyle support (n = 30), structured lifestyle support plus pedometer (n = 31), usual care (n = 31), or usual care plus pedometer (n = 31) for a 12-week period.

Results

A total of 103 participants were successfully followed up. The adjusted mean difference in weight in structured support compared to usual care groups was −2.63 kg (95% confidence interval [CI] = −4.06 to −1.20 kg), and for pedometer compared to no pedometer groups it was −0.11 kg (95% CI = −1.52 to 1.30 kg). One in three participants in the structured-support groups (17/50, 34.0%) lost 5% or more of their initial weight, compared to less than one in five (10/53, 18.9%) in usual-care groups; provision of a pedometer made little difference (14/48, 29.2% pedometer; 13/55, 23.6% no pedometer). Difference in waist circumference change between structured-support and usual-care groups was −1.80 cm (95% CI = −3.39 to −0.20 cm), and between the pedometer and no pedometer groups it was −0.84 cm (95% CI = −2.42 to 0.73 cm). When asked about their experience of study participation, most participants found structured support helpful.

Conclusion

The structured lifestyle support package could make substantial contributions to improving weight-management services. A trial of the intervention in general practice is feasible and practicable.     

Experiences of a commercial weight-loss programme after primary care referral: a qualitative study

BackgroundReferral to a commercial weight-loss programme is a cost-effective intervention that is already used within the NHS. Qualitative research suggests this community-based, non-medical intervention accords with participants’ view of weight management as a lifestyle issue.AimTo examine the ways in which participants’ attitudes and beliefs about accessing a commercial weight management programme via their doctor relate to their weight-loss experience, and to understand how these contextual factors influence motivation and adherence to the intervention.MethodTwenty-nine participants (body mass index [BMI] ≥28 kg/m²; age ≥18 years), who took part in the WRAP (Weight Loss Referrals for Adults in Primary Care) trial, were recruited at their 3-month assessment appointment to participate in a semi-structured interview about their experience of the intervention and weight management more generally. Interviews were audiorecorded, transcribed verbatim, and analysed inductively using a narrative approach.ResultsAlthough participants view the lifestyle-based, non-medical commercial programme as an appropriate intervention for weight management, the referral from the GP and subsequent clinical assessments frame their experience of the intervention as medically pertinent with clear health benefits.ConclusionReferral by the GP and follow-up assessment appointments were integral to participant experiences of the intervention, and could be adapted for use in general practice potentially to augment treatment effects.     

Judgements about fellow professionals and the management of patients receiving palliative care in primary care: a qualitative study.

BACKGROUND: Policies emphasise the importance of collaborative working in community palliative care. Collaborations are generally formed through formal and informal referral processes, but little is known about what influences professionals' decisions to refer to such services. AIM: To explore the influences on referrals within general and specialist community palliative care services. DESIGN OF STUDY: Qualitative, multiple-case study. SETTING: Three primary care trusts in the north-west of England. METHOD: Multiple data collection methods were employed, including documentary analysis, observation of referral team meetings and interviews. This paper primarily reports data from interviews with 47 health professionals, including GPs, district nurses, and specialist palliative care professionals. RESULTS: Judgements -- positive and negative -- about aspects of fellow professionals' performances appeared to influence referral decisions and ongoing collaboration and care. Attributes upon which these judgements were based included professional responsiveness and communication, respect, working and workload management practices, perceived expertise, and notions of elite practice. The effects of such judgements on referral and healthcare practices were altered by professional "game playing" to achieve professionals' desired outcomes. CONCLUSION: Palliative care policies and protocols need to take account of these complex and subtle influences on referrals and collaboration. In particular, teamwork and partnership are encouraged within palliative care work, but critical judgements indicate that such partnerships may be difficult or fragile. It is likely that such judgemental attitudes and practices affect many aspects of primary care, not just palliative care.     

Primary care access and its relationship with emergency department utilisation: an observational, cross-sectional, ecological study

Background

Recent health service policies in the UK have focused on improving primary care access in order to reduce the use of costly emergency department services, even though the relationship between the two is based on weak or little evidence. Research is required to establish whether improving primary care access can influence emergency department attendance.

Aim

To ascertain whether a relationship exists between the degree of access to GP practices and avoidable emergency department attendances in an inner-London primary care trust (PCT).

Design and setting

Observational, cross-sectional ecological study in 68 general practices in Brent Primary Care Trust, north London, UK.

Method

GP practices were used as the unit of analysis and avoidable emergency department attendance as the dependent variable. Routinely collected data from GP practices, Hospital Episode Statistics, and census data for the period covering 2007–2009 were used across three broad domains: GP access characteristics, population characteristics, and health status aggregated to the level of the GP practice. Multiple linear regression was used to ascertain which variables account for the variation in emergency department attendance experienced by patients registered to each GP practice.

Results

None of the GP access variables accounted for the variation in emergency department attendance. The only variable that explained this variance was the Index of Multiple Deprivation (IMD). For every unit increase in IMD score of the GP practice, there would be an increase of 6.13 (95% CI = 4.56, 7.70) per 1000 patients per year in emergency department attendances. This accounted for 47.9% of the variance in emergency department attendances in Brent.

Conclusion

Avoidable emergency department attendance appears to be mostly driven by underlying deprivation rather than by the degree of access to primary care.